Roads and Power for Health: Tackling the Infrastructure Challenge

The light in the clinic is dim. There is no electricity, so the only light comes from the sun, which is sinking, minute-by-minute, behind one of Rwanda’s many hills. The clinician, a wiry man with a quick smile, holds up what can generously be called an ancient microscope slide to the open door. He squints at the slide, trying to catch the last of the sunlight, and sighs. “I can’t really see it,” he tells us, “but, yes, I think malaria.” Outside, we see what passes for an ambulance here in the far outskirts of Kigali, Rwanda’s capital city. It is, essentially, an oversized basket. “There are no roads to the villages,” the clinician tells us, so people come by foot, up and down miles of Rwanda’s hilly landscape. If they cannot bring their sick with them, the clinicians send someone back with the “ambulance” to help. Sometimes they are in time. Sometimes they are not.

I was a year out of college and in Rwanda working on the President’s Malaria Initiative with the U.S. Agency for International Development. Some of my most striking memories of that trip – my first to Africa – come from our visit to the small health clinic on the outskirts of Kigali, in the midst of rolling hills and endless fields of banana trees. I remember being inspired by the enthusiasm of community health workers, who assured us they would see to it that Rwandan children followed the appropriate treatment regimen for malaria. I remember being shaken by parents who shared with us the tragedy of losing a daughter or son to a disease we knew to be preventable. And I remember seeing, in a way that only standing in a rural clinic in a developing country can allow one to understand, the huge challenges that face the global health community.

In much of the developing world, health care is ad hoc, with limited medicines, health care providers, and infrastructure. The global health community is working daily to address the many challenges of providing health care to the world’s most vulnerable populations, and we have seen much progress – the eradication of smallpox, the neareradication of polio, the wide reach of lifesaving vaccines, and the increasing presence of bed nets to prevent malaria. But even as we develop new vaccines, train health workers, and build the capacity of local governments, we have taken our eyes off one of the most critical components of ensuring access to health for all: physical infrastructure, and more specifically, well-maintained roads and electricity.

Paved roads and electricity are critical but currently weak points in health service delivery. The evidence is all over the developing world. Clinicians cannot read diagnostic slides because lack of electricity renders their microscopes useless. Drugs expire in warehouses rather than reaching patients because the roads are unnavigable in the rainy season. Vaccines cannot be stored. People who need services cannot reach them. Working in the field, it quickly becomes clear that without adequate infrastructure, our efforts, and those of the local governments, are not reaching their full potential. Roads and electricity will help us overcome these issues, magnifying the effects of the current aid and laying the foundations for a sustainable system. In addition to strengthening health services delivery, physical infrastructure is critical to economic growth, giving people access to markets and children access to schools, providing jobs and promoting international trade.

The United States should form a public-private partnership with other bilateral donors, private construction and energy companies, the World Bank, and regional development banks to build much-needed roads in, and provide electricity to, developing countries. The partnership should set feasible goals, and guarantee state-of-the-art road construction and electricity provision, as well as a system for ongoing maintenance.  This work will take meticulous planning and oversight.  We will have to focus at once on micro design and construction issues, as well as on macro issues.  How do we ensure that infrastructure development does not adversely affect peoples' lives by displacing families?  How do we build local capacity for follow-up and maintenance?  And how do we address related and burgeoning issues, such as road injuries, which are becoming increasingly prevalent in the developing world?

Infrastructure development has the potential to realize one of the worst images of foreign aid; big, expensive projects imposed by the developed world on the developing, that crumble when the donors cut the ribbon and exit.  This, however, is an image we can and must change.  The type of investment and effort that infrastructure development takes should be the face of our global health system: developing and developed countries working together to tackle the most complex issues of our time, aware of, but undaunted by, the challenges, and in pursuit of the greatest rewards.