‘Pathologies of power’ and its current influence on the state of Health Governance- the old and the new…..

I took a portion of the title of my blog from Dr. Paul Farmer’s book ‘Pathologies of Power – Health, Human Rights, and the New War on the Poor’- I found it to be apt for our current topic on ‘Health Care Governance’ and the reading material in this section that introduces us to the ‘shifts in power’ from well known organizations such as WHO to many new agencies that are often funded by private donors.

From time immemorial it’s been seen that as long as there remain weak and vulnerable individuals there will also be people driven by either power or greed or both that will subjugate the less fortunate. Although, I do not disagree with the paper ‘The New Colonialists ‘ by Cohen, Figueroa and Khanna that over-involvement of foreign aid agencies may precipitate ‘over-dependence’ and give already weak governments and political leaders ‘a way out’ of their responsibilities in not allowing them to foster self- dependence, I would like to take a more pragmatic approach. The question that begs to be asked is that if there was no availability of external help or if it was withdrawn from outside aid agencies would these ‘weak, dependant’ governments then wake up and try to reform themselves?. Or, have they merely become lazy and gotten used to the outside help that sustains the health in their states? It is well known that weak governments are often run by leaders who obtained their leadership either through family inheritance or through corrupt politics. Even if the leaders are competent and honest, the current burden of change in a state may be so huge that there is no quick solution to fix it. A competent leader may assign a significant health budget for his/her state, but does it and will it actually filter down to the poor and needy or line the pockets of corrupt officials in the chain?

My personal view is that social change is very slow to take place, inherent culture and attitudes are modifiable but more often than not difficult to change particularly so in societies where they have been ingrained into the human psyche over centuries. Many individuals from the weaker sections of society accept their circumstances as their ‘lot in life’ and do not want to raise their voices for change. Gradual education and economic development of a state (notwithstanding the religious and societal norms) enables the common man /woman to speak out and stand up for themselves against their weak governments/leaders and to bring in new leaders that are not corrupt. Simply criticizing the ‘good-will’ that is being attempted by international aid agencies as ‘over-involvement’ and thus not allowing them to play whatever role they may be currently playing in the international health arena ( ideal or maybe not so ideal) may be too simplistic and premature. Premature withdrawal of help will only take away from the poor, the diseased and those whose countries/states are in crisis/conflict. There are always bound to be individuals even in the aid agencies that may take their roles as an opportunity for political clout with the local governments- that remains person dependant. But, for the most part international aid workers have helped countries in crisis or in dealing with pressing health issues. They have often responded faster than organizations like the WHO – This was pointed out by Dr. Bloom in the case of the cholera outbreak in Haiti last year. A dose of internal politics, power struggle exists in every institution across the world- why not within foreign aid agencies? All institutions need external auditing once in a while and accountability to weed out the demon of corruption!

I believe the emergence of a myriad of foreign aid agencies in the recent past was inevitable as a dynamics of our changing times. After the world took an initial stance in creating authoritative bodies such as WHO, UNICEF etc there was bound to be a change, a shift in “power” as natural as the progression of time. Few large institutions can withstand a natural decay over time and the ‘creeping in’ of bureaucracy. I agree with Dr. Bloom that the WHO ‘needs change’ and his three suggestions of more ‘inclusiveness’, ‘more transparency’ and ‘external auditing and review’ are well taken. The WHO remains the best known health authority and its central role in providing the most recent epidemiological and practice data and guidelines for health care providers across the world cannot be undermined and this role should remain its primary one.

I agree with D. Sridhar (Lancet, 2008) that more transparency and accountability of disbursements of funds to local governments is a good strategy to inform local authorities about where they must place their health priorities and keep track of the flow of money in their state. However the author’s personal belief that ‘ BMGF’s’ role in allocating more funding for research and vaccines in Northern America/Europe as opposed to the ‘World Bank’ allocating funds for water, sanitation, roads, injury prevention , non-communicable disease is not necessarily correct. The superiority of one organization’s stance over its priorities versus the other is arbitrary. If BMGF wants to put their funding into creating new vaccines or new drugs that potentially in the long run may save millions of lives that should be viewed as its prerogative. An establishment of a centralized database by each organization that is available for all to see as far as its disbursement of funds should be adopted as usual policy.

-Dr. Shipra Kaicker


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