Millions of dollars in international aid for Pakistan's health sector have not significantly improved the health of most Pakistanis, says Wilson Center Pakistan Scholar Samia Altaf. A public health physician who has worked in both Pakistan and the United States, Altaf diagnoses the problem in the wryly astute "Pakistan Picaresque," published in the Winter 2008 issue of the Wilson Quarterly.

Developing countries urgently need money, and international lending organizations like the World Bank are under pressure to make loans, says Altaf, so the success of a program tends to be measured in "documented capital outlays (schools built, computers purchased, etc.) and published reports. There is little interest in assessing whether the projects have actually had an impact on people's lives." Health centers and schools sit locked and empty because success is defined by their construction, rather than delivery of services.

Most of the specialists who design, direct, monitor, and evaluate development programs are employed by foreign development agencies, and are not accountable to the people their programs are designed to help. According to Altaf, these Western specialists and their parent organizations tend to favor standardized and technocratic—rather than unique and sustainable—approaches that are not always suited to the cultural and economic realities on the ground.

Altaf is sympathetic, however: "Most specialists do their jobs to the best of their abilities. People with experience know full well that most of the time they are just muddling through, trying to meet deadlines. In the end, government officials, technical consultants, and aid agencies all hope that ‘some' good comes out of the muddle," she writes. "Alas, when muddle goes in, muddle comes out."

Altaf will offer more detailed recommendations for improving the effectiveness of international aid to Pakistan's health sector in a forthcoming book, her project at the Center.