The question Garrett poses us with is of note; How to design a health care system to direct the massive growth in public and private giving of funds?

The problem Garrett outlines is both centralization and decentralization, too much oversight and not enough transparency, too little coordination but also too many specific demands.

We are told that in practice donors act as competitors and thus “the only organization with the political credibility to compel cooperative thinking is the WHO”.

Of course the WHO is not a panacea and Garrett equivocates on the role of centralized institutions of planning.

We are given the Botswana Government, Gates Foundation, Merck, Bristol-Myers Squibb, Harvard AIDS Initiative “collaboration” as an example of when “forces align” properly. This kind of collaboration is contrasted with the majority of global health projects that are designed in a mode of “cooperation with local personnel and agencies” but which are for the most part designed managed and executed by ‘outside’ institutions and indeed with the “cooperative” thinking indicative of the WHO.

I thought it was just worth drawing out the distinction implicit but ignored in the article. Indeed she does not address what it would look like to focus on collaboration within the traditional mode of planning, rather than on cooperation. The real question for Garrett seems to be how to address the point that “if we don’t have a state system to coordinate and organize, we cannot move forward.”

One might characterize this as ‘planning plus’. Garrett recognizes institutional planning is necessary but insufficient to kind of goals that are within the shared problem space of all populations, institutions and states involved e.g. “The OECD and the G-8 should thus shift their targets, recognizing that vanquishing AIDS, TB, and malaria are best understood not simply as tasks in themselves but also as essential components of larger goals.” How these goals are articulated within a shared domain of problems is obviously crucial and it is a welcome call to hear something like the Botswanan example, issues and challenges notwithstanding, heralded as a way of thinking the contemporary problem of development.

Farmer’s response to Garrett of “not in my village” is not that helpful, but the example of why “stovepiping” in Haiti is not actually true is instructive; “through careful program design, intentions to stovepipe funds may be subverted — or “horizontalized” — in order to introduce new resources to the cash-starved public sector and disadvantaged rural regions in some of the poorest countries of the world.”

Perhaps it would be easy to have a critique of what has been called something along the lines of ‘community participatory development’, however what is clear is that those in the development industry are wise to the need to move from cooperation to collaboration, even if they don’t necessarily phrase it in those terms.

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