This week, Liberian President Ellen Johnson-Sirleaf is visiting Washington to raise funds and gather advice to help her war-ravaged economy. But previous western involvement in the country, which was designed to help, actually ended up harming Liberians’ health. Future generous assistance may cause even greater harm. What is going wrong?

More funding for health is certainly warranted, and diseases like HIV/AIDS must be tackled. But uncoordinated, generous efforts to combat high profile diseases are undermining the basic health systems on which entire countries depend.

Some countries are in such perilous states that nearly their entire health budgets are funded by donors. And while these external support systems save life, funding levels tend to be volatile and decisions hinge more on what donors care about than what locals need. And overwhelmingly, donors care about combating specific diseases.

Economists at the World Bank analyzed the Health, Nutrition and Population (HNP) data for Sierra Leone last year. They found that intentions to combat HIV in Sierra Leone overwhelmed the health department and drew doctors away from valuable work (such as child immunization programs) to deal with HIV. HIV is a problem in Sierra Leone, but it is not the disastrous epidemic that it is in other parts of Africa.

Now that situation is repeating itself, perhaps with worse effect, in Liberia. Once again the HNP data sets from the World Bank prove enlightening. The Bank is trying to encourage a better coordination and use of donated funds to prevent misallocation; but to do so they require help. The case of Liberia shows why.

The monthly wage for doctors in the Government health service is about $78, and for nurses around $21, compared to $450 to $2,000 a month for those working on donor-funded projects.

The total basic health care budget was around $10 million in 2005, for a population of 3.3 million. Some of those funds were from previous Western donations. Life expectancy at birth is very low at just under 40 years, and rates from infectious diseases like malaria, yellow fever, dysentery, and typhoid are very high—amongst the highest in Africa. Nearly half the death rate is due to malaria. The HIV rate is not low, at about 6%, but not seriously high, with only marginal harm to the economy, unlike many other places. Of course the combination of HIV with other disease can be debilitating.  

Given the exceptionally high malaria rate, it is not surprising that donors have been keen to combat the devastation wrought on the young by this disease. And grants just from large donors such as the Global Fund and USAID will provide over $60m in support for health projects aimed at malaria and HIV this year alone. This should be very good news. But the problem is that the monthly wage for doctors in the Government health service is about $78, and for nurses around $21, compared to $450 to $2,000 a month for those working on donor-funded projects.

One has to be a well-qualified saint to remain as a doctor in the decrepit health system when one can earn up to 25 times as much working outside of it. Few people are saints, so several doctors have left the Government service for higher pay, weakening immunization services and reproductive health work, while others continue to draw their Government salaries while free-lancing on projects. If they do this after hours then all well and good (until exhaustion takes over), but most leave full hospitals, during working hours, to take on more lucrative work elsewhere. The World Bank’s Maureen Lewis has demonstrated that this practice is widespread in Africa, and Liberia is apparently no exception. But then I dare say that if I were a Liberian doctor with a family to support the choices would be hard to make, and worthwhile projects paying vastly more would probably lure me. 

President Johnson has been made aware of these problems by several experts, and she wants to improve the situation. Speaking more generally, she told the Center for Global Development on Monday that "We believe that Liberia can be an example…that war-torn dictatorships can turn around and become responsible members of the international community…We are willing and ready to make the hard decisions, to adopt the right policies, to put in the right systems, if you are willing to be with us and support us, politically, analytically, and financially."

The real question is whether the donors, in health particularly, will do what she and her country need, rather than what they want to see happen.

The World Bank is in a unique position to help with the financial coordination of this effort, and it seems willing to do the job. The Bank also will help improve basic health infrastructure and could fund basic medical staff pay increases, thereby limiting the pay differentials offered to staff on donor programs. Unfortunately, the Bank President is unpopular at the moment for aggressively wanting to combat corruption, which may prompt fellow donors to discount the Bank’s correct advice.

Roger Bate is a Resident Fellow at the American Enterprise Institute.