Major Challenge, Minor Response

January 23, 2007

by Alex de Waal

Alex de Waal is program director at the Social Science Research Council and working group co-chair of the Joint Learning Initiative on Children and AIDS.

How to establish an effective and sustainable health system in a poor country? This is a formidable and complex challenge, long neglected in development theory and practice, which has re-emerged into the mainstream debate only recently — notably with the 2001 Commission on Macro-economics and Health (CMH, headed by Jeffrey Sachs) and the 2004 Joint Learning Initiative on Human Resources for Health (JLI-HRH, steered by Lincoln Chen). American scholars have been at the forefront of both these efforts, but U.S. public and private aid efforts have actually lagged behind those of Europe in integrating disease-specific responses into comprehensive plans for public health. Laurie Garrett's essay is thus very welcome: she has identified one of the central challenges of global health policy.

Garrett is enthusiastic in pursuit of her prey: how well-intentioned and well-funded stand-alone initiatives run the risk of undermining national priorities and setting up distorted and hence unsustainable health systems. And she makes a number of telling points about how national health systems are starved of resources and subject to the distorting priorities of foreign donors. But her chase is not systematic, and so, diverted to a final recommendation that fails to address the main problem she has identified, she doesn't catch her quarry.

Garrett identifies many shortcomings of stand-alone disease-specific initiatives, shortcomings that reflect the wider problems of policy coherence arising from the dominance of program- and sector-specific development assistance. (The World Bank's Poverty Reduction Strategy Papers, introduced in the late 1990s, represent perhaps the most systematic attempt to grapple with this problem.) But such narrow initiatives emerge for understandable reasons that cannot simply be brushed away.

Sachs' CMH has put some figures on what it would cost to deliver an overall health package globally — an average of $34 per person per year. The funds needed to reach this target are small by global standards, but huge in comparison to existing aid budgets. It has proven very hard to generate political backing and raise money for comprehensive programs. Stand-alone disease-specific targets, in contrast, have provided a way to generate focused effort.

The Millennium Development Goals, for example, adopted by the UN General Assembly in 2000, are an impressive and wide-ranging set of comprehensive health objectives of the sort Garrett favors. But they haven't inspired as much political momentum as, say, the WHO's "3 x 5" initiative (now superseded by a plan for universal access to AIDS treatment). Those who select and promote the narrower goals, meanwhile, recognize and are frank about their shortcomings and seek ways to bridge the gap between such efforts and truly system-wide ones.

Garrett's chosen new targets — life expectancy and maternal mortality — are already within the international development mainstream. Increasing life expectancy means dealing with the causes of death, which means focusing on child mortality and infectious diseases. Reducing child mortality by two thirds is accordingly Millennium Development Goal number 4. There is now broad consensus that the great majority of childhood deaths can be prevented with the proven technologies of the child survival revolution — vaccination against childhood diseases, clean water sources, oral rehydration therapy, and bed nets to prevent malaria. The last fifteen years' surge in adult mortality in sub-Saharan Africa that Garrett notes, meanwhile, is overwhelmingly due to HIV/AIDS and its associated TB pandemic, so life expectancy should increase soon thanks to today's efforts to grapple with AIDS and TB.

Reducing maternal mortality by three quarters is Millennium Development Goal number 5. This can be achieved by increasing the number of births attended by a health professional. Garrett is correct that an effort to bring down the maternal mortality rate requires a system-wide approach to health system. But here her quarry softly and silently vanishes away: her proposed response focuses on the equipment rather than the people required to operate it, and might be better named "box-for-a-doc." Experience shows that providing the infrastructure is the easy part: the hard bit is the training and retaining the competent staff.

Garrett has raised important questions about the direction of global health policy. But her essay neither does justice to the efforts to address this issue currently underway nor offers better alternatives.