[afro-nets] New Book: Critical Elements for Improved Global Health

[Ruth Hope <RHope@s-3.com>]

New Book: Critical Elements for Improved Global Health
------------------------------------------------------

I have been forwarding the following book review (I have not yet
read the book) which I think should be of interest to AFRO-
Netters!

Ruth Hope
mailto:RHope@s-3.com


-----Original Message-----

Critical Elements for Improved Global Health

Many people consider the health problems of the developing world
to be insoluble. Tales of incompetence, corruption, governments
with inadequate resources, and misguided policies favoring the
urban well-to-do make the possibility of large-scale public
health program success seem vanishingly small, even with sub-
stantial donor inputs.

"Millions Saved" is an attempt to counter that view. The book
provides seventeen diverse cases of success in overcoming, or at
least controlling, a wide range of major health problems. These
successes take place on a large scale, in countries that are
among the poorest on the globe, over a long duration (more than
five years), and at reasonable costs. The criteria for choosing
the cases, the demanding requirement for solid evidence that the
health improvement was caused by the interventions, and the at-
tention to costs and economics all add to the strength of the
demonstration. They support the implication that these health
problems can be overcome in other developing countries and that
the rich countries ought to be supporting such efforts.

These undeniable successes, however, in turn raise questions.
Are the methods replicable and likely to have the same impact in
other settings? Are the successes sufficiently likely and low
cost to kindle enthusiasm among donors to provide the kind of
the long duration funds that these seventeen cases needed? Can
one apply the lessons learned from these cases directly to other
health problems, in different settings, and still get the same
success? And are today's investment patterns in global health
likely to lead to these kinds of successes?

The cases in the book were developed under the aegis of the Cen-
ter for Global Development, a Washington, D.C.-based, nonparti-
san think tank, which assembled a group of fifteen experts in
global health, public policy, and development economics to form
the What Works Working Group. Through the National Institutes of
Health's Fogarty Center and its Disease Control Priorities Pro-
ject, the group tapped the expertise of more than 300 authori-
ties on international diseases, interventions, and health sys-
tems to identify candidate cases. These candidates were then
analyzed against demanding criteria: scale, duration, importance
of the problem, cost, and ultimately impact. The group put par-
ticular emphasis on the quality of the evaluation data-that is,
could they demonstrate not only that impact had occurred, but
also that it had been the result of the intervention, rather
than an accompaniment of economic improvement, improved educa-
tion, or other non-health improvements in the environment of the
improving health indicators?

The resulting cases are convincing. The interventions chosen had
substantial health impact, at reasonable cost, often with major
positive economic impact, over long periods of time, and on a
large scale in some very poor and difficult environments. The
authors include an analysis called "connecting the dots for suc-
cess" in which they analyze the ingredients common to all of the
cases. These are "political leadership and champions, techno-
logical leadership and innovation, expert consensus around the
approach, management that effectively uses information, and suf-
ficient financial resources." The implication is that these
kinds of successes are there for the taking, that we have
learned how to do it, and that we should go out and do likewise
elsewhere.

I don't believe that this is the case. In fact, neither do the
authors. They cite a half-dozen "wows"-conclusions apparently
surprising even to them: (1) Success is possible even in very
poor countries; (2) local governments can do the job and at
times can even pay the cost; (3) bringing about behavior change
is the most fundamental element in addition to technology; (4)
international coalitions and partnerships can be critical, par-
ticularly for regional and global efforts; (5) attribution of
measured outcomes and impact to the interventions is possible
(although often not available because of cost); and (6) suc-
cesses are not always the result of vertical programs and cam-
paigns such as polio eradication.

But the fact that these "wows" are surprising is itself good
evidence that successes such as these are not readily attained.
For example, regarding the first two "wows," very poor countries
typically make only minute per capita investments in health.
This leads to all kinds of lacks: lack of personnel to pay ef-
fective attention to a particular problem, lack of vehicles to
put supervisors into communities to work with outreach workers
and community volunteers, lack of an information system to pro-
vide managers with the means to improve performance, and lack of
skills and experience among the available workforce. Also, the
private sector is often a major part of developing countries'
health systems, but health ministries often have little interest
or skills in using and effectively influencing the private sec-
tor to accomplish public health goals.

Regarding vertical programs and campaigns, although they are not
essential, donors tend to prefer targeted investments, narrow
and clearly defined outcomes, and structured programs and pro-
jects. Such efforts lend themselves to clear contracts with im-
plementers and give the expectation (some might say illusion) of
predictable results. In poor countries' donor environment, the
broad support needed to improve the service delivery system as a
whole is often lacking. Systems with structural and functional
deficiencies not only do poorly at providing general health care
but often are unable to support targeted vertical programs.
Working in West Africa on a USAID-funded diarrhea technical as-
sistance project, we found that we often had to take action to
improve the general supply logistics to get oral rehydration
supplies available dependably at peripheral health posts and
centers and to improve other general system functions. Oral re-
hydration fluid turned out not to be the "simple solution" to
diarrhea we had naïvely thought it to be!

Perhaps the most important factor in improving global health is
information for management of performance. The hand and paper
systems that dominate many health ministries in poor countries
produce data slowly or not at all. Even when information is
available rapidly, managers are not accustomed to using it to
identify and solve performance problems. The programs repre-
sented in Saving Millions had to have effective information and
management systems; they had to be actively using monitoring and
evaluation data in improving performance at all levels to get
the results we read about here. This same information was criti-
cal as well for documenting impact and using those data to mar-
ket the program's activities to government decision makers and
private donors. But such effective information systems are the
exception.

Overcoming these challenges is possible, as these cases demon-
strate, but could hardly be considered customary. Clearly, long-
term investments by private-sector donors and governments are
needed, so that efforts to improve support systems and targeted
vertical programs and projects may proceed. Donors want to do
the right thing. Perhaps this well argued book will help encour-
age them to invest in health and also to include in those in-
vestments the range of critical elements needed for success.

by Robert S. Northrup

--
Millions Saved: Proven Successes in Global Health
by Ruth Levine and the What Works Working Group, with Molly
Kinder (Washington: Center for Global Development), November
2004), 167 pp., US$ 26.95; ISBN 0-88132-372-1

The full book and additional information - including interactive
maps, a teachers? guide, and a short video - are available
online at:
http://www.cgdev.org/publications/MillionsSaved/