Dr.

Wutich Global Health and International Development

Slide 1
Hi, This is Professor Amber Wutich. This module is about the global health and international
development. International development is a field that offers great promise for making
advances in global health, but it also holds some pitfalls both for communities that become
dependent on foreign aid and for development practitioners who find that designing successful
projects is more difficult than it seems.

Slide 2
International development is dedicated to improving living conditions for impoverished people
and communities, most often in poor countries. There are many different approaches to global
health in international development, including social, political, and economic strategies. Social
strategies include providing education and training, building and staffing hospitals, and
providing medicines. Political strategies include building democracy, improving governance, and
weeding out corruption to ensure that public investments in the health sector actual reach the
people who need them. Economic strategies include investments in the “social safety net”,
incentivizing improvements in the health sector (such as vaccine development), and supporting
economic growth such as through microfinance and small business development. All of these
strategies—alone or in combination together—have the capacity to improve global health.

Slide 3
Global health practitioners in the field of international development have made many
important accomplishments. For instance, the US Centers for Disease Control issued a list of the
top global health achievements at the start of the 21st century. These achievements included
reductions in child mortality, increased availability of water and sanitation infrastructure, the
development and use of vaccines for infectious diseases, the prevention and control of
infectious diseases like malaria, tuberculosis, and HIV/AIDS, plus enhanced pandemic and
disaster preparedness. From the years 2000 to 2010 alone, “average life expectancy at birth in
low-income countries from 55 to 57 years, and in high-income countries from 78 to 80 years”.

These impressive gains are the result of work done by local communities, national
governments, and international development agencies. Examples of these agencies include
intergovernmental organizations such as the World Health Organization and United Nations,
non-governmental agencies like CARE USA or the Red Cross, foundations like the Bill & Melina
Gates Foundation and the Ford Foundation, and even agencies of the US Government such as
the Agency for International Development or the Department of State. These achievements
give us powerful proof that international development has an important role to play in
improving global health.

Slide 4
For all the good that international development has done, many—including some of its
intended beneficiaries—have raised serious questions about its legitimacy and long-term
impact (Moyo 2009, Rieff 2003, Harrell-Bond 1986). One major issue is that international
development can be deeply anti-democratic. Instead of being run by local elected officials,
development projects are often headed up by foreign professionals who are paid and evaluated
by foreign governments or donors. Because of this, even well-intentioned outsiders may be
dangerously ignorant about the causes of local problems and how to create real, lasting
solutions. Even worse, sometimes such outsiders are not well-intentioned—they may have a
vested economic interest in creating new markets and consumers—rather than solving local
problems. And there are no “recall elections” when locals are displeased with project leaders’
performance.

Another set of problems is that—rather than being a rising tide that lifts all boats–development
initiatives can actually deepen existing inequities. Oftentimes, project beneficiaries are required
to make investments or borrow funds in order to secure international funding. In some
countries—such as Ethiopia and Gambia–up to 97% of the government’s budget is derived from
foreign aid (Moro 2009). Sometimes this can be a good investment, but it can also leave
impoverished communities indebted and worse off than before. Also, in some countries the
non-governmental sector is better-funded and more powerful than the governmental sector
(Easterly 2006). This means that, instead of serving their countries, the most skilled local
professionals are hired away by outside agencies. Also, it becomes less likely that energy,
money, social capital, and creative solutions will be developed through home-grown initiatives.
Instead of learning to solve their own problems, these communities may become laboratories
for foreign researchers and training grounds for idealistic but inexpert young international
students.

Slide 5
Beyond the big picture critiques of international development, it’s also important to understand
how hard it is to get the little picture right – and when I say little picture, I mean even the
smallest-scale projects, in tiny villages, with just a few hundred dollars of funding. In fact,
development professionals—usually well-educated and well-meaning people from wealthy
countries traveling to poorer communities that they may not understand as well as they
should—have made so many errors that there is a website called “Admitting Failure” was
designed to help them catalogue and prevent their missteps.

