I have quite deliberately described the above incident just to highlight few points. The episode does not show any insincerity on part of the concerned officials. After all, they were simply performing their duties, which can also be performed quite diligently without being emotionally attached to it. The young foreign national who uttered these words might be absolutely right in his conscience/discretion and has every right to earn his well-deserved breaks on weekends. He was paid to perform this 9 to 5 job. And, we do not have any right nor any mandate to deny his right of recreation. The guy might be one of the most sincere health staff of the local office. ‘Sincerity’ alone is a vague and an incomplete word. Until one ascribes its relation to something. A person can be callous, insensitive, and numb but still be the most sincere to the task assigned to him. These agencies may be sincere to their parent organizations, to their donors, to their parent nations, but what matters the most is the sincerity shown toward the effectors-the country, the community and the people. And in this context I have used this word.

The incident also shows how seriously they take professional bodies like IAP? Do they view IAP as a competent, serious academic body to look upon for any scientific advice especially in national context? Or they group this great organization with many other sundry NGOs? This was not the only stray incident. There are many more similar happenings that call for a dispassionate reappraisal of our association with these agencies. Do they really give a damn to us? In what light they view IAP? Recently, it has been reiterated several times at the level of IAP about the "achievement" of getting a sanction of Rs 1 crore for the various child survival projects all over the country from UNICEF. I was indeed baffled by this ‘achievement’. It is simply not sufficient to receive funding but more important is how the sum was spent? Were any worthy, value for money projects undertaken? Was some thorough follow up evaluation undertaken to assess the impact of the exercise? Did the project have any desired impact at the target population? There is no follow up also from the donor agencies. They are also, it seems, not bothered about the final outcome of their investment. Our dependency on theses agencies for financial support is gradually going up. In fact, most of the activities of successive IAP presient’s "Action Plans" depend heavily on the financial inputs from these agencies for their implementation and viability. Now a day, a UNICEF representative is given a VVIP status at most of IAP conferences. Organizing secretaries are willing to bend backwards to show their allegiance. And these officials probably enjoy all the attention, all the praise and a bit of flattery without realizing whether their ultimate purpose is being served or not!

We are competent, elite scientific body. We can provide advocacy and expert technical advice on the issues dogging child health in the country. We must stop begging these agencies. We are not equipped to implement any national program but we can provide advocacy and unbiased scientific inputs based on indigenous needs that serve the interest of our children in the best possible way. This quest of the Academy for finances for programs which we are not competent to implement is responsible for eruption of certain controversies in recent times. The demand at the just concluded Delhi Pedicon of having a separate office of IAP at the national capital must be viewed in this context.

Now, let’s come to the more crucial larger issue- whether these agencies are doing enough to improve the poor status of child health in the country? To me, there is poor utilization of ample amount of funds spent on various child welfare activities. Their approach is not streamlined nor focused. There is enough duplication of efforts. They work on an approach that dictates from top to bottom. Their ‘vertical programs’ are competing with other public health programs, marred with poor performance mainly due to scarcity of funds. The imposition of the agenda of their western headquarters has failed these agencies to connect with the masses who often deem their programs with some amount of suspicion, skepticism and alien to their immediate needs. The approach of these agencies should be ‘country-specific’ and from ‘bottom-to-up’ rather than the other way round. This realization came quite late as happened with ongoing polio eradication initiative. The agencies involved with

the program did fail to appreciate the ground realities, local health problems, the immediate needs and acute suffering of the target population. Their attempt to involve the local community without addressing their immediate concerns and showing some far-fetched benefits of a lesser evil, created resistance to ongoing polio activity and in certain backward, religious fundamentalist societies of lesser-developed nations created a form of ‘tribalism’ to counter the so- called ‘universalism’ imposed by the agencies. The clash between these new forms of ‘tribalism’ and the forces of globalization has been responsible for the unusual delays in polio eradication initiative.

