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# Aid, poverty and the illusion of better health
- URL: https://www.jaffnamonitor.com/aid-poverty-and-the-illusion-of-better-health/
- Published: 2026-09-06T19:05:42.000Z
- Updated: 2026-09-06T19:06:13.000Z
- Author: Prof. Mahesh Nirmalan
- Tags: Guest Column, September 2026

**By Mahesh Nirmalan, MD, FRCA, PhD, FFICM, and Jared Mecha, MD, MPH**

**Mahesh Nirmalan is Professor of Medical Education and Associate Vice President at the University of Manchester, United Kingdom. Jared Mecha is a Lecturer, Consultant Physician and Global Health Specialist at the University of Nairobi, Kenya.**

International development agencies, philanthropy, and health research funding agencies largely approach health outcomes in less developed countries (LDCs) as a problem to be solved within isolated silos. Official Development Assistance (ODA) for health has traditionally prioritised and invested in child health programs (including vaccination), family planning and reproductive health, nutrition, control of communicable diseases, and healthcare infrastructure. Similarly, health research, funded through government agencies or charities, has often focused on linear hypothesis-driven interventions expected to produce measurable outputs. Though these initiatives are well-intentioned, their ability to produce sustainable, positive changes to health systems have often been disappointing. The reason is simple – health outcomes are not produced primarily within healthcare systems but rather in complex, multi-layered, and interconnected political and socioeconomic structures. In such systems, improvements in population health metrics are the by-product of a broad base of social and economic development and institutional quality, catalysed by transparent, people-centred governance frameworks.

### 

### **The Preston Curve and the Development of Health**

The Preston Curve, first described by Samuel Preston in 1975, demonstrated this relationship between national income and life expectancy. By plotting risk of dying against per-capita income in multiple countries Preston demonstrated one of the most robust observations in development economics.

![Figure 1: Preston curve showing the inverse relationship between risk of dying and economic output.](https://storage.ghost.io/c/f0/aa/f0aaf7b7-6b61-437a-846a-1a80de683912/content/images/2026/09/aid-poverty-and-the-illusion-o-bhS-j0-kix7yw2f3xf8l5o.png)

Figure 1: Preston curve showing the inverse relationship between risk of dying and economic output.

The central message is that countries moving from extreme poverty to middle-income status experience dramatic reductions in death rates. This observation is attributable to better nutrition, housing, clean water & sanitation, general educational attainment, transport infrastructure, and access to basic public services that accompany economic development. As income rises further, however, additional increases in wealth produce smaller gains in longevity. Despite this diminishing returns in the higher-income countries, the relationship between economic growth and community health holds true across all health systems.

![Figure 2: The direct relationship between wellbeing and economic output.](https://storage.ghost.io/c/f0/aa/f0aaf7b7-6b61-437a-846a-1a80de683912/content/images/2026/09/aid-poverty-and-the-illusion-o-bhS-j0-kixagct1qnm2k9s.png)

Figure 2: The direct relationship between wellbeing and economic output.

Preston also demonstrated that countries today achieve higher life expectancy at equivalent income levels than several decades ago. This is likely to be the result of mass communication, which has enabled improved health literacy and knowledge of healthier lifestyles now than was possible in the past.

The implication is profound. Population health is shaped primarily by three interconnected domains:

Economic growth

Governance and institutional integrity

Technological and ‘medical’ interventions

Agencies distributing developmental funding, however, pay disproportionate focus on the third domain because medical interventions are easier to define, fund, and measure. The first two domains on the other hand are usually ‘messy’, politically sensitive, and difficult to evaluate through conventional metrics. Yet when economic systems fail or state institutions weaken, health outcomes deteriorate regardless of medical advances.

Therefore, as aid budgets shrink globally, donors (and recipients) face an important choice. Should the diminishing funds continue to support projects focused directly on narrow health outcomes, or should they view health outcomes as a ‘*dependent variable*’ and preferentially support economic development, trade, institutional strengthening, and nation-building? The experiences of Sri Lanka, Uganda, and Kenya since the end of colonial rule provide valuable insights in shaping this debate.

### **Sri Lanka: From Universal access to ‘enforced entrapment’**

Sri Lanka has long been celebrated as a success story in global public health with life expectancy approaching 78 years despite modest income levels. Many observers attributed this achievement to the country's free healthcare system. However, healthcare was only one component of a broader developmental story in the 2-3 decades that followed independence in 1948\. Successive governments invested heavily in universal education, female empowerment, public health legislation, sanitation, rural infrastructure, and social welfare. These investments created the social and economic foundations upon which an effective health system could operate synergistically. The health sector succeeded because wider society succeeded.

However, in the subsequent 3 to 4 decades, that immediate post-independence foundation has progressively weakened. The legacy of a prolonged civil war, rooted in a flawed nation-building project – with ethno-nationalistic leanings, diverted resources from development to security priorities. Growing debt and economic mismanagement in this context culminated in a severe economic crisis in 2022\. As public finances deteriorated and inflation soared, the health sector became increasingly underfunded and critical infrastructure became difficult to maintain.Health records – essential for clinical audits and quality improvement – were reduced to small ‘exercise books’ purchased and owned by patients. The situation was further aggravated by mass emigration of healthcare workers, further weakening the capacity for meaningful care in public hospitals.

