Learning from low income countries: what are the lessons?

Editor—Berwick's editorial on the lessons from developing nations on improving health care mistakenly abstracts improvement efforts from the complex context of poverty and inequality.¹ Improvement is “an inborn human endeavour,” yet an under-nourished or sick child who wants to “jump higher or run faster” cannot do so unless basic needs are met first.¹ In Peru we learnt that notable improvement can occur, even in resource constrained settings. But it takes more than goodwill. Aims, teamwork, and ability to do more with less and handle the political interface are important but insufficient. Consequently, some of the lessons mentioned should be read with caution. What may be waste in wealthy settings may not be so for impoverished ones.

“Dependency is waste.” This is not always true. Sometimes, reliance on donor funds may be the only means of providing or improving health care for poor people. Wealthier nations and organisations providing technical assistance should also help find new resources and help pursue technical and financial self-sufficiency.

“Complaint is waste.” This is not always true. Had we not complained in 1996, when multidrug resistant tuberculosis was considered “too expensive” to treat in poor settings, we could not have started treating the first of more than 2000 patients in Peru. Had we not complained, we would not have secured concessional prices on required drugs (reduced by 90% compared with 1996 prices). Had we not requested external financial support, today Peru could not provide free treatment for all patients with tuberculosis and multidrug resistant tuberculosis: it would be paying its external debt first.

Improving health care in developing countries cannot rely solely on local strengths. It requires that leaders, advisers, and donors become engaged in discovering and alleviating the structural constraints of poverty. Perhaps then, every child will have the opportunity to succeed in the intent to run farther and keep running.