The transforming power of global aid on health care—and care giving

In a new book, anthropologist Ramah McKay examines the entanglements that arise when foreign money pours into the health care system of a developing nation

In the introduction to her book, “Medicine in the Meantime,” Ramah McKay describes two disparate—yet adjacent—portions of a public health center in Maputu, Mozambique. In one section of the clinic, a fresh coat of paint tries but fails to conceal an aging infrastructure. In the other, cheery décor, slick facilities, and a television tuned to the Cartoon Network made for an entirely different first impression.

The dichotomy of the two clinic spaces hammers home one of McKay’s key findings, that so-called “global health” can mean vastly different things in different contexts, and often results in inequity. Trained as an anthropologist, McKay, now an assistant professor in the University of Pennsylvania’s Department of History and Sociology of Science in the School of Arts and Sciences, examined what happens to health care workers, as well as recipients of their care, when foreign aid constitutes a substantial portion of a country’s health care budget.

Ramah McKay

Mozambique, where close to half of the national health care budget comes from foreign donors or organizations, makes for an apt case study. Located along the coast of southeastern Africa, the former Portuguese colony was caught in warfare for nearly two decades following its 1975 independence. In the 1980s and early 1990s, Mozambique took out loans from the International Monetary Fund and World Bank to build up its infrastructure, with the stipulation that the country cut public spending. The result was a reduction in public health services.

In the meantime, the country was hard hit by the HIV epidemic. Malaria also imposed a burden. And around the same time, global health organizations grew in number and financial strength, allowing aid to flow into developing nations.

As McKay points out, however, that flow of dollars has typically gone to specific diseases. Rarely is it directed to support existing health care infrastructure, or to treat chronic diseases such as diabetes or complex conditions such as cancer.

“Global health has originated around communicable, infectious disease and is only now expanding to think more robustly about what kinds of health should be considered ‘global health,’” says McKay. 

While HIV and malaria can theoretically be managed pharmaceutically, enabling broad-scale interventions, the same cannot be said of cancer, diabetes, or mental health, which typically required more nuanced and individualized approaches. And even treating HIV and malaria are best done in a more comprehensive way than simply distributing pills. 

“We have prescriptions of malaria medications without malaria diagnostic technologies, and we have HIV treatment without the technology in place to measure someone’s viral load,” she says.

McKay has conducted research in Mozambique since 2006. For her book, she spent two years at several public health clinics in both Maputo and more rural areas, studying and following two global health non-governmental organizations (NGOs). She interacted both with the organizations’ workers and patients.

“One of the things I ended up focusing on in my book is how mid-level health workers navigated the changing resource landscape that arose following the influx of global aid dollars,” McKay says. “There were relatively few doctors compared to the demand for medical care, so people like nurses and health technicians were very much on the front lines in terms of mediating between patients and new protocols for caregiving, new agendas for caregiving.”

McKay's book delves into the complications that arise when foreign aid constitutes a significant fraction of a country's health care budget. (Image: Duke University Press)

One phenomenon that McKay observed was that some of these mid-level health workers applied their own morals when offering assistance. They would bend the aid organizations’ rules to give care to those they considered “worthy” patients. 

“Health workers were making these kinds of moral distinctions on the ground,” McKay says. “Someone might say ‘That woman is married so her children don’t technically count as orphans, but I know her husband doesn’t contribute to the family so I’m going to support her,’ or, ‘Technically this person qualified for food supplementation, but I actually think their family has more money than this other person who doesn’t diagnostically qualify but who I think needs that kind of support.’”

Like a game of Telephone, the message and mission of global health aid may change as it passes from a U.S.-based global aid organization through in-country staff and finally to the patients. McKay notes that this raises the question of whether it would be better to keep health care within the country, eliminating the role of international NGOs altogether. 

“That might be an ideal,” says McKay, “but my feeling is if we had no international aid, there are people who are getting medications right now who would not get them and would die, so that’s not a helpful binary to set up.”

For the people who are working on the ground, many of whom are aware of the critiques of international aid, NGOs provide vital support. “What these workers are asking for is not necessarily that the NGOs leave,” McKay says, “it’s that there will be a more morally accountable system of delivering aid, a system that is more sustainable, that doesn’t come in these dramatic influxes of resources and then rapid curtailments. That is really what we should be working for.”

McKay has noticed aid organizations moving in this direction, especially in the wake of the 2014 Ebola epidemic, which made visible the lack of health care infrastructure in many African countries. Instead of aid being earmarked for one disease, for example, more often it may purchase diagnostic equipment or other infrastructure that can be used for many different conditions.

Meanwhile, though funding for global health soared from the 1990s until the early 2010s, recent years have seen funding levels plateau. McKay is keeping an eye on what this means for medicine in developing nations, and how the relationships between funders, caregivers, and patients will continue to adapt and change. 

“Is the private sector going to step in? Is it going to be health care only for the elite who can fly to other countries to access it?” she says. “That’s one set of issues I’m thinking about.”