The Challenge of Global Health

Laurie Garrett

From Foreign Affairs, January/February 2007

Summary:  Thanks to a recent extraordinary rise in public and private giving, today more money is being directed toward the world's poor and sick than ever before. But unless these efforts start tackling public health in general instead of narrow, disease-specific problems -- and unless the brain drain from the developing world can be stopped -- poor countries could be pushed even further into trouble, in yet another tale of well-intended foreign meddling gone awry.

Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations and the author of Betrayal of Trust: The Collapse of Global Public Health.

Data from international migration-tracking organizations show that health professionals from poor countries worldwide are increasingly abandoning their homes and their professions to take menial jobs in wealthy countries. Morale is low all over the developing world, where doctors and nurses have the knowledge to save lives but lack the tools. Where AIDS and drug-resistant TB now burn through populations like forest fires, health-care workers say that the absence of medicines and other supplies leaves them feeling more like hospice and mortuary workers than healers.

Compounding the problem are the recruitment activities of Western NGOs and OECD-supported programs inside poor countries, which poach local talent. To help comply with financial and reporting requirements imposed by the IMF, the World Bank, and other donors, these programs are also soaking up the pool of local economists, accountants, and translators. The U.S. Congress imposed a number of limitations on PEPFAR spending, including a ceiling for health-care-worker training of $1 million per country. PEPFAR is prohibited from directly topping off salaries to match government pay levels. But PEPFAR-funded programs, UN agencies, other rich-country government agencies, and NGOs routinely augment the base salaries of local staff with benefits such as housing and education subsidies, frequently bringing their employees' effective wages to a hundred times what they could earn at government-run clinics.

USAID's Kent Hill says that this trend is "a horrendous dilemma" that causes "immense pain" in poor countries. But without tough guidelines or some sort of moral consensus among UN agencies, NGOs, and donors, it is hard to see what will slow the drain of talent from already-stressed ministries of health.

GOING DUTCH?

The most commonly suggested solution to the problematic pay differential between the wages offered by local governments and those offered by international programs is to bolster the salaries of local officials. But this move would be enormously expensive (perhaps totaling $2 billion over the next five years, according to one estimate) and might not work, because of the problems that stem from injecting too much outside capital into local economies.

In a recent macroeconomic analysis, the UN Development Program (UNDP) noted that international spending on HIV/AIDS programs in poor countries doubled between 2002 and 2004. Soon it will have doubled again. For poor countries, this escalation means that by the end of 2007, HIV/AIDS spending could command up to ten percent of their GDPs. And that is before donors even begin to address the health-care-worker crisis or provide subsidies to offset NGO salaries.

There are three concerns regarding such dramatic escalations in external funding: the so-called Dutch disease, inflation and other economic problems, and the deterioration of national control. The UNDP is at great pains to dismiss the potential of Dutch disease, a term used by economists to describe situations in which the spending of externally derived funds so exceeds domestic private-sector and manufacturing investment that a country's economy is destabilized. UNDP officials argue that these risks can be controlled through careful monetary management, but not all observers are as sanguine.

Some analysts, meanwhile, insist that massive infusions of foreign cash into the public sector undermine local manufacturing and economic development. Thus, Arvind Subramanian, of the IMF, points out that all the best talent in Mozambique and Uganda is tied up in what he calls "the aid industry," and, he says, foreign-aid efforts suck all the air out of local innovation and entrepreneurship. {See Footnote 1} A more immediate concern is that raising salaries for health-care workers and managers directly involved in HIV/AIDS and other health programs will lead to salary boosts in other public sectors and spawn inflation in the countries in question. This would widen the gap between the rich and the poor, pushing the costs of staples beyond the reach of many citizens. If not carefully managed, the influx of cash could exacerbate such conditions as malnutrition and homelessness while undermining any possibility that local industries could eventually grow and support themselves through competitive exports.

Regardless of whether these problems proliferate, it is curious that even the most ardent capitalist nations funnel few if any resources toward local industries and profit centers related to health. Ministries of health in poor countries face increasing competition from NGOs and relief agencies but almost none from their local private sectors. This should be troubling, because if no locals can profit legitimately from any aspect of health care, it is unlikely that poor countries will ever be able to escape dependency on foreign aid.

Finally, major influxes of foreign funding can raise important questions about national control and the skewing of health-care policies toward foreign rather than domestic priorities. Many governments and activists complain that the U.S. government, in particular, already exerts too much control over the design and emphasis of local HIV/AIDS programs. This objection is especially strong regarding HIV-prevention programs, with claims that the Bush administration has pushed abstinence, fidelity, and faith-based programs at the expense of locally generated condom- and needle-distribution efforts.