Lawrence Gostin, in a recent scholarly op-ed in JAMA, has argued passionately that health inequality is deeply unethical. I fully agree. The question is how the current architecture of global health assistance can be changed so that it becomes more responsive to the unethical reality of global health disparities.
I just finished an essay for publication in which I am arguing that more money for global health is not necessarily going to have much of an impact on the global disease burden. Why? Because it is being spent on causes for which marginal returns have already been reached. Focusing on either the ‘classic’ neglected (tropical) diseases, on maternal and neonatal health or even the ‘new’ neglected diseases such as depression and obesity would be a much better way to invest in healthcare in developing countries.
Why is it not happening? Because donors follow the flock; one donor rarely deviates from what other donor agencies set their priorities on. And a significant mortality reduction over, say, a decade is more difficult to measure and attribute to a specific intervention that, for instance, the purchase of medical equipment or large training programs to halt the spread of HIV.
Can these dilemmas be solved? I think so. But it requires political action, and that is challenging because of the ongoing portrayal of international development as a field which, most of all, requires good intentions, strong partnerships and more money. This is a gigantic fallacy.
Development involves trade-offs. It is usually not the kind of win-win scheme as some prominent authors suggest. Understanding these trade-offs necessitates that political dimension is brought into global health care analysis and planning.
Susan Erikson recently argued [no full text version available] that health professionals need more training in political analysis and activism. To me, this sounds like a promising first step. But it will hardly be sufficient to nurture fundamental change. What is ultimately needed is agency–political activism, in other words–in recipient countries.
The current euphemistic talk about partnerships between donors and recipients, public and private sectors risks masking the fact that little progress has been made during the past decade in creating a more egalitarian playing field for developing nations in their negotiations with rich countries.
Where we have seen positive developments, these have originated in targeted South-South cooperation and grassroot organization, and not in more technical assistance and high-level donor conferences.
This, then, is the tall order to catalyze change: acknowledge that apolitical development is a fiction; engage constructively with the recipients so that they can really become ‘beneficiaries’; most of all, listen to local priorities rather than imposing international agendas.
Are these changes likely to happen anytime soon? No. Are they impossible to achieve? No.
Daniel Esser 
I am sympathetic with the argument that health inequality is unethical. Life is not fair. But I am not convinced that this is an issue that could be solved by aid as usual.
Actually, I am not convinced that we should use the title global health at all. Health seems to be, at least when we are dealing with classical neglected tropical diseases and neonatal/maternal health, a national public good, which spillover effect is restricted to the national borders. That is why is so difficult to come up with a genuine and effective global effort to address such issues that should be handled at national level. It is true that there is scope for international cooperation, but it seems, by design, a SSC undertaking. Countries that benefit from the cure of a tropical disease, basically poor countries on the tropics, would have a natural incentive to combine resources and efforts to find such cure. The problem is: they do not have resources or political will to tackle such issue. Perhaps the development community would provide a greater service by pooling resources, which would otherwise be spread thin among many countries, to procure the development of the cure. There are precedents. The US first sent the men to the moon, developed the atomic bomb and the Internet, by procuring such innovations. The development community perhaps should also try to reach for the sky.
The pooling function is definitely crucial. The challenge arises where pooled finances translate into political leverage, as they usually do. Convincing donors to let recipients decide how such pooled resources need to be used is unsurprisingly tricky. The problem with the status quo is that the current decision-making scheme is both ineffective (see, for instance, CBS News: “Little Proof U.N. Health Programs Work“) and inefficient (see the latest World Bank report on its own funding for HIV/AIDS). The crucial question is HOW the current structure can be changed.
Dear Sir,
I like your article, but have a problem with the solutions. I will take one example “listen to local priorities rather than imposing international agendas.”
The problem is not listening or not . The problem is who are the locals that will set priorities?.I have been working in development for the last 15 years of my life and worked with the so-called grass root level. The sad reality is that the grass root level are not grass root anymore. NGO’s movements developed into a businesslike enterprise in most developing countries. It has it ‘s own experts that not only live out of development money but turned it to a profitable industry ( profitable for them of course).
On the other hand on what bases people will set priorities in countries were information and education are lacking. Short term priority maybe posible to be identified. But, health is not a short term plan and can’ not be equal to building a needed bridge or a class room. It should engage different administrative levels and authorities and should be part of a long term plan.