Doctoring Aid

Reallocating resources in a new era of global health

In recent decades, great strides have been made in global health, with 90 percent of tuberculosis cases in Africa being appropriately treated and HIV prevalence rates dropping in some of the hardest-hit areas. However, neglected diseases, once eradicated—trypanosomiasis, dengue, leishmaniasis—are reemerging. With a multiplicity of goals and myriad sources of aid, the global health community has fragmented and lots its shared vision. Unless global health actors unite behind common projects, the community itself may become a major impediment to ensuring a healthy world.
In this fight, “there is no uniformity of opinion or players. It is not unorganized, but disorganized and highly political,” Marc Mitchell, a lecturer at the Harvard School of Public Health, told the HPR. Because of a focus on results and goals, politics, and a constant need to please donors who provide funding, organizations act non-synchronously, Michael Van Rooyen, Co-Director of the Harvard Humanitarian Initiative, told the HPR. Governments, for example, tend to undertake large and intensive endeavors, utilizing lots of their own resources and businesses and focusing attention on short-term interventions. The highly successful HIV/AIDS efforts of the 1990s were “not the result of somebody necessarily prioritizing AIDS, but rather the result of paying attention to very substantial pressure groups,” Mitchell recalls.
Localized Efforts
It is easy from this perspective to draw the line between donor-dependent infrastructure and politics-driven planning. For the sake of politics and interest-group goals, America’s highly successful family planning efforts have disappeared. For most of the 1990s, the United States promoted family planning around the world, helping populations to better control their own decisions. Recently, these policies have been reversed; the U.S. government now refuses to consider approaches other than abstinence. Many experts suggest this trajectory has hindered HIV/AIDS and other disease control efforts.
What has suffered most from scattered efforts have been long-term, broad-sighted approaches. For example, many populations receiving antiretroviral drugs do not have access to basic health services. Moreover, as Thomas Bossert, Director of the International Health Systems Program at the Harvard School of Public Health, told the HPR, even disease-specific efforts are hindered over time by the lack of broader infrastructure. Peter Drobac, a clinician with Brigham and Women’s and Partners in Health, said in an interview with the HPR that there is evidence that “vertical” efforts tend to sap healthcare resources away from “horizontal” or broad efforts. Along the way, larger goals and less publicized diseases are forgotten: maternal and child health are neglected, treatments for leishmaniasis and river blindness not pursued.
But recently, organizations have begun to see the importance of integrating health infrastructure development into disease-specific pursuits and donor groups are shifting funding toward not only treating HIV/AIDS, but also addressing the economic and social roots of the disease and strengthening the basic services that can serve patients post-intervention.
Ensuring Consistency
Yet in the heat of introspection the international community should not overlook intrinsic capacity building. “It’s important that national governments have an active and central role in developing strategies,” Drobac emphasizes. Sustainability has been readily addressed in other arenas, but quite overlooked in regards to health. Part of the problem may be that aid flows appear endless. “Massive increases in funding in the last 10 or 12 years have left governments unwilling to become self-sufficient,” Bossert says, which could create a frightening scenario in which private and international aid lessens and national governments can no longer pursue important policies.
Opinions as to how to approach sustainability vary. Drobac holds that health organizations should emphasize increasing transparency and reducing corruption on the donating and receiving ends of the health aid process. The key to such development, according to Bossert, are public-private partnerships. While NGOs, because of their small size, flexibility, and capacity for innovation, were at the forefront of earlier vertical interventions, they now have the potential to train the private sector in nations with underdeveloped health systems to take on tasks that governments alone may be unable to sustain.
What is clear, however, is that despite several decades of successes, it is time for the global health community to look forward broadly. It is time to ask the big questions—how can we make individual innovative, groundbreaking ideas part of a larger vision? How can we ensure sustainability? Providing for those on the fringes of society will undoubtedly require leaving the beaten, successful path and eyeing problems with a fresh perspective.