18 November, 2016

Rethinking Aid Delivery

By Paul Farmer
Kolokotrones University Professor at Harvard University, chair of Harvard Medical School's Department of Global Health and Social Medicine, co-founder of the non-profit organization Partners In Health, and Special Adviser to the United Nations Secretary-General

When we talk about “aid effectiveness,” what do we mean?  Is it just jargon? It is, until we ensure that in the midst of all of our efforts to respond, our investments are not fleeting and that they don’t undermine the struggling public sectors and care delivery systems that are often already weakened. In the recent Ebola outbreak in West Africa, there was no mystery about how we got there: we got there because after the last crises in the region, too few resources were invested in building a health care system able to deliver on the promise of both prevention and care.

We have too often failed to link emergency responses—and there were many during the latter years of the past century and first years of this one—to building local capacity and professional training programs that draw on the world’s largest gold mine, which is its human capital.  Over the last few decades, despite good-will efforts to accompany our partners in settings of poverty, we have too often failed to invest heavily in national institutions, sometimes skirting them altogether.

While numerous international policies such as the Paris Declaration and most recently the Busan New Deal encourage us to invest in national institutions, we’ve all heard why it’s “impossible” to partner with local authorities because of weak absorptive capacity and alleged corruption.  In order to avoid risk, so goes the story, we build parallel systems to deliver and assess the impact of humanitarian aid. All too often, we worry about our own institutions rather than about the grotesque risks faced by those left behind by human progress.  We whisper about “reputational” and “institutional” risk.

As a physician, I cannot resist inserting a little bit of clinical medicine that is pertinent certainly to the course of the Ebola virus but also the struggles that we all face in contemplating what we should do collectively when we are delivering aid: We’re familiar with the notion of a visual field defect.  Basically it means that part of your visual field is obscured, and this is a major challenge before us: how do we see the entire field when we approach any development challenge?  It’s difficult, for example, to have a conversation about aid effectiveness without asking ourselves some difficult questions about how we will ensure that we will, at every step of the way, make every effort to link our work to long-term strengthening of the public sector.  Are we spending as much time ensuring our efforts add up to more than the sum of their parts as we are on divvying up the parts?

Those of us in the field of public health—or more broadly, those tasked by self or other with serving the poor—are quick express concerns about “sustainability” or “cost-effectiveness.”

With so many lives lost because of a lack of access to basic public health interventions such vaccines or adequate sanitation, how can we begin to think about using “scarce resources” to provide cancer treatment, or antiretroviral therapy for AIDs patients, or training new generations of nurses and physicians to address the ongoing crisis in human resources? Scarcity obscures our vision and we set our sights and our aspirations lower.

Yet it is important to remind ourselves that so much of what we consider as not being “cost effective” in places like Liberia or Haiti is rarely questioned as anything but a necessary facet of a functioning healthcare system when located in wealthier settings. Without these investments, without willing to accept anything but high-quality, comprehensive care for the poor, we are setting ourselves up for failure.

When we reject the low-ball aspirations, cynicism and defeat, that make it all too easy to accept business as usual approach, which in poor settings means providing only the most basic elements of modern medicine and moving on with no long-term plan to leave lasting public systems in place, there is no reason why we cannot make the investments needed to prevent the next epidemic before it occurs. The alternative truly is “unsustainable.”

We know that this can be done. Take the the Hôpital Universitaire de Mirebalais in Haiti as an example. The facility is a modern 205,000 square foot, 300 bed teaching hospital, owned by the Government of Haiti and operated in partnership with the NGO Partners In Health. Since opening its doors in 2013, the hospital has provided high-quality care to 250,000 people, most of whom  never had access to modern medicine, while at the same time training new generations of Haitian physicians and nurses. If this is possible in Haiti’s Central Plateau, there is no reason it cannot be replicated in Liberia, Sierra Leone, Guinea, or any other resource poor setting.  We need to reimagine what is possible.

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