Top 3 Debates in Global Health

Victor Roy has a great post up on GlobeMed‘s Article 25 Blog about 3 major debates common in the global  health community: 1) horizontal vs. vertical design of health programs, 2) the prevention vs. the treatment of disease, and 3) paternalism vs. measuring the effectiveness of international aide $$.

I think that the debate of horizontal vs vertical health programs is nicely summed up by the back and forth correspondence between Dr. Paul Farmer and Laurie Garrett published in Foreign Affairs‘ discussion of how to best promote global health. Garrett is a strong critic of the “stovepiped” models of providing disease specific, large scale funding citing evidence that it can pull vital resources away from underfunded primary health care efforts. Farmer tends to agree with Garrett in that western dominated funding of programs that ignore the social underpinning of suffering and disease are not nearly as effective as those that engage grassroots leaders and address fundamental human rights. However, he cautions us not to be so quick to dismiss the good that can come from using disease specific aid and diverting it to programs that work towards achieving more broad health equity goals.

The influx of AIDS funding can indeed strangle primary care, distort public health budgets, and contribute to brain drain. But these untoward or “perverse” effects are not inevitable; they occur only when programs are poorly designed. When programs are properly designed to reflect patients’ needs rather than the wishes of donors, AIDS funding can strengthen primary care. PIH has shown this throughout central Haiti, in eastern Rwanda, and in the mountains of Lesotho, and is going to use the same model in southern Malawi. In each of these settings, we work under the aegis of the Ministry of Health (and, in three of them, with the Clinton Foundation) in order to promote the notion of health as a human right. In some cases, programs have to be built from scratch; in others, it is necessary to rebuild public infrastructures damaged by war, neglect, or the misguided advice of outside experts.

Farmer et al. has been tremendously effective in developing a model that is able to take foreign funding – which in many contexts has at best shown modest results and at worst (as Laurie Garrett discussed) negatively impacted people’s health – and transform it into a vehicle for equity. Hopefully PIH‘s model and evidence of success will act to catalyze a change in international aid from a force propagating structural violence to a force restoring human dignity and rights.

I’ll try to add some comments about debates #2 and #3 as well as the wild card – public vs. private models in global health – in the coming days. Stay tuned!

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3 Responses to “Top 3 Debates in Global Health”


  1. 1 Christine Gorman January 15, 2009 at 7:22 am

    Hi Jon,
    Congrats on launching the blog.

    This post gives me an idea. What if we organized a roundup of blog entries around one or more of these three topics. Sort of like a “blog carnival” but more limited in duration.

    It would take some organization. Sending tweets/emails to the few global health bloggers we know. Pick a date a few weeks from now and then have everyone post on the same day. Afterwards, we collect and comment on all the posts.

    Since you already started with horizontal vs. vertical, we could move on to prevention vs. treatment.

    What do you think?

    Christine

  2. 2 Jon Shaffer January 15, 2009 at 10:32 am

    Hi Christine,

    I love the idea! I think that it would be really great to coordinate with all of the global health bloggers out there on a topic that is perhaps controversial and can generate some decent discussion. I think prevention vs. treatment would work well 🙂

    Let me know what I can do to help/be a part of it.

    Looking forward to driving these discussions forward!

    Best,
    Jon

  3. 3 Isaac Holeman January 16, 2009 at 12:44 pm

    Hey Jon,

    You hit the nail on the head with

    take foreign funding – which in many contexts has at best shown modest results and at worst (as Laurie Garrett discussed) negatively impacted people’s health – and transform it into a vehicle for equity.

    In a way PIH is getting the best of both vertical and horizontal approaches. A couple years ago I listened to Jim Kim give a talk called “Global Health, and Ethnography in Progress” at a global health conference at the University of Washington. He called translating vertical funds into horizantal care and a vehicle for equity the Holy Grail of global health. He also was quite clear, however, that vertical approaches have a unique ability to inspire, focus, and get people involved. He discussed his stint at WHO where his hallmark program was the 3X5 initiative – trying to get 3 million HIV+ patients on medication by 2005. At face value it sounds like the epitome of inspiring… and dangerously narrow minded and vertical. The actual programs had a much bigger focus on social transformation of communities that tend to be burdened with HIV.

    Anyhow, if you do the blog carnival idea, I’d love to take part. After reading Victor’s post I started but didn’t finish a long comment that turned into a blog post about US politics and global health, looking specifically at US political intervention in Guatemala and associated global health issues. Let me know if you’d like me to argue that it’s a “major debate.”
    cheers
    Isaac


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Welcome to the Students for Global Health Equity (SGHE) blog. Published by university students, the SGHE blog seeks to explore news and issues related to global health.

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