A Healthier Approach to Canadian Aid
Despite the Canadian government shutting down CIDA, Prime Minister Stephen Harper has made clear that he strongly supports Canada focusing on maternal and child health worldwide. The need is clear: more than 7 million children and mothers die every year from largely preventable or treatable causes. But what is needed to make an actual difference to the world’s poorest citizens?
A few suggestions. I’ll begin by emphasizing the importance of Canadian taxpayers investing in the health of mothers and children worldwide, even in tough economic times. Not only is this an important investment in its own right, it is a way of achieving better, more stable economies with whom Canada can trade, as well as enabling more secure and stable governments with whom Canada can work. New money, not simply existing aid repackaged, is needed. $400 million per year for five years has been proposed, which is considerable, but it is not that much in macroeconomic terms (equivalent to about a movie and popcorn per Canadian taxpayer) and smaller still compared to the approximately $22 billion allocated to health annually (over half of which is for HIV/AIDS alone) by the international community as a whole.
But simply demanding Canada devote more money to health is not the answer; we must also demand healthier returns from the money we invest. Canada must start doing health aid better, and move beyond what is a less than stellar record by CIDA in health assistance. This will require leading with ideas and innovations. How can we do this?
To start, Canada could be more proactive in asking low-income countries to increase their domestic spending on health and other components of social safety nets, even if they also face deficits. For the poorest countries, Canada should also make the case with the World Bank and others that a larger proportion of their foreign aid should be directed toward building the components of universal health care (not just doctors and hospitals, but also community-based disease control programs). The 2008 global financial crisis presented an opportunity for most governments to re-think major investments in health security as part of each country’s fiscal stimulus. Consider that out of pocket spending on health, mostly in the way of clinical services by the poor, is already about 2% of global GDP. Governments would do well to displace this inefficient spending with public-financed health care, which would enable better quality and coverage. This money could be used more productively as poor households often sock away substantial funds to prepare for health disasters while others descend into poverty from catastrophic health bills. For example, in India more than 35 million people – the entire population of Canada – fall below the poverty line every year from health care costs. Imagine if these funds were made available to India’s economy? Economists often want 'shovel-ready' fiscal stimulus to counter downturns like occurred in 2008. I argue that rapid expansion of health insurance would be one of the best ways to fight poverty, and to grow economies. Sadly, most governments missed this window, largely because publicly-financed universal health care has been inexplicably low on the agenda of Finance Ministers. The important exception was U.S. President Barack Obama, who wisely introduced the Affordable Health Care Act (known widely as Obamacare) as a central pillar of long-term fiscal sanity in the United States.
Canada’s universal health care system is respected around the world. We can use new aid funds to help governments develop technically and financially sound country-led health plans that eventually become universal systems. A publicly financed universal system (delivered via public and private sectors) is affordable, costing perhaps only 5% of GDP (with each country buying as much health care as it can afford, and buying more as economies grow). Besides delivering better health per dollar spent, a universal system can eliminate the unnecessary spending that robs the poor and then forces them into poverty when they fall ill.
Second, Canada would need to focus primarily on the delivery of high impact, cost-effective interventions. For example, safe newborn care, institutional births, low cost treatments for kids who are sick, and vaccines – critical components of viable strategies for maternal and child health. There is ample knowledge that these measures save lives. The most effective tool to do so is via the multilateral institutions, most notably the Global Alliance for Vaccines and Immunizations and the Global Fund for AIDS, Tuberculosis and Malaria. These institutions have a better track record of funding evidence-based strategies than does typical bilateral aid, and also lower overhead costs.
Third, Canada should aim to become the 'steering wheel' of global health. This might involve partnering with the Gates Foundation, which creates new products and methods, and focusing Canadian funds on developing innovative mechanisms to deliver these lifesaving interventions. For example, the Mexican government has developed a policy that pays families to adopt good health care practices. Canada can show leadership by building simple systems to monitor if child and maternal deaths decline following the implementation of new programs (amazingly, such a system has not yet been built for most low and middle-income countries, despite billions spent thus far). A system built by the Registrar-General of India with help from the University of Toronto and St. Michael's Hospital to record who dies, and from what causes, now covers some 1.1 million homes and monitors all the major childhood and adult diseases of India – all at less than $2 per household.
Finally, it matters which institutions rise from the ashes of CIDA. It would be helpful if Canadian foreign aid gave a higher priority to research. Research into what works and what does not is crucial. The spread of this knowledge is probably the most cost-effective and practicable way for Canada to punch above its weight in global health. Canada has done so before, for example, with research that enabled widespread use of bed nets to prevent malaria, now used worldwide. There is huge capacity in Canadian universities to tackle problems of delivery, and the enthusiasm among students for global health is nearly endless. But the government’s current way of working with universities is slow, bureaucratic, and wasteful. It is inefficient for universities to compete with NGOs, who deliver actual services (say set up a clinic to treat childhood pneumonia and diarrhea), but universities have far greater skills at organizing systems and solutions (such as how to set up simple ways to monitor the vaccine delivery system). Imagine what could be accomplished by a 'Grand Challenge' call from the government that asks doctors, nurses, business managers, engineers, and other professionals to partner with CIDA to solve a few tough problems in delivery of health. Additionally, Canada has adopted too narrow a focus on certain countries, mostly in Africa. India, for example, has over 1.5 million child deaths a year, but the Canadian government has become largely irrelevant to this major power. The G-8 and companion G-20 effort might be a chance for Canada to get back into India, with smarter ideas and clearer focus, and make a real difference.
Mr. Harper’s global health initiatives have their critics and cynics. But as we head into an election in 2015, he has a chance – as indeed do all of our political representatives – to debate how Canada can best improve the health of potentially millions of people. It is a chance that should not be ignored, for if properly done, Canadian aid can save lives around the world.