Reality Check

Roger Bate & Kathryn Boateng | 23 Jan 2007
Foreign Affairs

Laurie Garrett argues that although the developed world is increasingly willing to combat global medical scourges such as AIDS and malaria, it is still failing in its efforts to provide basic health care to most of the world's population. She identifies as one of the key problems a donor preference for short-term, high-profile, disease-specific programs over support for work on less glamorous problems such as maternal health and public health infrastructure. Garrett's descriptions of the appalling symptoms of poor health systems are eloquent. But she overlooks some causes of the problem and offers an unconvincing solution.

Public health is primarily the responsibility of national governments, yet many governments in poor nations simply do not consider it a political priority. For decades, these governments neglected to allocate adequate public funds to their health systems, resulting in a severe loss of clinical capacity. This fact prompted the WHO in 1978 to launch the Health for All campaign to encourage more spending on local health systems. Before its target date of 2000, however, the ambitious campaign was quietly dropped due to broad program failures. Only now, in response to growing international criticism, are some countries increasing their health budgets.

Garrett correctly notes, "efforts should focus less on particular diseases than on broad measures that affect populations' general well-being." But more needs to be said on why such holistic population-targeted initiatives have failed previously and how the pitfalls of the past can be avoided this time around.

For example, to combat the very real problem of "stovepiping," Garrett wants donor interests coordinated by a body with proven competence and she favors the WHO for the job. But it is unclear that the WHO is up to such a task, or can even follow through on its own organizational goals.

The WHO's "3X5" campaign to bring antiretrovirals (ARVs) to three million people by 2005 was ill considered. It set unrealistic country treatment targets, often without even consulting with the relevant countries; it promised funds that never materialized; and it mismanaged drug supply and testing. The campaign put tremendous pressure on precisely those fragile local systems the WHO wanted to strengthen. Its failure was inevitable from the beginning. Garrett's claim that the WHO is "the only organization with the political credibility to compel cooperative thinking" must thus be taken with a grain of salt. Many WHO-led health programs have succeeded in raising considerable funds, and when dealing with informational exchange, such as with SARS and now bird flu, its important role cannot be ignored. But its capacity-building efforts must be stepped up before it can assume the role of coordinator for any multilateral aid health initiative.

Garrett is also understandably concerned about the exodus of well-qualified health workers from the developing world to western hospitals. Brain drain is a problem, but any action to penalize the medical personnel who choose to emigrate would be misguided. In our increasingly globalized world, health workers may receive training in a foreign country but then choose to return home to use their skills. They may also repatriate a lot of the funding they receive while abroad. According to a study undertaken by the Hudson Institute, in 2003 alone remittances from foreigners living in the United States totaled $35 billion dollars. Far from destabilizing countries' economies, these capital inflows have come to be relied on heavily in some places, particularly Zimbabwe. Efforts to make it more attractive for such workers to stay in their own countries, meanwhile, are few and far between; Garrett discusses some, but more do exist — such as the franchise of nearly 70 private clinics in Kenya, backed by the HealthStore Foundation, which provides local nurses with up to twice the government salary and keeps them in country — and still more could be encouraged.

Garrett hopes to "witness spectacular improvements in the health of billions of people, driven by a grand public and private effort comparable to the Marshall Plan." But evoking the memory of the Marshall Plan is a double-edged sword. This legendary reconstruction aid effort after World War II was given to well educated, well governed, previously wealthy countries that needed to rebuild their destroyed infrastructure. Today's developing nation recipients would be, broadly speaking, poorly educated and poorly governed. Given the poor track record of foreign aid in developing countries, one can predict that unless drastic changes are made, simply sending more aid would be counterproductive (a point that Garrett herself recognizes).

In the end, therefore, Garrett demonstrates a superior understanding of the complexities of the global health enterprise, but past experience and current realities show that there are more problems associated with even well-intentioned policy objectives and programs than she acknowledges.