The health infrastructure built to last is built for the population it will serve, maintained with the resources that population can provide, and governed by the community whose health it protects.
What Lasting Health Infrastructure Requires
Health infrastructure regularly fails to last in low and middle-income settings for reasons that are understood and largely preventable. Facilities are built to donor specifications serving demonstration purposes rather than local functionality. Equipment is procured without the maintenance infrastructure required to keep it operational. Supply systems are designed for the commodities and logistics networks of the donor country rather than the recipient country's realities. And governance is structured around accountability to external funders rather than to the communities the infrastructure is supposed to serve.
The Maintenance Investment
The most consistently neglected dimension of health infrastructure sustainability is maintenance. Maintenance is unglamorous, not photographable, and not fundable through the project grant mechanisms that finance most health infrastructure development. It is also the investment that determines whether the infrastructure continues to function after the project that built it has closed. The community health centre built with donor funding and then left without a maintenance budget is a five-year investment rather than a twenty-year one. The maintenance budget built into the infrastructure's operating model from the outset converts it from a temporary demonstration into a permanent asset.
Health infrastructure that will not be maintained will not last. Building it anyway is not an investment in health — it is a short-term activity that produces the appearance of investment while consuming the resources that a sustainable approach would have deployed differently.
Discussion