The Tragedy of Unintended Consequences
The Centre for Global Development, a well-respected DC think tank, has a sobering new report out arguing that "AIDS donors may actually have weakened the health systems necessary for an effective AIDS response." $20 billion in spending may have actually been counterproductive:
"The big HIV donors are creating AIDS-specific systems that compete for health workers and administrative talent, share the same inadequate infrastructure, and further complicate already complex flows of information," said Nandini Oomman, lead author of the report.
(That summary is from Reuters, via the UN. The full report does not appear to be online yet. When it is we'll get it on the front page here.)
Laurie Garret, a fellow at the Council on Foreign Relations, made a similar point in Foreign Affairs in January 2007:
Today, thanks to a recent extraordinary and unprecedented rise in public and private giving, more money is being directed toward pressing heath challenges than ever before. But because the efforts this money is paying for are largely uncoordinated and directed mostly at specific high-profile diseases -- rather than at public health in general -- there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground.
The reasons for this are almost entirely political: individual diseases are easily identified, targeted, and measured; disease-specific interventions are easy to sell to domestic audiences; affinity groups of those in the rich world with the same disease provide powerful lobbying help; perhaps most importantly, system-wide health interventions are really, really hard to pull off, and may be impossible to manage without many times more money.
It's not time to abandon disease-specific interventions, even if these arguments are correct (and it's by no means certain that they are; I'm sure responses and critiques by people who know more than me will surface soon): at the very least, interventions to address HIV-AIDS or malaria or tuberculosis benefit the millions of poor who have or are at risk from these diseases, and that's no small thing.
But findings like this are a healthy reminder that, even when taken with the best of intentions, backed by the best science available, and run by the smartest, most committed individuals possible, any foreign policy is going to cause unintended side effects. The best policymakers can do is try to anticipate them, and when unanticipated ones come along, try to adjust.
With the HIV-AIDS projects, it seems like a few incremental changes - simplified reporting requirements, broader mandates for health care providers, and focusing more on working with and strengthening local health care systems - could probably go a long way. Even if it has created challenges, the commitment by so many countries to fight nasty diseases on a global level is itself an important start towards making genuine improvements in world health. Let's hope reports like this inform efforts to make this commitment more effective.