Take the example posted by the head of one organization that works in Cambodia. Like many
agencies, they try to help poor communities develop small businesses that will generate income
to eventually be invested in healthcare, education, and other social programs. In the past, they
had successfully supported a community mushroom growing initiative, and attempted to do
reproduce this project in another village. Unfortunately they made many errors. First, they tried
to reproduce a successful project from one village to another, without first studying local
conditions. Second, they failed to provide local oversight of the project. Third, they did not ask
community members to invest any of their own funds, so the project beneficiaries had little
stake in ensuring the project’s success. As a result, they ended up investing in training and
equipment that was not appropriate for the community’s needs. By the end of the project, they
had purchased equipment and sent community members to a training for mushroom spore
growing equipment that required electricity—in a village that had no electrical power!

These kinds of errors—and others that emerge from development practitioners’

misunderstandings about local cultural, political, and economic conditions or wrong ideas about
how to fix social problems—are all too common in international development. There are
countless examples of training, equipment, and infrastructure that go unused because it wasn’t
really what people needed. And they mean that fixing problems in global health is far more
complex than building a hospital or a water system.

Slide 6
The good news is that international development practitioners have developed a number of
approaches for dealing with and overcoming the challenges inherent in global health—
challenges like fostering local social capital, being democratic, being culturally appropriate, and
designing projects that address real needs. And the answer is always community participation.
In this lecture, I’ll briefly discuss four models used to successfully cultivate community
involvement in development projects.

Slide 7
First, the community involvement model involves the active solicitation of community ideas and
feedback for a development project. In the case of a tuberculosis control project in low-income
countries, Hadley and Maher (2000) found that community members can play an important
role by urging “tuberculosis suspects to come forward for treatment”, encouraging
“established tuberculosis patients to continue treatment”, and consulting on how to ensure
that “treatment is accessible” both physically and financially to those who need it. In this case,
authorities identified a need for a TB program and provided funding and treatment, but
community members provided informal support to ensure the projects were a success. While
community involvement projects are typically conceptualized and executed by outside
agencies, consultation with project beneficiaries is used to ensure that projects are culturally-
sensitive and locally appropriate.

Slide 8
In participatory development, local communities are much more deeply involved in identifying
a problem, conceptualizing possible solutions, and actually carrying out the project itself.
International development professionals are typically responsible for facilitating community
involvement and providing technical assistance. For example, Christopher et al. (2005) reported
on a cervical health project conducted in the Apsaalooke Nation, located in Montana.
Apsaalooke women participated in a participatory development project designed to create
educational materials on cervical health. Women in four communities studied existing cervical
health materials and made suggestions for how they could be adapted to meet their needs and
concerns. Then, the health professionals working with the women used their own technical
skills to produce a new cervical health brochure. Since community members are responsible for
identifying key problems and proposing a solution, it is much less likely that a participatory
development project will encounter the pitfalls associated with outsiders designing and
executing projects.

Slide 9
A community-based development model is designed, through consultation with a community,
to ensure that a project is tailor-made to deal with local needs. In New Zealand’s Maori
communities, a long history of colonization and mistreatment has made people mistrustful of
outsiders. As Voyle et al. (1999) explained, health workers in New Zealand understood that a
successful health intervention had to be empowering, community-driven, and supportive of
Maori self-determination. In this case, health workers began by establishing a partnership
committee to oversee their work, appointing a community-based liaison worker to facilitate
program development, and ultimately set up health groups and programs that were taken over
and run by the Maori themselves.

Slide 10
In some cases, communities have their own long-standing healthcare traditions, knowledge,
and social systems. In such situations, projects and programs imposed by outsiders may be
more disruptive than they are helpful. Kelm (2004) discusses such a case in the Nisga'a Nation
of Northwestern British Columbia. Rather than relying on services provided by the Canadian
government, the Nisga'a have been “pioneers in the area of obtaining administrative control
over health services”. Through treaties with the local government, the Nisga'a were able to
arrange the transfer of government resources to autonomous Nisga'a control. Primary medical
care in the Nisga'a Nation is now deeply integrated with the local leadership and social
structure and with Nisga'a cultural values.

Slide 11
While global health excels in identifying global problems, there are in truth no global solutions.
In many cases, international development agencies can contribute funding, materials, and
expertise to confront global health challenges. But international development practitioners
must overcome many challenges associated with identifying the local causes of health
problems, the social and cultural acceptability of proposed solutions, and the long-term
capacity for programs and projects to be maintained. None of the challenges associated with
creating local solutions can be overcome without the active participation of local communities
and project beneficiaries.