Sustainability in global health
by Paul Dewar and Mark Brender
The Vancouver Sun
March 17, 2016
When it comes to foreign aid and global health, you won’t hear many discussions on the pitfalls of ‘sustainability.’ That’s too bad, because clarifying what we actually mean when we talk of sustainability as a pillar of successful global health projects would do everyone a world of good — starting with those we say we’re trying to help.
The question that needs to be asked is, sustainable for whom? Too often, the mindset of Western aid agencies is to ensure programs are sustainable for those who have resources rather than those in need of them. In mistakenly flipping the starting point, we end up with negative consequences on our intended impact of saving lives and helping to build a healthier future in developing countries.
The issue goes deeper the amount of money we spend on official development assistance, although that’s a good place to start. Under the Conservative government between 2012 and 2015, hundreds of millions of dollars announced and allocated in federal budgets to international aid and development programs were never distributed, and instead ended up being returned to the treasury. While disingenuous, it was at least consistent with an approach that would say the most ‘sustainable’ action of all is to never spend the money in the first place.
The Liberal government can begin to rectify aid spending starting with the upcoming federal budget. We should also loosen the rigid ties between aid priorities and foreign policy objectives implemented under the Conservatives. Still, greater effectiveness and improved health outcomes will best be realized with a renewed commitment to health system strengthening and all that it entails: accompanying developing country governments and communities in their vision to improve their public sector health systems.
We know for certain what this does not look like: Rigid, vertical, disease-specific funding programs designed without flexibility to address systemic issues; using our aid dollars to build bricks-and-mortar institutions that sit empty or underused because of inadequate consideration to how they will be operated, staffed, equipped and maintained; programs that promote nurse or doctors trainings as panacea with minimal regard to where and the conditions in which these health professionals work.
The benefit of such short-term thinking, of course, is that it allows for ‘sustainability.’ A three-year project ends, knowledge transfer takes place, ribbons are cut, check boxes checked, targets reached. Donor governments move on to a new project to broaden their impact with a good story to tell back home about the exit strategy and what was accomplished.
The challenge is that three-year projects aren’t sustainable for those living in poverty. What’s truly sustainable are health centres with electricity and running water and medications; nurses who receive a regular salary; surgeons who have functioning surgical suites; and paid, certified community health workers to serve as vital links between clinic and community. In other words, as Partners In Health co-founder Dr. Paul Farmer puts it, the “staff, stuff, space and systems” necessary to be able to treat patients anywhere as they deserve to be treated.
It’s a more ambitious project, absolutely, but shying away for fear of the size of the task at hand will make the world more susceptible to communicable diseases like Ebola and Zika, not less. Health systems in places like Sierra Leone, Liberia and Guinea remain far from prepared to cope with the next outbreak, whatever it will be, and tuberculosis and other infectious diseases are on the rise — yet global health dollars have moved on. For proof of the damage caused by not making long-term investments in health systems, we need only look to our First Nations communities, where the need is as great and the consequences of inaction as painful as anywhere in the world.
The irony is that we have long since proven that our commitment to global health and development is sustainable. Canada has been providing foreign assistance for more than 60 years, and thankfully we’re not about to stop anytime soon. As for any fear of creating dependence, the dependence is already there: People living in poverty are indeed depending on Canada to help them push back against huge global inequities in resources and access to care.
Mark Brender is Director of Partners In Health Canada. Paul Dewar is a board member of PIH Canada (until recently the MP for Ottawa Centre and NDP Opposition Critic for Foreign Affairs)