Archive for May 2008
The special session Primary Health Care: A New Vision for the Fourth Decade just finished. WHO Director-General Margaret Chan was in attendance, but is not speaking until later in the day. I missed the beginning, so I’m just sharing some select comments.
Dr. Ahbay Bang, director of Society for Education, Action and Research in Community Health (SEARCH) in India. [Right now he’s not listed as a speaker on that panel, but he was there.]
He described research as the vehicle for grassroots work to affect policy. Three key points he addressed:
- Research must begin with people, not libraries. He described how he gets new research ideas “from the people”. In Geneva some years back, his colleagues asked him “How come you can see problems 10 years ahead of time?” HIs response? “I’m 10 years nearer to the people.” The secret, which he shared with us today, was having the community help define the research problems.
- “Meticulous, rigorous measurement”. (“Nothing exists unless it is measured.”)
- Research also needs to be about equity. We need to go beyond the clinical, epidemiological, legal, and biomedical research to consider the political, cultural, economic, and organizational.
Yesterday’s plenary session The First Mile: Setting the Framework for Effective Community Health Systems was a global health conference experiment. The session linked the Global Health Council Conference (Washington, D.C.) to the Geneva Health Forum by video conference. Keep in mind these were sessions attended by hundreds of people on both sides. Louis Loutan, who modertated from Geneva, a self-professed “technical skeptic”, was so impressed by the technical success of the video conference that he proposed it as a model that we need to consider for future meetings.
Both meetings had complementary themes this year: “Community Health” and “Strengthening Health Systems and the Global Health Workforce”, respectively. This session brought together these themes in the context of community health systems.
Here’s who was involved from each side:
- Sigrun Møgedal, HIV/AIDS Ambassador, NORAD, Ministry of Foreign Affairs, Norway
- Frank K. Nyonator, Director, Policy, Planning, Monitoring, and Evaluation Division, Ghana Health Service, Ghana
- Halfdan Mahler, Former Director-General WHO, Switzerland
- Moderator: Louis Loutan, MD, Head, Service of International and Humanitarian Medicine, Department of Community Medicine of Primary Care, University Hospitals, Geneva, Switzerland
- Fazle Hasan Abed, Founder and Chair, Bangladesh Rural Advancement Committee (BRAC)
- Gretchen Glode Berggren, MD, MScHyg, Consultant, International Health and Nutrition
- Molly Melching, Founder and Executive Director, Tostan
- Moderator: Nils Daulaire, MD, MPH, President and CEO, Global Health Council
I’m really happy that I attended this session because of the shift in thinking that it seems to represent. Key quotes from each of the 6 people on the panels (tried to get quotes verbatim, but will be off by a few words):
- “Health must not only be seen as a whole internally, but also externally as an integral part of social and economic development.” -Mahler [he had a beautiful metaphor involving kaleidoscopes, but I didn’t capture it – he also quoted Mark Twain and Niels Bohr]
- “Maybe we can’t do great things, but we can do small things with great love.” -Berggren, quoting Mother Teresa who said this at the Global Health Council Conference in the 1980’s
- “Doing holistic healthcare was hard, it was messy … it lost its energy” -Møgedal
- “We need someone nearby, who tells us what’s wrong, what to do, and where to go.” – Nyonator, quoting an opinion leader from a community in Nigeria describing what is needed in terms of healthcare workforce
- “If 10 people dig, and 10 people fill, we have plenty of dust, but no hole.” -Melching, citing one of her favorite African proverbs
- “Small is beautiful, but big is necessary.” -Abed, describing BRAC’s village health worker system in Bangladesh
There were five themes throughout the session that stood out to me:
- Revisiting Alma-Ata
- Collective impatience
- Listen to the people
- Changing social norms
- Community health workers
- Why it came up: the WHO Declaration of Alma-Ata (PDF) is celebrating its 30th anniversary in September, Dr. Mahler directed the creation of the declaration, the WHO has recently recommitted to strengthening primary health care, and the theme of both conferences and this session were very relevant to Alma-Ata
- There was a “total betrayal of Alma-Ata within months” because structural adjustment programs (e.g. FMI) “sapped energy” from health systems and “made it impossible for developing countries to conduct experiments necessary to test the recommendations achieved by global consensus” -Mahler
- At the time, one of Mahler’s colleagues told him “It is not doable. We must only do what is doable.”
- Alma-Ata is about “bottom-up” approaches and “social justice” -Møgedal
- “It’s not about convincing your adversaries that they’re wrong, but it’s about uniting with your adversaries at a higher level of insight.” -Mahler
- “It takes time.” “We suffer from ‘Instant Coffee Syndrome’.” -Berggren
- Møgedal spoke of an impatience that we have in addressing the problems of global health in the context of a “broad-based global health push”.
- “Let’s go back and listen to the people.” “Everyone deserves a home visit.” “We must return to be more in touch with people.” -Berggren
- We need to think “where people are” and “what makes a difference to people” -Møgedal
- “We must change social norms.” -Nyonator
- Melching spoke of the role of social networks and testimonials (not her words) in effecting behavior change in FGC (female genital cutting) with Tostan in West Africa. She called this the “organized diffusion approach”. The goal was “widespread change of social norms.”
