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A. Reframing the Approach to Development Assistance Currently, international development assistance is often driven by emotional, high visibility events such as large-scale natural disasters, diseases that capture the public’s imagination, or diseases with the potential for rapid global transmission. These funding streams, however, skew priorities, and divert resources from building stable local systems to meet everyday health needs. A relatively small number of wealthy donors currently wield considerable influence in setting the global health agenda. Although well meaning, this small group of wealthy countries and philanthropists often sets priorities that do not reflect local needs and preferences. Sometimes donors exert control over the use of funds that discourages local leaders from taking ownership. For example, the Bush Administration’s insistence on abstinence, fidelity, and faith-based programs undermines effective HIV prevention. Similarly, development banks have encouraged or required poor countries to “cap” internal spending on health as a condition of loans or debt relief. Donors often fund politically popular projects, rather than what is most likely to improve global health, leading experts to conclude, “Funding is skewed towards what people in the West want to deliver.”   International health assistance, moreover, is fragmented and uncoordinated. Relief agencies and NGOs often establish programs that compete with each other and, still worse, compete with local government and businesses. Rather than integrating policies and programs within local hospitals, clinics, and health agencies, they set up state-of-the art facilities that overshadow and detract from governmental and private enterprises. Foreign philanthropists can offer salaries and amenities that are far more generous than those that can be offered locally. As a result, local innovation and entrepreneurship are stifled; talented individuals in business, health care, and community development migrate to foreign-run programs; and the local health industry cannot profit or easily survive. Many humanitarian initiatives also set narrow, short-term goals that do not improve basic infrastructure and create sustainable systems. Donors want quick, observable, and quantifiable results. By focusing so narrowly, often donors fail to see the long-term benefits of building human resources and sustainable health systems. Finally, and perhaps most importantly, the massive infusion of humanitarian assistance into a very poor countries can lead to reliance and dependency. If charity is the main vehicle for health improvement, it means that local government and businesses lose the desire and ability to solve problems on their own. One day, the foreign cash, clinics, medicines, and aid workers will leave. And when that happens, the least healthy will be no better off, and perhaps worse off, unless they gain the capacity to meet their own basic health needs. It is important to stress that host countries also bear responsibility for the failure of international development assistance. Many poor countries spend a minute percentage of their GDP on health, preferring to spend on the military or other perceived needs. At the same time, some governments misappropriate foreign health assistance, whether by excessive bureaucracy, incompetence, or corruption. The World Bank estimates that roughly half of all foreign health funds in sub-Saharan Africa do not go for health services on the ground, but are spent on payments for non-existent services, counterfeit drugs, equipment diverted to the black market, or bribes.