Unfortunately, this just doesn’t really make sense if you’re familiar with the governments in these places, local politics, or more generally how weak states actually work. I see more opinion than evidence. To me, it illustrates the perils of doing research from afar, and ignoring politics.
First, it assumes the thing that’s holding the country back is not enough money for public spending. Places like Liberia and Sierra Leone are actually awash with more outside money than ever before.
More importantly, after decades of war and political instability, the real problem is that they don’t have the people or the public organizations capable of spending more money well, even if they want to. We’re talking about countries that can’t get basic supplies like plastic gloves out of the warehouses by the port and into hospitals. The reason is not too little public money.
If you haven’t worked in a weak state, you have no idea how hard it is to get even basic things done. Trying to run research and programs in Liberia nearly broke me. It takes decades for countries to recover from complete state collapse. Liberia and Sierra Leone have only had about 10 years of real stability. In the meantime, a lot of things we take for granted in other countries, even other poor countries, just do not work.
Second, the Lancet comment assumes the government actually wanted to spend more money on health systems. As it happens, these countries have reasonably good and well-intentioned governments. It could be a lot worse.
Even so, the governments have a dozen priorities that come before health systems. Some of them are reasonable ones (like power supplies and roads) and some are not (lining the pockets of supporters). Health was not top of their lists. And health systems in remote areas of the country wasn’t even in their imagination.
This is exactly the right choice: When you’re three steps removed from war or a coup, and you don’t have a functioning police or justice system, building a fine public health system is not your first investment.
Finally, it assumes the IMF had any real influence over health policy and spending. As one senior adviser to the Liberian government wrote Tuesday, “the IMF has about as much influence over health systems building as the Lancet does over central banking.”
We so easily default to a Western-centric view, where it’s our aid or financial policies that are responsible for the success or failure of poor countries. It’s egoistic and exaggerated, and ignores domestic politics.
In my experience, you don’t see this as much when people write about India or China or Iraq. Too many people know something about these countries, including newspaper and journal editors. As a writer or researcher, you don’t get away with ignoring the context: who makes the decisions, who has what incentives, and what arms of the government can actually get things done.
When it comes to Africa, however, too many people are willing to assume it’s a blank slate, and that nations dance to the tune of Western donors and banks. Or that weak states are functioning, rational bureaucracies. I think this is one reason why so many newspapers are picking up the “IMF caused the Ebola crisis” so uncritically.
Ironically, this is exactly the mistake that the IMF made through much of the 1980s and 1990s. Whether you agree with the actual policies or not, the IMF prescribed reforms assuming they were dealing with governments that could and would implement them. And it backfired.
The Lancet piece, and the global health system in general, is making the same mistake today. This more than anything is what worries me about the global response to Ebola.