![Figure 3: The booming private health care sector is a regular feature in all parts of Sri Lanka.](https://storage.ghost.io/c/f0/aa/f0aaf7b7-6b61-437a-846a-1a80de683912/content/images/2026/09/aid-poverty-and-the-illusion-o-bhS-j0-kixck5q64jlcnkl.jpg)

Figure 3: The booming private health care sector is a regular feature in all parts of Sri Lanka.

The consequences of this transformation for ordinary citizens have been profound. Patients who once relied entirely on free public healthcare (delivered to a standard sustainable by the local economy) increasingly found themselves forced into the private sector as public facilities could not meet their expectations. This shift, unfortunately, was not a matter of choice, even for families with modest means. Modern healthcare technologies, surgery, intensive care, cancer care, and other advanced therapeutics could only be accessed in the private sector “to save his/her life” at costs far beyond many families’ means.

The recent case history of a patient - admitted to a private hospital in Colombo, with ascending paralysis due to *Guillain-Barré* syndrome and requiring intravenous immunoglobulins and prolonged ventilation and then having a bill close to LKR 5.5 million before being transferred to the National Hospital in Colombo encapsulates the dilemma of many middle-class families with no access to insurance schemes. This family, for example, exhausted its entire life savings as a result of this life-changing and financially catastrophic encounter with private health care in Colombo. Similar dramas are being enacted up and down the country on a daily basis, and the crucial point is that opting out of such care is NOT an option due to socio-cultural imperatives. It is a cruel form of *‘enforced entrapment*’ indeed.

Sri Lanka's experience demonstrates an important lesson. The country's earlier population health gains were not created solely through health services. Likewise, its recent deterioration has not been caused solely by failures within health care. Both success and failure closely followed broader economic and institutional realities, reinforcing the message implicit in the Preston curves.

### The Replicated Pattern: Structural Failure in Kenya and Uganda

Similar challenges in health care closely linked to socio-political upheavals in the country are evident in many other countries in Sub-Saharan Africa. Uganda in particular presents a different but equally revealing example.

Decades of conflict, political instability, and reliance on donor-funded programmes have left deep structural weaknesses within public institutions. One striking illustration emerged in Northern Uganda following the conflict between the Lord's Resistance Army (LRA) and the Ugandan government. The war left many people with major limb loss and permanent disabilities. Rather than developing sustainable – even if suboptimal – public rehabilitation services, much of the response was outsourced to NGOs (such as AVSI International) and short-term donor-funded research projects. Although these initiatives delivered valuable short-term support, perhaps to higher standards, they did not create enduring health systems capacity for sustainable rehabilitation of victims. Rehabilitation services in the Acholi sub-region remained dependent entirely on external actors. As a result, when priorities shifted, or projects ended, vulnerable populations were left without essential, reliable long-term support. One child victim – now a married woman with two children, who lost her leg to a land mine, reflected in 2019 (13 years after the war with the LRA formally ended) *“If AVSI goes I have to kill myself*”. The net result of this well-intentioned NGO-led program in the region was therefore a significant disconnect between humanitarian intervention and sustainable institution-building.

![Figure 4: HIV prevention/treatment programs were outsourced to external agencies such as USAID in many African countries such as Uganda and Kenya. (Source: Wikimedia Commons).](https://storage.ghost.io/c/f0/aa/f0aaf7b7-6b61-437a-846a-1a80de683912/content/images/2026/09/aid-poverty-and-the-illusion-o-bhS-j0-kixd28sjy9ibmfo.jpg)

Figure 4: HIV prevention/treatment programs were outsourced to external agencies such as USAID in many African countries such as Uganda and Kenya. (Source: Wikimedia Commons).

Kenya demonstrates many of the same pressures. Although the country has experienced notable economic growth and technological modernisation, major challenges remain within public healthcare. Persistent personnel shortages, industrial disputes, supply-chain disruptions, and equipment failures continue to affect service delivery. Consequently, private providers occupy an increasingly dominant position within the healthcare landscape.While various reforms seek to improve insurance coverage, out-of-pocket payments - secured through the sale of houses, land or livestock, remain substantial with family illness becoming one of the most effective routes into poverty.

As in Uganda, in Kenya too the provision of many vital services was outsourced to international donors. Programs aimed at prevention and treatment of HIV, Tuberculosis and Malaria were entirely in the hands of organisations such as USAID and the Global Fund. The dependency was such that, according to an informed Kenyan academic, “*the national and many county governments did not have a budget allocation for these essential programs*”. The rapid withdrawal of USAID-funded programs in Kenya, almost over a single weekend, has created a huge gap in service provision accompanied by unimaginable human tragedy.

Reflecting on these different but inter-connected case histories across Sri Lanka, Uganda, and Kenya, the common denominator was not primarily healthcare policy. The glaring deficits in health care in all three countries were undoubtedly a manifestation of the strength or weakness of the wider economic and institutional environment in which healthcare operated. This is what the Preston curves teach us.

