Sustainability or sustainable assistance?
A recent paper in PLoS Medicine in a sense applauds the Global Fund for its acknowledgement of the challenges of implementing such projects in resource-poor countries. It is not enough, to make such projects work, to merely supply resources such as medicines. Someone, possessing the relevant knowledge and skills, has to administer the medicines. Someone has to stockpile and control the distribution of medicines. Someone has to monitor the progress of the afflicted. And these people have to be paid for their time and effort. This is where other funding agencies jump ship. Financially supporting the purchase of medicines for the poor is sexy; paying for the basic preconditions of health services, such as the wages of poor doctors, nurses, pharmacists or counselors is not so appealing. Often funding agencies regard wages as something that should fall under the responsibility of the local health care system, even when it is clear that the local health care system is not capable of paying a living wage, training a sufficient number of new doctors or nurses, or stopping the health workers they do train from migrating to Australia, Canada or the USA.
As the authors of the article indicate, new global health initiatives need to be realistic about the notion of sustainability. The usual concept of sustainability assumes that beneficiary countries will gradually -- sooner rather than later -- replace international financial support with domestic resources. Resource-poor countries will not be able to seriously tackle diseases killing millions of their citizens unless there are vast improvements in local health care infrastructure, but the latter will require international funding (including funding of wages) for a very, very long time. The authors call for what they call 'sustainable assistance': reliable international support that supports developing world health systems over decades. To use current political rhetoric, trying to seriously fight AIDS, TB or malaria in a couple of years on the cheap amounts to 'cutting and running' or 'leaving before the job is done'.