What they ought to have done was to first ensure a ‘level playing field’ to all participating countries before initiating any ambitious universal endeavor. In other words, they should have first invested heavily in developing mature, competent, effective public health delivery systems in most poor, developing countries before asking them to undertake an exercise meant to benefit more their rich, developed western counterparts having impeccable public health systems. In fact, most vertical programs of these agencies are adversely affecting the most ‘horizontal’ programs of the developing nations. At some spheres, there is inefficient overlap of efforts amongst various multilateral organizations, while paradoxically; there are voids of responsibility in executing some key functions. First and foremost, these organizations must augment the efforts of individual nation to erect efficient public health systems. They can provide expert technical advice, training and resources to develop efficient infrastructure. There are instances of where sizable sums of public money are spent on tertiary level hospitals at the expense of cost effective interventions delivered at primary level.

Almost, the entire cost of health care in the developing world is borne by the developing countries themselves. Aid from international health organizations in the developed countries pay less than 5% of the total health care costs in the developing world. Although the aid given to the developing world as a whole is relatively small in financial terms, it can be of crucial importance. Research and pilot programs sponsored by agencies from the industrial nations have generated many of the best ideas for improving health in developing countries. Also, the international health organizations are a major source of expert technical advice and training for local health professional. But as development of effective and sustainable health systems underpins all other priorities. This is one area where the requisite support and encouragement from them are missing. As a matter of fact, some of the world’s poorest countries are receiving the least amount of support. And despite contributing only a fraction of total health budgets in an individual developing nation, they are calling the shots as far as deciding the priorities of public health is concerned. Their approach is not country-specific but often dictated by their donors. Take a case of WHO, which has two funding sources. While its ‘regular budget funds’ are paid by its 192 member states, it also receives ‘extra-budgetary funds’ from a handful of member states (called donor countries), other UN organizations and private donors. This extra-budgetary funding makes up two thirds of WHO’s total budget. Although extra-budgetary funds can benefit the health of low-income countries, they come with strings attached- donors can influence these agencies programs "by deciding on the allocation, volume, designation and specification of their extra-budgetary funds." They could influence how their donations were spent. This influence ultimately translates in to disparate and sometimes, uncalled for priority at the target countries. Their programs often neglect the more pressing acute problems faced by the local community.

Further, all these agencies are highly bureaucratic, fragmented and feudal organizations rife with cronyism. They do not like questioning their policies and activities at ground level especially by the ‘effectors’. They are often accused of allegations of corruption and favoritism. They prefer ‘head nodding’ experts and do not seem tolerating anyone who dares to question their style of functioning. This explains their disdainful attitude towards "lesser mortals" like the IAP. Their activities seem disparate and often uncoordinated. Their priorities often follow donor’s preferences and the amount of available resources rather than rational evaluations of health problems.

All these problems seem to diminishing the efficacy of these agencies, which has further crippled by lack of coordination, overlapping mandates, and the duplication of efforts.

After ensuring proper investment and creation of national health system, they should turn their attentions to problems that local governments can no longer deal on their own. They are the ideal vehicle for contending with health problems that go beyond the capacity of individual health system like emergence of a new disease or a pandemic threat-i.e. surveillance and control of diseases that represent a regional or global threat. Candidly, these health agencies were initially designed for a different world, where few problems needed global action. One single organization could manage world health affairs, especially given the clear priorities that characterized that time. Today, the world is a different place. The development of multilateral health agencies has not kept pace with the evolution of new health challenges and some agencies have adopted functions that exceed their original mandates. And, in the process, they seem obstructing certain local need based programs of an individual nation.

Notwithstanding the errors in the strategies of the polio eradication program, the sheer sincerity of the ground workers has brought results. But because of the lacunae in the strategies, it is being increasingly realized that it will be difficult to achieve the target or to sustain it. But the lesson to be learnt is also that where there is a will there is a way. If the International agencies put the priorities in proper prospective, much greater strides can be made. The need to take up the challenge of public health system (may read sanitation also) as the foremost priority cannot but be emphasized again and again.