Development cooperation and

International policies

For more than 30 years, development aid policies replaced clinical health care with public health programs in public services in recipient countries. Medical cooperation has simply disappeared. After 30 years of evaluating these policies, we can safely say that they have dramatically reduced access to care and the quality of care in LMICs without disease control programs succeeding.

Thus, the Millennium Goals were not achieved in the only continent where they would have represented a breakthrough: Africa. Preventable death and suffering have increased. The health sector generated political instability in low-income countries and, sometimes, contributed to make them failed states. Besides, international health policies also contributed to international migration, which European and American citizens seem to fear so much.

Two summaries of our research on development cooperation and international policies in the health sector

International Health and Aid Policies. Editors: J.-P.Unger, P.De Paepe, K.Sen, W.Soors. Cambridge University Press, 2010 (275 pages).

Review in the Journal of American Medical Association (JAMA) by David Chinitz, PhD. JAMA. 2012; 308(8): 819-820.

See also


Unger, JP., Morales, I. & De Paepe, P. Objectives, methods, and results in critical health systems and policy research: evaluating the healthcare market. BMC Health Serv Res 20, 1072 (2020).

An analysis of international health policies based on the evaluation of national healthcare policies and disease control


We concluded our analyses of national healthcare policies as follows. While the international policy substituted public health programs to individual care delivery in LMICs public services, it drastically restricted access to care, provoking thereby suffering, avoidable mortality, political instability and international migrations (that Europeans and Americans seem to fear so much). Almost none of the Millennium Development Goals were achieved in Africa – but international health agencies failed to reflect on this failure.


To explain why MDGs couldn’t be attained in Africa despite a limited scope of action and a huge financial effort, we demonstrated that successful disease control programs require health facilities actually used by patients


Unger JP, d'Alessandro U, De Paepe P, & Green A. Can malaria be controlled where basic health services are not used? Tropical Med Int Health. 2006; 11,3: 314-322.


We also studied the mechanisms whereby integrated disease control interventions strain patients’ access to care in those health services in which they are integrated.


Unger J.-P., De Paepe P., Green A. A code of best practice for disease control programmes to avoid damaging health care services in developing countriesInt J Health Planning and Management2003; 18: S27-S39.


We could then demonstrate that a and b together produced a catch-22 system failure because patients with various symptoms represent a pool of users that disease-specific programs require for early case-detection and follow-up


Unger J.-P., De Paepe P., Ghilbert P., Soors W., Green A. 1. Disintegrated care: the Achilles heel of international health policies. In low and middle income countries. International Journal of Integrated Care2006; 6. ISSN 1568 – 4156


For LIC populations, the mortality and suffering related to losing access to individual care proved immense. As a consequence, international health policies resulted in international migrations and political instability in Low Income Countries.

International health policy and efficiency of public spending


In 1985, we examined the financial assumptions of the Selective Primary Health Care strategy, (promoted by Rockefeller Foundation associates just one year after the Alma Ata conference (Walsh J. A. and Warren K. S., 1979, Selective primary health care: an interim strategy for disease control in developing countries. NEJM, 301 (18), pp. 967-74) ( on the grounds that PHC was unaffordable. Accordingly, LIC public systems would deliver disease control and risk control interventions instead of individual health care.


In 1992, we published a practical guide to international cooperation in health (in French), intended to guide actions in support of public health care services and their systems. While international medical cooperation gradually disappeared, the book remained idly.

Unger J.-P. Guide pratique de la coopération médicale. De l'analyse des systèmes de santé à l'action.  l'Harmattan, Paris, 1992 (221 pages).

Using retrospective data, we demonstrated that the cost of primary care services delivering individual health care and disease/risk control could be similar to that of first line services delivering disease/risk control only – e.g. because of different administration efficiency.


Unger J.-P., Killingsworth J. R. Selective Primary Health Care: Methods and Results. Soc. Sci.Med. 1986; 22: 1001-1013.


In 2007, on a review of the multilateral agencies’ grey literature, we concluded that over 25 years, all of them adopted policies restricting the function of LIC public services to disease control and allocating individual health care delivery to commercial services


De Paepe P., Soors W., Unger J.-P. International Aid Policy: Public Disease Control and Private Curative Care? Cadernos de Saude Publica2007; 23 (Suppl. 2): S273-281.


