In 2002, the Ethiopian Federal Ministry of Health set out to provide primary health care for the nation's 85 million rural citizens -- many of whom didn't live within accessible distance of a hospital or even a doctor. The plan was shocking to some, said Dr. Kesetebirhan Admasu, Ethiopia's Minister of Health. After all, they had given themselves only five years to implement it, and lacked both the resources and facilities needed to train an anticipated 30,000 community health workers. With only a year of training, these workers would be sent out to villages across the country to address disease prevention and promote general health. Since the program's unlikely implementation, however, Ethiopia has seen decreases in the number of women dying in childbirth, and in children dying before the age of five, among other markers of success.
That Ethiopia's health care development began with simple, community-driven improvements, instead of through "top-down" means like the creation of hospitals, is itself significant. Equally important, however, is that the idea was implemented by the nation's own government.
It's far from the norm for a government to pilot its own program when the money is coming from outside donors -- Ethiopia receives over 70 percent of its aid from the United States and from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. In fact, it's rare for the governments of developing countries to have much say in where aid money goes at all. Kampeta Sayinzoga, representing Rwanda's Ministry of Finance and Economic Planning, explained how when her government asked for seed money for low-income health insurance, they were told by donors not to waste their time. Using tax money, the government funded a three-year pilot anyway, and 90 percent of Rwandans are now insured.
In these two particular cases, it wasn't that the developing nations failed to appreciate much-needed investment in their health systems. But both acknowledged that it's one thing to be grateful for aid, and another to accept it passively, without questioning its potential to be effective. It's this new culture of questioning, commonly attributed to the signing of the Paris Declaration on Aid Effectiveness in 2005, that is now driving the World Health Organization (WHO) to change the way international aid is delivered. The reform, which now includes close to 60 signatories, is driven by coordination. Donors, be they contributing governments or non-state actors, don't just go into developing countries and start implementing their own programs. Instead, they're asked to contribute to a single health plan, which is managed and implemented by the government receiving the aid. The U.S. officially signed on to the initiative last Tuesday, signalling its commitment to reform.
The initiative, called International Health Partnership, sounds idealistic, but made a certain kind of sense when discussed last week at the World Health Assembly, an annual gathering of the WHO's 194 member states that just wrapped up in Geneva. One of the most surreal aspects of the two weeks of policy talk and resolution making that took place there was the equal footing given, at least theoretically, to each country represented. In the main meeting rooms, nations were organized alphabetically: Ethiopia sat between Estonia and Figi; Rwanda between the Russian Federation and Saint Kitts and Nevis (the smallest sovereign state in the Americas); representatives from all were given the same three minutes in which to say their piece.
This diplomatic equality made it possible for the ministers of health from countries most often on the receiving end of aid -- Rwanda, Ethiopia, Myanmar, and Senegal -- to stand up, at a side meeting attended by about 200 people, and accuse those countries with the money and power to direct international development of undermining their own investments, by failing to allow the countries they claim to be helping to have any say in where the money goes. Or, as they put it, by being "backseat drivers."