It is difficult to trace the origin of foreign aid to a certain date or event. Historically countries and empires would donate and support allies in times of need or war to help populations in distress. One of the first foreign aid public health initiatives dates back to 1803 by the Spanish government. Physician Xavier de-Balmis vaccinated large parts of South and Central America, Caribbean, Philippines and China for smallpox (1). Another important historical event was in 1859 when the Swiss businessman, Jean-Henri Dunant, witnessed the Battle of Solferino. Dunant was shocked by the lack of respect for human life and quickly organized a medical aid team which provided non-discriminatory, basic medical care to surviving soldiers (2). Upon return to Geneva, Jean-Henri Dunant was instrumental in discussing health as a human right, which culminated in the creation of International Red Cross Societies in 1864 at the Geneva Convention. World War I prompted the creation of the League of Nations whose mandate was to promote world peace and address basic principles of human rights.
It was not until the atrocities of World War II that the international community responded and created the United Nations system (UN). The UN mandate is to promote international cooperation, ensuring economic, military and environmental stability, and adherence to The Charter of Human Rights (3). UN’s World Health Organization, along with an array of other programs (UNAIDS, UNICEF, UN-Women), advocates for global health. Determinants of health are not solely reliant on access to medical care but are related to the degree of poverty, economic stability, peace, human rights, gender equality, development, water access and education (4). The UN has a plethora of programs, which oversee the non-medical components of public health. Examples include the World Bank Group, International Monetary Fund (IMF), World Trade Organization (WTO) and United Nations Educational Scientific and Cultural Organization (UNESCO) (5). Figure 1.
The initial UN, US and Canadian post-war efforts were geared to rebuilding war torn countries, and infectious disease control (6) (3). Later in the 1960’s, the growing donor community shifted their attention towards Africa, South America and parts of Asia. It was the era in which colonial powers were removing their military dominance in the geographical south, leaving countries stranded with little governmental, economic or health care infrastructure (7). The WHO was the voice for health during the transition from colonial rule. Donations became progressively larger with little transparency. Little attention was paid to equity, sustainability and development (8). By the 1970’s the WHO emphasized that health care accessibility and primary health care goals were not being realized (7). In 1978, The Alma Ata declaration brought the international community together to reiterate the importance of health care accessibility and a goal of “health for all” by the year 2000 (9). Throughout the 1980’s, humanitarian assistance continued to flourish. It is estimated that, by 1980, over a trillion US dollars were donated to Africa (8). In the 1990’s, musicians, actors and influential global figures popularized the idea of foreign aid (8). This increased altruism and the guilt of the geographical north to continue to donate. Large vertical programs were being instituted yet comprehensive, sustainable programs were being undermined. This was further exacerbated by the increasing private-public partnership, which favored policies that had better financial returns, yet again undermining health care at a grass root level (10). During late 1980’s and 1990’s vertical programs focused their attention towards the HIV/AIDS epidemic, arguably diverting attention away from other global health threats (11).UN system chart_11x17_color_2013 (click to enlarge)
By the year 2000, the Alma Ata goals were not realized. The same problems, which existed in Sub-Saharan Africa in 1970, remained a reality. Maternal Mortality Ratio (MMR), access to obstetrical care, Infant Mortality Rate (IMR), access to primary health care and poverty continued to be major issues (7). The international community agreed upon the Millennium Development Goals (MDGs) to improve these shortcomings by 2015. Although many MDGs do not specifically address health care, health determinants are dependant on economic, social, environmental and governmental stability (4). MDGs 4, 5 and 6 target specific health care deficiencies including child mortality, maternal mortality and the fight against HIV/AIDS malaria and other communicable diseases. As we transition into the post-2015 era, varied success with MDG targets are reported. For example, in Uganda, many economic and poverty targets have been realized, however MMR remains high, falling short of 2015 targets; prevalence of HIV/AIDS is increasing; perinatal care remains limited; access to safe surgery and safe cesarean section in the community is restricted (12).
At the turn of the century, the WHO identified Non Communicable Diseases (NCDs) as the largest global health threat (13). NCDs are a conglomerate of diseases that include cardiovascular disease, chronic respiratory disease and cancer. These pathologies share common etiological risk factors that involve behavioral risk factors such as physical inactivity, obesity and smoking (14). It is estimated that NCDs will contribute to 60% of deaths globally, and the WHO predicts that the greatest increase in NCDs will be seen in African countries. For example, the WHO estimates that by 2030 cardiovascular disease will be the leading cause of death globally and 80% of global cardiovascular deaths will occur in LMICs (15). NCDs are mistakenly thought of as diseases of High Income Countries.
In 2010, the WHO identified that the global surgical burden results in over 5 million preventable deaths (10% of deaths globally) and 15% of total Disability Adjusted Life Years (DALYs) (16) (17). Epidemiological data suggest that the burden of surgical disease affects the young, the population that is the economic driving force of a country (18). The WHO advocates that basic surgical services, which include basic trauma care and surgical obstetrical care, are necessary to tackle the Global Burden of Surgical Disease (19). In 2013 Lancet Commission on Global Surgery was created to examine global surgical inequities and provide recommendations to overcome barriers that limit global access to safe surgical services (18).
Some efforts have been made to improve the surgical burden by instituting programs such as the Global Initiative on Emergency and Essential Surgical Care (GIESSC) and the Essential Surgical Care toolkit (20). As we transition to the post 2015 era, it has become evident that essential surgical services and NCDs are major public health threats (14). The end result is a large surgical burden in a patient population with advanced medical comorbidities (18).