### **Why Donor Agencies Get It Wrong: The Illusion of Technical Fixes**

Many international development organisations continue to organise their activities through strict administrative silos. Health specialists focus on health; education specialists on education; infrastructure experts on infrastructure; and governance teams on governance. This compartmentalised architecture can create a dangerous intellectual trap. Health professionals understandably view suffering through a medical lens and therefore propose medical solutions - more clinics, more medicines, more training programmes, more disease-specific interventions, and more research.

Such outputs are attractive because they can be counted or listed. Donors can report the number of vaccines administered, clinics built, workers trained, or papers published. Yet these metrics often bear only a weak relationship to durable improvements in population health. A modern clinic funded through a donor grant may look impressive in the departmental annual report. However, if surrounding roads remain broken, electricity unreliable, local employment hard to find, and governance corrupt, the facility - however impressive it looked in the project report and the associated posts in social media, become rapidly ineffective. Similar examples can be found across many low-income countries where donor-supported infrastructure exists but broader systems necessary for sustainability do not.

Vertical health programmes also struggle to address macroeconomic realities. Vaccination campaigns and training workshops cannot compensate for food inflation or healthcare workers emigrating. Similarly, disease-specific interventions or research cannot stabilise a national currency or repair dysfunctional institutions.

The same fragmentation often exists within donor countries. The United Kingdom's Overseas Development Assistance system illustrates this challenge. Funding is distributed across multiple departments and agencies including the Foreign, Commonwealth and Development Office (FCDO), the Department of Health and Social Care, the Department for Energy Security and Net Zero, and research bodies such as UKRI. These organisations frequently pursue separate priorities, procurement systems, accountability frameworks, and performance indicators.As a result, a research innovation funded by UKRI or Welcome Trust may have no clear pathway into wider development policy or infrastructure investment. Health projects, scientific research, and governance programmes often proceed in parallel rather than as components of an integrated state-building strategy. The consequence is a pattern of fragmented interventions rather than transformative change.

### **Political Institutions and Fiscal Protection Matter More Than Medical Hardware**

The most important determinant of national health is the quality of a country's institutions. Competent governments create security, maintain infrastructure, support education, regulate markets, collect taxation, and deliver public services. These functions create the conditions necessary for economic growth which in turn generates the financial capability to finance healthcare systems that are sustainable by the local economy. When governments cannot retain healthcare workers, regulate private healthcare markets, or maintain basic public infrastructure, externally funded programmes merely amount to *‘pacifying the donors’ conscience*’ rather than achieve real change.

Countries with capable institutions on the other hand frequently improve population health rapidly even when foreign assistance is modest. The major health transformations seen across South and East Asia during the twentieth century - China, Vietnam and India included, were driven primarily by economic development, educational expansion, and calibrated/proportional state interventions rather than donor-funded isolated medical interventions. In Vietnam for example a basic war-recovering health system has transformed into a 4-tiered universal health care model backed by >90% health insurance coverage within the past 5 decades. Such transformations in health care are only possible if the local economy drives aspirations for better health care.

### 

### **What Should Development Assistance Support Instead?**

Recognising the broader determinants of health does not require abandoning traditional health programmes. Rather, it requires placing health within a wider developmental framework as implied by Preston. Development assistance should therefore place greater emphasis on public infrastructure & productivity**;** education & human capital development; macroeconomic resilience & regulatory capacity**;** agricultural productivity, waste management and food security etc*.*. When these basic foundations are in place improvement in health usually follows, supported and resourced in a more sustainable manner by national budgets. The goal however is not to abruptly abandon healthcare support (as done by USAID in Kenya) but to recognise healthcare's place within a much larger ecosystem.

### Conclusion: Health and Wellbeing are Consequences of Development

The enduring lesson of the Preston Curve is that health is not an isolated bubble. Life expectancy, mortality, wellbeing, and vulnerability are shaped by economic growth, educational attainment, infrastructure, governance, and institutional strength. Sri Lanka's recent experience illustrates how outstanding achievements in health care can be undone by economic collapse that follows corruption concealed by sectarian rhetorics. Uganda and Kenya demonstrate the risks of excessive dependence on externally funded programmes and the failure to strengthen sustainable indigenous public systems concurrently. Collectively, these examples show that when state capacity diminishes, citizens are increasingly exposed to predatory commercial healthcare markets and financial ruin for families.

For too long, development agencies and donor governments have treated health primarily as a technical challenge requiring technical solutions. Whether through vertical disease-control programmes or fragmented aid, this approach has often overestimated what health interventions can achieve in isolation. As aid budgets are slashed, donor (and recipient) governments have important choices to make. The realisation that health grows most effectively in societies that are productive, stable, and resilient is an important facet in informing this choice. The ultimate task of development policy is therefore not merely to subsidise medicine or build new health centres, but to help build societies where better health is an outcome of better governance and a stable economy.

***The opinions expressed in this article are that of the authors alone and not the views of the Universities of Manchester and/or Nairobi on the subject.***