Historically, foreign aid projects have long been criticized for creating dependency, prompting some critics to argue that normative foreign aid should be rejected by African recipients altogether for the seemingly inevitable outcomes of increased corruption and dependency.
As more than 80% of the Malagasy health care system is supported by a myriad of foreign aid donors and INGOs, Madagascar provides an ideal context to assess whether self-sufficiency is being fostered by foreign aid interventions.
Where most Euro-American health aid in African contexts tends to focus on the treatment of specific communicable diseases, such as HIV, malaria, and TB, China’s health aid more broadly develops infrastructure (the building of hospitals and clinics) and provides medical resources (equipment and pharmaceuticals), as well as human resources (via medical teams assigned to a specific hospital or clinic for two year periods).
In order to foster self-sufficiency and reduce dependency, China’s health aid would need to foster recipient resource development, yet Chinese aid can inadvertently undermine such local resource development in several ways.
Embedded Dependence on Infrastructure and Medical Resources
In 2015, China built a new hospital in rural Madagascar (below). This development would appear to foster self-sufficiency except for two issues: An agreement was made with the Malagasy government that all medical equipment in the hospital, which came from China, would need to be replaced with Chinese equipment. Furthermore, all instructions for the equipment were in Chinese.
Therefore, rather than teaching Malagasy workers how to use the equipment, or find ways to translate instructions, it became necessary to maintain Chinese nationals for the management and maintenance of this medical equipment on site. When queried, hospital officials could not explain the rationale for not fostering Malagasy management of the hospital equipment.
Pharmaceuticals and The Malagasy Marketplace
For a period, Chinese medical teams provided Chinese pharmaceuticals to their patients at no cost. As more Malagasy patients learned of this, Chinese drugs began to be favored over commonly available drugs, predominantly imported from India and France. There has been no attempt by China, in its 40+ year health aid history in Madagascar, to help develop local pharmaceutical manufacturing.
Thereby, rather than fostering the domestic sales of drugs, or the development of local Malagasy products, Chinese drugs began to compete with commonly available drugs, driving their value down. This resulted in the Malagasy government placing a heavy import tax on Chinese drugs, forcing the Chinese to charge a fee for their drugs that was more in line with the cost of Malagasy drugs. Hence, similar to the issue of the need to replace the equipment in Chinese hospitals with Chinese equipment, without the Malagasy added tax, favoritism toward Chinese pharmaceuticals might have shifted Madagascar’s trade with other countries; resulting in an overreliance or dependence on Chinese pharmaceuticals.
Dependence on Chinese Medical Teams
Similarly, Chinese medical teams have been working in the same Malagasy hospitals since 1975. According to Malagasy government officials, there has been no training by the Chinese health workers for Malagasy health workers in these hospitals or anywhere in Madagascar. In general, the Chinese medical teams had few interactions with Malagasy health workers.
Furthermore, Chinese teams go to hospitals where local doctors prefer not to go. Thereby, Malagasy officials are never incentivized to resolve the lack of Malagasy physicians for these rural facilities and are now completely dependent upon the Chinese health teams to continue to serve these areas year after year.
Bypassing Opportunities to Strengthen Local Healthcare Self-sufficiency
As in their home country, working with Malagasy civil society is not prioritized by Chinese medical teams and rarely, if ever, done. Local NGOs working with alcohol and drug addiction and maternal child health report that they were unsuccessful in their repeated attempts to collaborate with China donors.
More problematic is China’s prioritization of working with the Malagasy Ministry of Foreign Affairs on health projects, thereby bypassing a significant opportunity to benefit and help strengthen the Ministry of Health. However, few, if any, state or private foreign donors in Madagascar appeared to coordinate their health projects through the Ministry of Health.
Unlike many of the Euro-American donors who rationalized that the Ministry of Health was considered too corrupt to work with, the Chinese officials reported that all aid work was conducted through the Ministry of Foreign Affairs regardless of the recipient country or aid sector.
A Way Forward
In order to engender the development of a more sustainable and self-sufficient health care system in Madagascar the following considerations are recommended:
- fostering Malagasy management of Chinese-built hospitals and medical equipment;
- supporting the development of local pharmaceutical manufacturing that would lower the cost of pharmaceuticals in Madagascar;
- training of local human health care resources that can replace Chinese medical teams;
- working with the Ministry of Health and with civil society to ultimately strengthen Malagasy health care.
Although Sino-Malagasy health aid does not appear to have fostered a self-sufficient health care system independent of aid from China, a better way forward is evident.
Paul Kadetz is an associate of the China Centre for Health and Humanity at University College London.