When International Aid hurts more than it helps

Operating Theater

by Jayson Marwaha

There’s a special corner of the Major Operating Theatre corridor in Sea View Hospital (real name not disclosed due to confidentiality agreement), a 400-bed government facility in East Africa, reserved for unopened boxes of donated medical materials. Every few days, wooden crates labeled with the names of Chinese or Italian shipping companies are put there until doctors find time to crack them open.

In that corner a few years ago sat two anesthesia machines from Europe. Today those two machines sit just one room over, in the same department, having never been used since their arrival. Why? While most anesthesia machines require only an oxygen input to function, these two need an oxygen and a compressed air input. For that you need an air compression machine, and Sea View has none.

Ask anyone in that department, “You know exactly what you need — so what are you waiting for?”

“Someone to donate an air compression machine,” they’ll tell you.

The story is no different two floors down, in the Maternity Operating Theatre. Two months ago, you’d have found doctors scooping bodily fluids out of patients with a kidney dish, because none of the suction machines in that room were working. A few weeks ago, MED International engineers from the U.S. were able to fix both broken suction machines with a $2 capacitor, some glue, and two hours. Yet the hospital administration’s solution was to seek donations of new suction machines, rather than to invest in a technician team for these kinds of quick, cheap fixes.

The Problem

In Sea View Hospital and health care systems across the developing world, there is a systems-level dependency on international aid for virtually everything related to medical equipment. In fact, at Sea View Hospital, dependency seems like a part of standard operating procedure — few necessary medical purchases are made without a foreign donor. For years, the government that owns Sea View Hospital has had no impetus to invest in equipment maintenance because a foreign aid agency has been doing it for them. The government’s procurement process is plagued with bureaucratic speed bumps because there’s no pressure to refine the system — buying new equipment takes ages because that job is so often covered by donors.

It’s been more than three months since the only X-ray machine in one of the government’s districts broke down, and the report has been sitting at the Ministerial level ever since. It’ll be at least a few more months before a new one is bought.

What Needs to Happen

This is clearly the government’s fault, right? Not exactly. For the government, waiting for foreign donors to provide medical equipment makes the most financial sense. Why buy and fix your own hospital equipment when an aid agency has already decided to fund those things for you for the next five years? Why fund the training of more local specialists when other countries send volunteer surgeons every month? Why invest in anything related to health, education, or infrastructure when the likelihood of someone else doing that for you is so high? The problem lies with the donor: Traditional humanitarian aid reduces government accountability, which, in turn, reduces a government’s pressure to perform.

The solution also lies with the donor. International aid powerhouses — on the scale of USAID and UNICEF — need to redefine what it means to provide aid. The wrong kind of aid is one without which everything would fall apart. The right kind of aid is focused on building in-house capacity for repairing medical equipment, hiring teachers, and constructing power grids — so the country still benefits even after you’ve left. In just a couple of years, this East African government’s foreign supporter of medical equipment maintenance will be pulling out, after having created a systemic dependency on their money by funding sunk costs like technician salaries. If they leave the government with a budget that doesn’t account for those salaries, spare parts, service contracts, and more, their stay will have been more of a disservice than an aid mission.

Last week, my colleague and I sat down with a Ministry of Health official to map out the timetable for MED International’s intervention, which focuses on building in-house capacity for equipment maintenance. To express his gratitude, he told us that he “hoped MED International could stay for many years to come.” But I wish he had expressed it differently. “Finish your intervention and get out — you’ll have no more business here once it’s over,” I would’ve preferred to hear. “Because by then, we’ll be able to do it all on our own.”

Jayson Marwaha is the founder and co-executive director of MED International, a nonprofit that designs, implements, and advises governments on medical equipment interventions.  


photo of the Operating Theatre by Jayson Marwaha