Projectitis? Supporting health reform

BMJ 2005; 331 doi: (Published 21 July 2005) Cite this as: BMJ 2005;331:243
  1. Peter D Toon, general practitioner (petertoon{at}
  1. Canterbury

    In 1992 I visited Russia as the Royal College of General Practitioners' St Petersburg fellow. The next year I hosted two Russian doctors in England. Since this exchange I have visited St Petersburg at least once a year and been asked to work on development projects in several countries of the former Eastern bloc. A few of these projects have led to real change; others achieved their objectives but left a vacuum when they finished; and a few collapsed halfway through. Each country and project is different, and practice cannot be truly evidence based. But lessons can be learnt about how we help other countries develop their health services.

    The brand of Western democracy that was on offer after the fall of Communism was strongly influenced by the prevailing economic philosophy. An important legacy of this philosophy is development through “projects”—defined programmes of work with clear objectives and of fixed scope and duration (often one or two years, rarely more than four). Typically they are funded through agencies such as the World Bank, the European Union's programme of technical aid to the Commonwealth of Independent States (TACIS), or the UK Department for International Development. A small industry in selling development expertise has grown up, with organisations tendering competitively for contracts often worth several millions of dollars or euros. These organisations manage the project, employing experts like me to deliver the technical assistance. This approach has major limitations in supporting the sustainable development of health care and in encouraging expertise to “cascade” through the post-communist world.

    Not all countries are ready to move to a health service with democratic values

    Communist health services tended to be top heavy, with too much badly functioning technology in secondary care and an inadequate skills base in primary care. Too many doctors were paid badly to practise tiny specialties after a short and narrow postgraduate training; access to research findings and evidence based ideas was limited; and there was too much reliance on professorial authority and ideas learnt many years before. I have met some doctors I would be happy to have treat me or my family, but I have also come across neurologists who could not elicit reflexes, ear, nose, and throat surgeons who treated tonsillitis by scrapping the pus off the tonsils, and paediatricians happy to give tetracycline to children for urinary tract infections but rejecting the use of steroids for asthma.

    There is a limit to how fast sclerotic organisations can change. Political turmoil—even positive events like the recent “orange revolution” in Ukraine—can halt progress for weeks or months. The attraction of well funded international projects for key local stakeholders is considerable. This does not necessarily mean corruption (though that certainly exists), but it does include lucrative consultancies and foreign study tours and conferences and the kudos that they bring. Effective reform comes well down the list of incentives.

    I had been visiting Russia for more than seven years before I heard anyone tentatively acknowledge that successful healthcare reform might mean redundant doctors. Yet doctors realise this; and unless acceptable exit strategies are offered they have a powerful incentive to resist reform.

    Personal relationships and knowledge of local political, legal, and institutional frameworks are often important to successful outcomes. However, by the time these have been built up projects are often almost over. Part of a successful project is often defining the next step, but having done that development organisations are often barred by anticorruption procedures from taking that step. Many countries have common needs, but no funding system exists to develop tools that could be used in several countries. Indeed the competitive “market” in technical assistance discourages sharing of experience and expertise.

    So what should be done? Health care cannot be reformed piecemeal. Model practices and pilot initiatives in one area of the system may lead to envy and antagonism rather than be catalysts for change. Offering expensive training to high fliers may mean they escape to a new country rather than lead reform.

    Funding organisations and development consultancies need to be better coordinated and to work in several countries, enabling an evidence base of experience to be built up and tools developed that can be used across several countries. Often the political will to tackle reform seriously will be lacking. Not all countries are yet ready to move to a health service with democratic values. Perhaps the most we can do is to support the development of long term partnerships and educational programmes that encourage local experts who are open to change.


    • Competing interests PDT has received several small grants from the UK Department for International Development and has been paid as a consultant on projects funded by the the department, the World Bank, and TACIS.

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