Waste In Global Health

Waste In Global Health

While reading through some of the global health literature, I was surprised at the staggering amount of waste in global health efforts. Resources are finite and should be spent to their utmost potential especially when considering the importance of reducing health inequities among the disenfranchised, the marginalized, and the impoverished.

Although, as we recently discussed in class, globalization has had many negative effects on health globally, it has contributed to increased global health funding through global/international organizations: mostly from wealthy, egalitarian entities. However, one must consider the effectiveness of such organizations. Funding from outside sources are seldom aware of the difficulties faced by the beneficiaries of their funds. Often, funds must be allocated according to the donor’s wishes which may be driven by emotional responses to issues faced in the donor country; and the donor’s priorities, politics, and values.¹ This effectively silences the voice of needy and impoverished populations leading to programs lacking sociocultural, economical, political, and health-related awareness. Thus, waste can be seen as misappropriated, although well-intentioned, funds and resources for services and diseases that miss the underlying causes of global health inequity. A common example can be seen in how organizations commonly “stovepipe” funds in a vertical fashion to predetermined services or diseases as Garret illustrates that, “a government may receive considerable funds to support, for example, an ARV-distribution program for mothers living in the nation’s capital. But the same government may have no financial capacity to support basic maternal and infant health programs.”¹

Cultural competence is another factor that can be overlooked and lead to waste. In Vietnam, a program was developed to treat tuberculosis that failed to take into account: cultural perceptions about the common side-effects of the regimen, that many perceived western medicine as being too strong, and that family, peer, and community support (particularly from family leaders) is essential for maintaining long-term treatment compliance. The failure to incorporate these sociocultural aspects into the program led to widespread medication non-compliance resulting in the waste of program funding, TB-medication, and time. Moreover, the program may have done more harm than good as widespread TB medication compliance fosters an environment from which multi-drug resistant (MDR) strains of TB can emerge and spread. This, in effect, would lead to higher mortality rates and increased cost of treatment as the cheaper, first-line treatment for TB is no longer efficacious for treating TB. ²

Beyond the waste involved with the utilization of funds at the interface of programs and health inequities, the underlying framework and structure of how funds are appropriated and distributed are fraught with corruption, and greed. A 2006 World bank report estimated that “about half of all funds donated for health efforts in sub-Saharan Africa never reach the clinics and hospitals…[and that money] leaks out in the form of ghost employees, padded prices for transport and warehousing, the siphoning off of drugs to the black market, and the sale of counterfeit – often dangerous – medications.” Moreover, in areas where corruption is widespread, “an amazing 80 percent of donor funds get diverted from their intended purposes.”¹ One would suspect that these areas also have the greatest need for funds. Governments appropriations also play a significant role in the waste of global health funds. Economist Paul Collier has estimated that “something around 40% of Africa’s military spending is inadvertently financed by aid.”³ The inappropriate use of foreign aid by governments is not only wasteful, it has been shown to be linked with negative health outcomes as one study indicated that “Life expectancy at birth is reduced by between 3 and 6 months for each 1% of GNP spend on military programs…[and that] this association is three times stronger in the poorest countries compared with middle-income and more affluent nations.”⁴ The most disappointing news to this story is that this problem is perpetuated through the same bodies who ostensibly pledge to fight against global health inequities but yet are “complicit in this process through the global arms trade…[as] permanent members of the United Nations Security Council together account for 80% of the world arms exports, much of it flowing to developing countries.”⁴

These issues cause me to speculate about the progress that could have been made in the absence of this waste. The truth is that waste seems to be widespread and can also be seen in: duplications in parallel health systems causing increased transport costs and increased labor demand,⁵ loss of water  and contamination of water through leaking water distribution systems resulting in 40 to 70% of wasted water (that could have been used for hygiene and sanitation) and 30% of waterborne outbreaks.⁶ It seems that much of the research and international focus rests on the clinical and program implementation strategies and not enough emphasis is put on the underlying systems that result in widespread waste. Imagine the progress that may occur if governments and organizations are held accountable for their use of health aid monies. Imagine if those funds could be used in a manner that not only represents the needs of the impoverished, but was also sensitive to their political, economical, and sociocultural context. Imagine if funds could be used to create sustainable sources of water that reduces waste and creates opportunities for increased personal hygiene and sanitation. Imagine if global health efforts were based on rigorous application of scientific approaches and informed by local knowledge and resources. In medicine they have a saying “Primum non nocere” meaning “first, do no harm.” Should global health adopt this as well? Should waste and inefficiency (as I have demonstrated a couple of times) worsen the health outcomes of the purported beneficiaries and further drive the impoverished and needy into the pit of health disparities? One could only wonder the progress that could have been made had these issues not held us back.

Sources:

1.       Garret L. The Challenges of Global Health. Foreign Affairs. Jan/Feb 2007. www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health.html?mode=print . Accessed 12/3/2013

2.       Ito K. Health Culture and the Clinical Encounter: Vietnamese Refuges’ Responses to Preventative Drug Treatment of Inactive Tuberculosis. Medical Anthropology Quarterly, New Series. Sept.1999; Vol. 13: 338-364

3.       Schrecker T. Globalization and health: the need for a global vision. Lancet. 2008;372:1670-76

4.       Chapter 1 Globalization and Health: Challenges and Prospects Ichiro Kawachi and Sarah Wamala

5.       Phyllida T, Bennett S, Haines A, et al. Overcoming health-systems constraints to achieve the millennium development goals. Lancet. 2004;346:900-9006

6.       Moe C. Rheingans R. Global challenges in water, sanitation and health. Journal of Water and Health. 2006;0.4 suppl:41-57