In 2008, we studied how 120 public/private global health initiatives were extended from the world capitals to the smallest African villages (57 such programs in Congo only). Despite a discourse stressing prioritization in disease control, the international cooperation agencies had created the biggest ever bureaucracy – ironically on the basis of efficiency claims.


J.-P. Unger. How could disease specific programs strengthen health systems delivering comprehensive health care? Strategic and technical guidelines. European Commission, DG DEV, 30 Sept 2008, Brussels

Also in 2008, we analyzed why the low funding of health services was not sufficient to explain why maternal mortality stagnated at unacceptable levels in LMICs, and why it was also necessary to blame the replacement of clinical care by public health programs. in LMIC public services.

Unger J.-P., Van Dessel P., K.Sen, De Paepe P. International health policy and stagnating maternal mortality. Is there a causal link? Reproductive Health Matters, 2009, 17 (33):91-104 


We critically analyzed pro-market policies on four other key characteristics: the mismatch of commercial health care delivery with Hippocratic ethics; the tensions between disease control and people’s demand for multi-function, bio-psychosocial care; the subsequent obstacles to community participation; and the restriction of professional autonomy by organizations conceived as machine bureaucracies to deliver hyper-standardized interventions.


Unger J.-P., De Paepe P., Ghilbert P., Soors W., Green A. 1. Disintegrated care: the Achilles heel of international health policies. In low and middle income countries. International Journal of Integrated Care2006; 6. ISSN 1568 – 4156


Unger J.-P., De Paepe J.-P., Ghilbert P., Soors W., Green A. 2. Integrated care:a fresh perspective for international health policies inlow and middle-income countries. International Journal of Integrated Care2006; 6. ISSN 1568 - 4156


These publications thus critically assessed the strategies that undermined public services - such as focused underfinancing, purchaser provider split, management property split, municipalization, and focalization of public services on disease control and on the poor.


The conclusion of these studies is crystal clear: the commoditization of health care, health services and health insurances leads to mortality amenable to care and inefficiency.

Studies of health policy determinants


The gross contrast between the efficiency of US and Costa-Rican health systems, amongst other indications that the Costa Rican model was superior, did not lead the WHO and allied agencies to promote the Costa Rican single public health insurer and public services model worldwide.

Instead, the UN and bilateral cooperation agencies generally promoted the US model of managed competition between commercial insurers. We could thus investigate the policy determinants that led international agencies to implement the health insurers agenda despite the scientific evidence.


Over 2 decades, health systems reforms have explicitly aimed to expand the market of health care delivery and disease control. However, we have seen in different settings the weakness of scientific evidence in support of this policy.

Commercial ambitions were a more important determinant of reforms than the alleged gains in efficiency and health status. In other words, science was being used as leverage to privatize health care delivery, services and insurances. On this ground, we began to probe the determinants of policy design, focusing on the political economy of care delivery and financing.


We thus explored the history of


  • the international policy to verify that it allocated public health programmes to public services and individual care to the private sector, thereby disintegrating disease control and clinical medicine


De Paepe P., Soors W., Unger J.-P. International Aid Policy: Public Disease Control and Private Curative Care? Cadernos de Saude Publica 2007; 23(Suppl. 2): S273-281. (confer supra)


  • the Ecuadoran national policy


De Paepe P, R.Echeverria, E Aguilar Santacruz, JP Unger. Ecuador's Silent Health Reform. Int J Health Services, 2012 International Journal of Health Services, Volume 42, Number 2, Pages 219-233.


  • USAID activities in Bolivia


Herland Tejerina, Pierre De Paepe, Marie-Christine Closon, Patrick Van Dessel, Christian Darras, JP Unger. Forty years of USAID health cooperation in Bolivia. A lose–lose game? Int J Health Plann Manage 2014;29(1):90-107.


  • The World Bank interventions in the Bolivian health sector


Herland Tejerina Silva, Pierre De Paepe, Werner Soors, Oscar V. Lanza, Marie-Christine Closon, Patrick Van Dessel, and Jean-Pierre Unger. Revisiting health policy and the World Bank in Bolivia


Historical studies enabled us to explore economic and non-economic determinants of policies, such as the US geo-strategic stakes that had a greater impact on aid priorities in Bolivia than did the interest of health insurances in its market.

We concluded these health market studies on its incapacity to secure the Right to Healthcare, to deliver healthcare of professional quality, to ensure ethical medical practice, and use taxes efficiently. The partial privatization of health insurances (as with Medicare andMedicaid in the USA) is not a model to be followed.