Kim Bonner, MPA
We sat on the dusty porch and exchanged self-congratulations as people trickled in, signed up to receive the bed nets, and returned home. This was my second national bed net distribution drive in Tanzania and I was ever vigilant to make sure it ran as smoothly as possible. All was going well on the final day of our pilot run, and after two hours watching others put the finishing touches on our successful campaign, I strolled around the back of the medical clinic dispensary, where a smattering of village residents had gathered, but not to pick up their free bed nets.
There were two rows of women stretched around the perimeter of the porch. Awkwardly trying to be friendly, I greeted the older woman nearest me and asked her why there was such a crowd on the dispensary porch. Her neighbor leaned in and told me that this woman’s daughter had lost so much blood in labor that after delivering the baby that she had collapsed. She was lying inside the dispensary, still bleeding.
“But,” I sputtered, “Why isn’t anything being done? Why don’t they just give her stitches?”
The woman leaned in again. “They don’t have anything here. No medicine. No needles. Nothing to stitch. The clinic worker called the district hospital for an ambulance almost two hours ago, and it still hasn’t arrived.”
Horrified, I thought of the NGO’s landcruiser that had been sitting out front the dispensary the entire time. We moved the car around back just as the ambulance arrived. Heavily supported by her mother and the clinic worker, the woman climbed in the car. It was the last we saw of her.
To this day, I have no idea of this woman’s fate. I hope that she survived, that she’s enjoying watching her child take his or her first few steps right about now.
What stays with me is the nagging feeling that many crucial areas in health are being overlooked. While I am happy to report that many more people have bed nets, I can’t say how many dispensaries have a full supply of medicines at any given time.
In a world where donor governments are willing to give billions to the highest profile diseases, there is no reason for logistics and procurement maintenance to be neglected. The interplay of conditional aid and decision-making in cash-strapped governments can create perverse incentives to neglect lower profile components of the health system. Foreign assistance for health has been associated with a consequent decrease in government expenditure for health, ranging from a $0.43 to a $1.14 decrease per $1.00 received. 
Much of this foreign assistance is earmarked for certain high-profile diseases. The Global Fund alone has granted $22 billion for HIV/AIDS, tuberculosis, and malaria since its inception in 2002.  Consequentially, countries that displace domestic health funding with foreign assistance encounter restrictions on how much of their budgets can be used to support the mundane, but crucial, task of running a health system.
While there has been a shifting focus towards strengthening health systems in general, a demonstrated national and global commitment towards the lower-profile health activities is yet to be shown.  Fortunately, increasingly donor governments are shifting to health basket funding, where unrestricted aid is contributed directly to ministries of health. While this system faces challenges in accountability and timely disbursal of funds, it enables governments to spend funding in accordance with their priorities. While these priorities don’t necessarily make for photos as lovely as our bed nets, they are just as necessary for improving the quality of healthcare in Tanzania and around the world.
 95% confidence interval. Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ. “Public financing of health in developing countries: a cross-national systematic analysis,” Lancet (375: 9723), 17 Apr 2010, pp. 1375-87.
 The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. Grant Portfolio. http://www.theglobalfund.org/en/
 Waddington C. “Does earmarked donor funding make it more or less likely that developing countries will allocate their resources towards programmes that yield the greatest health benefits?” Bulletin of the World Health Organization.