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GLOBAL HEALTH: Physician Heal Thyself — Stealth Reform In Foreign Assistance



December 27th, 2006

The global health literature is rich in studies of the challenges and intricacies of translating slivers of economic surplus from the industrialized countries into effective health, education, and development programs in the poorer countries to the south. Donors often express frustration over unpredictable behavior, byzantine politics, incomprehensible values, and an apparent absence of accountability on the other side of the aid relationship. 

But dysfunction in the machinery of international assistance appears to be a bilateral phenomenon. A crisp summary in the Journal of the Royal Society of Medicine and a more detailed study from the Center for Global Development bring us up to date on the State Department’s efforts to bring some order to a fragmented and rudderless foreign aid regime. But Democrats have complained that State’s recent efforts have been conducted behind closed doors. And the global health community -– while freely acknowledging the need for a more rational and coherent approach -– worries that in seeking better alignment between U.S. foreign policy and its aid programs, traditional goals in health and development will be subordinated to national security objectives. 

The relationship between traditional USAID programs and Bush administration initiatives like the Millennium Challenge Accounts and PEPFAR lie at the heart of many of these concerns, which are explored in depth on CGD blogs and elsewhere on the center’s content-rich Web site. The appointment of former Eli Lilly executive Randall Tobias as director of foreign assistance brought managerial muscle to Secretary Rice’s take-charge initiative. But Tobias lacks authority over programs outside State’s domain. 

The intersection of health, foreign policy, and security is not unexplored territory. The Nuffield Trust, among others, has sponsored useful investigations. The upsurge in public support for global health aid -– reflected in the work of the Gates Foundation, for example, or the notion of a “Marshall Plan for Africa” –- falls inevitably in the context of a long debate over development assistance, where questions about effectiveness and strategic relevance are perennial. Humanitarian imperatives notwithstanding, the pragmatic center has an iron grip on this turf. Selling global health priorities in the U.S. policy market will require arguments based on utility more than virtue. Perhaps in the short run, though, an appeal to pride and self-respect would have some effect. We’ve really got to clean up our act. 

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