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.