Beware False Tradeoffs

January 23, 2007

by Jeffrey D. Sachs

Jeffrey D. Sachs is Director of the Earth Institute, Quetelet Professor of Sustainable Development, and Professor of Health Policy and Management at Columbia University.

I agree with Laurie Garrett that there is an urgent need for improvement in Africa's health systems, but it's not clear what her solutions really are. Her article is filled with misguided aid bashing and disdain for targeted disease-control programs. I disagree on both counts. We need much more aid, not aid bashing. We need targeted disease-control programs as well as programs to build Africa's health systems. We don't have to choose between AIDS control and maternal mortality. And we don't have to choose between topping up health worker salaries and breaking the donor bank. Garrett's article highlights a serious problem — the continuing health crisis in Africa — but responds with a number of false dilemmas and false choices.

Garrett leaves the strong impression that there is ample donor funding for health but very poor use of it, mainly because it is uncoordinated and directed to single diseases. Yet near the end of the article she says that triple the current spending will be needed. She repeatedly denounces current aid funding (which she derides as "putting nations on the dole"), as if health systems can be built without financial resources.

Let me refer readers back to the 2001 report of the Commission on Macroeconomics and Health, which I chaired and which helped to lead the resurgence of financing of donor assistance for health. That report, available online at www.cmhealth.org, made clear that building effective disease control and health systems would require an increase of donor aid to about $30 billion per year in today's prices ($27 billion per year in US dollars at 2002 prices), or about 0.1 percent of rich-world GNP. The report helped launch the recent increases in aid for health, but the actual aid levels that have been reached to date fall far short of what was recommended then and what is still needed today.

Garrett's suggestion that I called for annual foreign aid for health of "well under $20 billion" is seriously misleading. Perhaps she is referring to the CMH estimates for Africa, which called for country-level aid of around $19 billion per year in 2002 dollars. She says that the aid levels that I recommended have "actually been eclipsed," but this is not even close to being true. Actual donor aid disbursements per year for African health care are far below $20 billion per year. It is therefore grossly inappropriate of Garrett to leave the impression that aid targets have been met or exceeded, thereby blaming the shortfalls in outcomes on poor performance.

Those of us on the front lines of this fight do not recognize her black-and-white contrasts between vertical disease-control programs and public-health-system strengthening. Health systems, including that of the United States, obviously need both kinds of programs, and most practitioners work for both. Leading health practitioners are vividly clear on the point that "vertical" programs for AIDS and TB control actually also help to build health systems. Garrett's attack on disease-control programs is passé, a straw man.

Salary levels for health workers remain miserable in Africa and the continent's entire health sector therefore remains prone to brain drain, as Garrett rightly notes. Yet her expressed doubts about raising local salaries make little sense. She argues that bolstering local salaries would be "enormously expensive (perhaps totaling $2 billion over the next five years)," without putting the $2 billion over five years in any perspective. Let me do so. The rich world's annual GNP is around $35 trillion. Thus, $2 billion over five years, or $400 million per year, is approximately 1 penny per $1,000 of rich-world GNP. This is obviously tiny in the scheme of things, not "enormously expensive." The U.S. Pentagon, to offer another metric, spends $1.5 billion each day.

Let's recognize the iron laws of extreme poverty involved here. A typical tropical sub-Saharan African country has an annual income of perhaps $350 per person per year, of which much income is earned in kind (as food production for home use), rather than as money income. The government might be able to mobilize 15 percent of the $350 in taxes from the domestic economy. That produces a little over $50 per person per year in total government revenues (and in many countries, much less). This tiny sum must be divided among all government functions: executive, legislative, and judicial offices; police; defense; education; and so on. The health sector is lucky to claim $10 per person per year out of this, but even rudimentary health care requires roughly four times that amount. (In rich countries, public spending on health is $2,500 per person or more.) Foreign aid is therefore not a luxury for African health. It is a life-and-death necessity.

Doctors and nurses, meanwhile, are — and will continue to be — extremely scarce there, even without brain drain and deaths of health workers from AIDS. There are frequently 5 doctors or fewer per 100,000 population, and often virtually none in rural areas. Of course more doctors and nurses need to be trained, and urgently. Just as important, however, will be new cadres of village health workers who should be trained for a few months each in order to help handle a host of basic health challenges within the village context (malaria control, diarrhea control, family planning, etc.). Such village health workers would work under the supervision of doctors and nurses, and would provide direct contact with households in the community. Tens of thousands of village health workers can and should be mobilized in the coming years. At the same time, health worker salaries need to be topped up significantly with donor aid, so that brain drain is at least restrained.

Africa's tropical disease ecology, finally, is particularly pernicious for several killer vector-borne diseases, the most important of which is malaria. This means that even as Africa lacks the domestic financial means to mount an effective health system, it bears by far the world's highest burden of some tropical infectious diseases.

Until Africa's economies pull Africa out of extreme poverty — something that will be powerfully assisted by disease control — foreign aid is not a whim, a matter of dole, or a matter of avoidable dependency. It is the difference between life and death. It can also be used to do exactly what Garrett rightly wants: to build an effective health system. We have just started on the road to doing this, after decades of shocking neglect. Garrett is right to call for more coherence and better strategy, but the real answer to the problems she describes is a further scaling up of aid, combined with comprehensive efforts at training, targeted disease control, and overall public health system building. All of this is within reach, if Africa and the rest of the world can persevere.