- We need “change agents and fieldworkers.” -Abed
- “How come we keep talking about community health workers without talking about the support that they need?” “Work at each problem … solution in each context.” -Møgedal
- “Community-based health workers need extra arms and legs.” “We must work with groups.” -Berggren
On Tuesday of the conference, I attended the Social Marketing to Facilitate Behavior Change and Action workshop. I personally found it to be very educational, although I did have one gripe (see #3 below). A few thoughts I had during the workshop:
(1) Creating new products and the lead user. In describing the role of social marketing, the facilitators considered the question “how do we make the choice easier [for adopting healthier behaviors]?”. Their answer was “creating new products” and the example they gave was the LifeStraw. A woman from Vestergaard-Frandsen, the company that makes LifeStraw, was in the audience and shared the story of the conceptual development of the product – it seems this was a case of a lead user. One of the fieldworkers who worked on a national Guinea worm eradication campaign created her/his own life straw with reed and some mesh for local use.
(2) Social marketing and social design ethnography. The reason I went to this workshop was to establish a better understanding of how my work relates to social marketing. My work uses applied ethnography for the purposes of design in global health, not just products, but also services and systems. While there is considerable overlap, the idea of creating new products felt like an awkward fit within the framework of social marketing. I expect it was there because it has no other home (e.g. social product design). The danger in placing it in the context of social marketing is that it may ignore the considerable knowledge we have developed and are developing in the field of human-centered design. There is also a difference in the methods. Ethnographic research seems play a minor role in social marketing, and as in many fields, the label ethnographic seems to be used fairly loosely.
(3) Know your audience. The majority of examples (not all) in the workshop were drawn from the US context (e.g. commercial advertisements, surveys, anecdotes), and further weren’t well-contextualized. Not what I expected at a global health conference, with a very international group, where the focus of the workshop was “know your audience”.
(4) Adapt, don’t adopt. One of global health’s strengths is that it borrows from so many diverse fields. The dangers with this are in simply adopting the idea rather than adapting it to the contexts of global health. In the case of social marketing the ideas that have been borrowed are framework (effect behavior change), process (how to understand your consumer), and theory (behavior change models). The typical dangers of doing this are: (a) what is borrowed can be viewed as gospel (e.g. if Madison Ave. does it this way, it must be right) or (b) the ideas don’t progress as they do in the original field (e.g. is social marketing making use of advances in commercial marketing? is it evolving on its own?). I still don’t know enough about social marketing to argue this, but I’ve seen this pattern with other ideas that have been borrowed across fields.
(5) “We’ve already been doing this”. One of the audience members brought up the fact that people have been doing this for a long time in many places and that it simply hasn’t had the “social marketing” label. Agreed, but in my opinion – and that of the facilitators – the value is in the framework. By creating a formal way of thinking, we can improve the social marketing work that people have been doing by other names, and bring it to people who haven’t been thinking in these terms.
Ben was there for part of the workshop and may have more thoughts.
From Ben (cross posted):
I’m leaving Berkeley early to hike a short segment of the Appalachian Trail this Memorial Day weekend before next week’s conference. There will be two presentations on OBA in East Africa. Tuesday 3-5pm Claus Janisch will talk about the Kenya OBA program for targeted subsidies for antenatal and maternal delivery services. Look for the panel A2: “Getting Creative: Innovative Models for Health Care Financing“.
Thursday 2:30-4:30 Richard Lowe presents the eponymous Uganda OBA program’s “Output-Based Aid Program to Treat Sexually Transmitted Infections in Uganda”. Not sure why it’s currently booked in the “Chronic Disease” roundtable section; it’s scheduled for the Ambassador Ballroom (hotel map). I’ll update this post if the room changes. Readers may be interested too checking out the Abt Associates’ Private Sector panel scheduled 1-4:30pm Tuesday.
I’ll be checking in to the conference on Monday night and will be there through the end of the week. On Thursday (29-May), I’ll participate in the Human Resources in Health, Community Health Workers poster session. I’m still planning my schedule for the week, but do know I’ll attend the Get Smart: Technology and Community Health session hosted by AED.
A couple of weeks ago I was lucky enough to steal a few hours of Usha Balakrishnan’s time. I first saw Usha at the Global Health Council meeting in 2006 and was both wowed and inspired – she is a global health mover and shaker with strong business, technology and non-profit experience (read her bio here). She is now devoting her life to a broad range of global health issues. I am writing about our conversation here just to introduce Usha and her new non-profit, CARTHA. We had a refreshing dialogue about a wide variety topics and also about challenges in global health. For example while there has been a very recent surge of interest in global health as a field or major at the university level, we wondered where all the new trainees where going to go and whether there was adequate infrastructure to support smart placements of students eager to give back.
The panel I saw Usha lead at GHC was “The Role of the Private Sector” which had a great line up. As a “founder of the Technology Managers for Global Health (TMGH) group within the Association of University Technology Managers, Usha has introduced global health-related academic technology transfer sessions at key conferences, and has spurred dialog and seminars on a number of campuses in the US and abroad”.
Usha has recently formed her own non-profit – CARTHA which “provides education, training, and professional development programs to inspire Collaborative Doers…—who leverage academic practitioner collaborations to enhance the positive impact of technological and social innovations. CARTHA aims to inspire, link, and help mobilize resources for Collaborative Doers in Academic-Public-Private Technology Transfer Partnerships, Global Health and Corporate Social Responsibility.”
“Global health challenges demand that thinkers and doers from multiple disciplines, sectors, and regions—be linked in new multisectoral collaborations to generate innovative, pragmatic, culturally-appropriate and sustainable solutions. Who will design and build the bridges to connect, activate, and leverage the stores of institutional resources, human capital, and scientific and technological prowess to advance global health causes?”
I encourage you to look into CARTHA and TMGH more, we certainly need more people like Usha who are using their considerable experience to contribute to a global goods “market” and who are enabling others to do the same. We will try to do an interview with Usha in a few months with more detailed advice, perspective and information.