It would be interesting to see a content of analysis of the sort of literature you are looking at to see whether the modernization talk subsides in any way post-Cold War.
How much do you know about Partners In Health? Personally, I feel that worthwhile attempts at real improvement in public health must be framed at the level of grand strategy.
If you don’t read the newspaper, you are uninformed; if you do read the newspaper, you are misinformed. – Mark Twain (attributed)
I wonder about that. A small vignette to illustrate why...Originally Posted by ganulv
Every municipality in the Philippines has a government-run health center, or Rural Health Unit (RHU). Many of these are barely functional. The staff are underpaid and often lethargic to the point of being comatose. Medicines and equipment are routinely sold. Statistics are invented. Little or nothing gets done.
The town I now live in has the most effective RHU I've seen in this country. Same pay, same equipment, same supplies, totally different result. The staff are incredibly proactive: if a pregnant woman hasn't showed up for a checkup or a kid has missed a vaccination, they go out and find them, even if that means chasing them down in the fields or home visits after working hours. Home visits are routine, someone comes by quarterly checking blood pressure, making sure the salt is iodized (we're far from the ocean and goiter is common), checking on sanitary facilities, talking over health and nutrition issues.
Overall the system works extremely well, despite being the same system that works so poorly in so many places. That's partly because this is a tribal community, all the staff are local people, and there's a strong sense of looking after their own. It's also because the doctor in charge is a rather formidable woman of enormous competence and integrity, who tolerates no slacking and takes no scheisse from man or beast.
The lesson of the tale, to me, as that at the end of the day it's about the people. With the right people, even a flawed system can work. If the people on the implementing end aren't motivated or capable, all the grand strategy on earth will get you nowhere.
“The whole aim of practical politics is to keep the populace alarmed (and hence clamorous to be led to safety) by menacing it with an endless series of hobgoblins, all of them imaginary”
H.L. Mencken
What you are describing sounds not unlike how health care works in rural Cuba, except that there all the docs and nurses stay on top of things. Yeah, one clinic with one good doc can make a world of difference (if sufficiently and consistently provisioned) but to make a real dent in public health issues you have to go regional and beyond. The eradication of malaria in the U.S. is an example of the scale I am talking about. The wartime Office of Malaria Control in War Areas was established in 1942 and morphed into the contemporary CDC; the National Malaria Eradication Program was an interagency effort cross-cutting jurisdictions which ran from 1947 into the early 1950s.
If you don’t read the newspaper, you are uninformed; if you do read the newspaper, you are misinformed. – Mark Twain (attributed)
True, for major disease eradication programs you need the grand strategy approach... though even there the effort hinges on effective local implementation. Actually delivering effective health care at the local level requires more than that. If the Cubans can do it, and if individuals can do it in other places, it can be done, and if it can be done with limited resources in some places, it can be replicated.
Sometimes the priorities get skewed. HIV gets more attention than malaria or TB, both of which are arguably bigger problems. Even those get more attention than the combination of invisible combination of malnutrition and parasitism... invisible because it shows up in the data as death from respiratory or GI infections. Grand strategy could be useful in dealing with these problems, especially if it focused on clean water and sanitation (less sexy, alas, than eradication of dreaded diseases), but again effective local primary health care will always be the most cost-effective response.
Last edited by Dayuhan; 05-22-2012 at 03:02 AM.
“The whole aim of practical politics is to keep the populace alarmed (and hence clamorous to be led to safety) by menacing it with an endless series of hobgoblins, all of them imaginary”
H.L. Mencken
Dayuhan hit the point exactly. The most well thought out strategy in the world will still fail if it is not properly executed at the regional/local level. There are a lot of great ideas out there that do not seem to take that into account. This is a big part of my problem when people start talking about the West and the US in particular not doing enough to "fix" this problem or that in developing world states. The solutions to many or most of these problems are at the micro, not macro level. Few states have the resources, never mind the national will, to devote to that kind of work. None that I have seen have shown any particular talent for it in any case. The idea that a Western power can come into a developing world state or region and implement a "grand strategy" that will fix their problems for them is, to borrow a phrase, a fatal conceit.
