The author, Josh Ruxin, a professor at the Mailman School of Public Health at Columbia University, draws on his experience working in Rwanda to argue that international donors should shift their focus from drug and service provision to efforts to strengthen entire public health systems.  There is little point, he argues, to providing drugs if health care systems are not capable of distributing them to local clinics and staff are not able to manage and administer them properly.  In Sierra Leone, many major donors have already begun to shift focus.  With the finalization of the Government of Sierra Leone's Reproductive and Child Health Strategic Plan, for example, donors like Irish Aid and the European Commission are focusing their new calls for proposals on projects that work with bodies like the District Health Management Teams (DHMT) and District Hospital administration to improve management of maternal and child health services.  In my experience, this focus is crucial.  If the DHMT does not monitor drug distribution and consumption properly, for example, it is much easier for drugs to be stolen or administered incorrectly.  Additionally, in many parts of Sierra Leone there is little monitoring of health services so gaps in service provision are not identified and quality controls do not exist. 

At the same time, Ruxin's article makes it sound easy to reform these management systems.  His examples include a new manager whose energy and willingness to fire corrupt employees turned around a hospital in Rwanda and a McKinsey senior consultant who expanded AIDS testing services from two clinics to 65 in the course of a year.  It seems that all you need are the right people, with the right skills and attitudes, and everything will work out.  But what happens to that great hospital manager when his/her staff have not been paid in months and thus refuse to come to work?  What happens when donors withdraw their funding and suddenly the manager is no longer paid either?  What happens when a government refuses to supply equipment for AIDS testing and donors are no longer available to pay for it? 

These situations crop up in Sierra Leone everyday.  I have seen health programs struggle to get DHMT staff into one room on a regular basis to plan their activities and financial reports because staff know they are not going to be paid, that they don't have money to buy fuel for vehicles to conduct monitoring trips, and that they have run out of drugs to distribute to health clinics.  In Sierra Leone, the health system lacks both management capacity and inputs, like drugs, to manage.  The problem, then, goes all the way to government structures that do not provide necessary support and inputs, often because these ministries and departments are corrupt and/or mismanaged themselves.  Unfortunately, reforming the perverse incentives at the government level will take a lot more than a few McKinsey consultants.

Ruxin is absolutely right that health systems must be reformed and that a focus on good management is essential.  However, the task is going to be a lot harder than his article suggests.  Additionally, donors and the public must realize that focusing on systems and structures does not mean that support is no longer needed to provide inputs such as drugs and medical supplies.  In Sierra Leone, the government still needs assistance to purchase drugs.  Sierra Leone has some of the highest rates of maternal and child death in the world and if donors do not continue to provide assistance with drugs many people will die.  It's as simple as that.  Anyone who has worked in development knows that donor-driven service provision is not sustainable.  But for now, as we move toward tackling larger systematic and management problems, we also can't forget the importance of direct service provision and even small-scale community interventions that also play a vital role in saving lives.