There’s a lot of arm twisting going on in international health policy.  It reminds me of the crude sibling games I played with my brothers trying to see who will throw in the towel first……”UNCLE! I give up.”  Attempts at national health reforms under the best of circumstances is quite a challenge but in the uncontrolled political and social environments that often exist in some developing countries, the task is formidable.  Many nations are buffeted from all sides by forces within, without, and a third somewhere in between.

Many of these forces are external, highly organized, and well-funded international well-wishers and well-intended aid agencies and NGO’s as well as opportunistic multi-national companies single-mindedly focused on further increasing their coffers at the expense of hosting nations.  They all come with strings attached:  some are attached to purses that only open with the state’s surrender to the will of the owner of the purse; others are attached to threats of abandonment if one fails to comply.  Few seem to take stock of the medium and long-term impacts of their ‘help,’  while some seem to find their voices in complaining about the ‘cycle of dependency’ of developing countries and the ‘slowness of progress and change’ as if all these happen in a vacuum, away from the active participation of these players.

But hold up!  These nations are not themselves blameless victims, they have their own ‘home-grown’ forces, from the rotund political and entrepreneurial plutocrats who put personal gain above national good or benefit, to the home-inspired NGO’s wielding their limited influence for their own private agendas, failing to see ‘the forest for the trees,’ to even the ‘powerless’ masses who fail to realize their true power and neglect to acquire the greatest of all power: information and knowledge; resigning, instead, to distrust the ‘System’ that IS truly broken and pining for the Western green pastures of ‘marketization’ with its promise of ‘economic freedom’ and ‘tide-riding boats’ to the land of riches.   Look out, there are yet unforeseen icebergs ahead!

Ok, so there’s enough blame to go around…but is it wise or even useful to dwell on such things?  Here’s the reality.  Change is hard but necessary.  It requires sustained effort and HARD WORK and it’s only brought about by you.  Yes, YOU.  What will you need?  Information.  Organization.  A reality check; context, both socially and politically, because you are going to need the help of the players mentioned above: you know, the ‘well-wishers’ and ‘plutocrats’ too.  Learn to schmooze; be politically savvy.  Also, know your stuff; be technically correct, equipped with the evidence you will need to both sell your point and ultimately make your point; accomplishing the reforms you seek.  See?  No, sweat, now get to work!


  1. Reich, MR. (2002) “Reshaping the state from above, from within, from below: implications for public health.”  Social Science and Medicine.  54(11):1669-75.
  2. Glassman, A. (1999) “Political analysis of health reform in the Dominican Republic.”  Health Policy Plan.  23(2):150-60.

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