“Build a man a fire, and he'll be warm for a day. Set a man on fire, and he'll be warm for the rest of his life.”
Terry Pratchett
With the sad reversal of the effective eradication of cholera in Haiti we can see that, yes, you have to get things right at the lower levels if you want a regional or national public health initiative to succeed. But the notion that many or most public health issues is a micro issue is just incorrect. For example, what can be done about MDR–TB at the local level besides treat and isolate infected individuals?
I don’t disagree, but I nowhere said that the West had to be involved at all.
The Musevini-lead anti-HIV/AIDS campaign in Uganda is an example of success at that kind of work, and one which the West (unless you count Cuba, whose role was minor in any case, as the West) did little to formulate or execute.
If you don’t read the newspaper, you are uninformed; if you do read the newspaper, you are misinformed. – Mark Twain (attributed)
The government can provide the drugs or the vaccines or the treated insect nets but it is up to the local providers to implement protocols, treat patients and distribute medical supplies. Dayuhan's vignette is a perfect example of that. If the local provider is simply selling the supplies and equipment that the government provides then the plan fails. Please do not misunderstand me. I am not saying that these problems are only at the micro level. I am simply saying that you cannot ignore the micro level.
Sorry. That was not aimed at you. I was speaking generally because there are a lot of people who do make that complaint. I did not mean to imply that you had.
“Build a man a fire, and he'll be warm for a day. Set a man on fire, and he'll be warm for the rest of his life.”
Terry Pratchett
This vignette also illustrates why the phrase "government-run" is often at the root of a problem, regardless of the government. Correct me if I am wrong Dayuhan, but I suspect that the reason that these RHU's fail more than they succeed is that, like most large scale government programs, there is little incentive for them to succeed and virtually no consequences for failure. The fact that they are Rural suggests that oversight is weak or non-existent. It clearly does not pay well enough to attract the best staff. The fact that the problem is so widespread also suggests that either there is no system for locals to redress problems with the government or that the system is extremely poor. If I was to hazard a guess, I bet that there are occasional (say, around election season) high profile cases where one of these RHU's is investigated and perhaps someone is fired or goes to jail but overall little changes because there is either a lack of incentive or a lack of resources to change things, or a combination of both. When the system is broken that leaves it up to individuals to fix things locally. Dayuhan is fortunate that the head of his local RHU is not only competent and strong willed enough to run an effective clinic but is also willing to do so for a paycheck that does not seem to have attracted the best of her peers to other clinics. That is an extremely rare thing.
This is not meant to be a dig at the government of the Philippines or developing world states specifically. It applies to rich-world states as well. Governments, no matter how well intentioned, tend to be poor stewards of large scale social programs (surprise).
“Build a man a fire, and he'll be warm for a day. Set a man on fire, and he'll be warm for the rest of his life.”
Terry Pratchett
All of this is true, but in many cases there are few alternatives to government management of rural health, especially in developing countries. There's little money in it, and few health care professionals are willing to stick with providing GP and primary health care services out in the countryside when the "good life" in the city beckons. It's not only a problem in the developing world; even in modern countries there's real shortage of physicians in many rural communities. In the absence of material incentive (or the presence of much greater incentives elsewhere) it's difficult to find a fully private sector solution.
Of course there are systems here for oversight, but the systems, like most systems in the Philippine government, often aren't implemented with any great vigor. In much of this country there's an established culture of complacency, self-service, and corruption in government service, and those who actually want to do something find themselves slogging through a morass of bureaucratic inertia.
“The whole aim of practical politics is to keep the populace alarmed (and hence clamorous to be led to safety) by menacing it with an endless series of hobgoblins, all of them imaginary”
H.L. Mencken
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