One of my current research areas focuses on the effect of health development assistance on health systems and health in developing countries. There have been a number of other scholars who have looked at the question of whether or not donor priorities “match” disease priorities in developing countries. I have blogged about them before, including the work of Devi Sridhar, Jeremy Shiffman, and others.

In JAMA this week, there is another related editorial on this topic. In this piece, the authors argue not that there is a mismatch between donor priorities and disease burden, but make a different point. Rather they argue that HIV/AIDS treatment programs are much less cost-effective than other programs that do not receive nearly as much attention from donors. They argue that the US government could be achieving much more health if they were to focus on better buys, in particular by focusing on maternal and child health programs.

While I agree with the point the authors make, I want to argue that even this type of thinking misses the point. I think any attempt to tackle poor health in developing countries must take a systems view. The assumptions that have been made to come up with calculations for cost-effectiveness rarely take into consideration whether or not the resources are available to scale up the programs. What might be true in a few studies is rarely true at the national level.

Investments into education, training, sustainable financing that creates incentives for quality care, and infrastructure is what is needed to build health systems. It is not sexy stuff, plus it will take years before this type of approach will generate results, but it is what is going to be needed if real improvements in health are our goal.

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