It went OK

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It went OK. Or rather, it is going OK, because we’re four days into a five day training programme that I’m running, and my assessment is that we’re pretty much where I wanted us to be by now.  And actually we won’t really know if it went OK even after tomorrow, because after tomorrow the people I trained will have to go and use what we’ve worked on to do some research.  And even after that, we’ll only really know if it went OK if the results of the research end up changing things for the better.

I’m freelance and I work in development, which invariably means taking on work without knowing exactly how it is going to play out.  You get a short period of time to do something that is worthwhile for the people you are trying to serve (I mean the real people, the poor or the marginalised or the participants or the beneficiaries if you prefer old-fashioned terms).  Worthwhile for them but in a way that the client (the donor, the government, the technical agency, the NGO etc) will actually recognise. Because the two things don’t always join up.  A lot of development work is about good stories, not results.

It’s going OK because the client gets it and is supportive and has let me get on with it, by and large. It’s going OK because the participants, are joining in and making the most of it and, I think, learning quite a lot from it.  And I think when they go out and do the research, they’ll do a good job.  A very good job for a group who have, for the most part, never been trained to do anything like this and who are, by all accounts, treated like shit by most of the people in the towns they live in.

Also, I think it is going OK because I’m having a good week.  With these things there isn’t much scope for having a bad one.  Earlier this year I had a bad week and some unlucky client and even unluckier participants got me for that week.  I wrote a report and I got paid, but if I hadn’t been having a bad week it would have been a whole lot better.  It’s a bit haunting because I’m well paid and a lot is expected of me, and the people I’m supposed to be working for (the real people) don’t get much support.  I suppose occasions like that are where the image of the fly-in fly-out consultant who cares only about invoicing comes from.  I’ve never much believed in that image: I think it’s more a case of, we try our hardest, but sometimes we aren’t given a chance to do a good job, and sometimtes we just suck.   

But anyway this week it went OK, and I think we’ve got a good chance of it continuing to go OK, and that makes it worthwhile.

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Learning from the global response to HIV/AIDS

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It is encouraging to see more and more thought being put into figuring out what the global response to HIV has taught us about delivering health care and promoting public health.  There has been a particular buzz recently in the lead up to a big UN meeting on non-communicable diseases (NCDs), with short comments in the New England Journal of Medicine, and PLoS Medicine, as well as action by AIDS activists to push for concrete commitments to tackling NCDs, as described in this Guardian article.  

The pieces referenced above focus very much on the “top-level” principles; they mention things such as financial political commitment, involvement of communities and advocates, and lessons that can be drawn about taking a “vertical” programming approach and the impact that it can have on health systems; as well as more technical issues such as the importance of good disease surveillance systems and linkages between different services at local level.  It is nice to see that the authors of the PLoS article focus not just on the positives but also on the things that were done to respond to HIV that definitely shouldn’t be repeated.  Also encouraging is the recognition that much of what has been done in the name of HIV prevention has been based on limited evidence.

An article published earlier this year in Global Public Health goes into more detail, and I hope we see more in-depth studies that explore the different mantras of the response to HIV.  I hope in particular that research in this area tells us more about how to maintain the links between health and human rights and how to best serve the needs of highly vulnerable and marginalised people, and that it helps give more structure to some of the more vague mantras such as community action, multisectoralism and leadership.

Also, AIDS hasn’t gone away and current and future programmes also need to learn these lessons… it’s not as if they’re all getting everything right.

Community-based monitoring

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Originally posted here (Google+).

I’m reading loads of stuff about community based monitoring of health services, like community scorecards of health worker performance (Bjorkman, M. and J. Svensson (2007). Power to the People: Evidence from a Randomized Field Experiment of a Community-Based Monitoring Project in Uganda, http://vle.worldbank.org/bnpp/en/publications/governance/power-people-evidence-randomized-field-experiment-community-based-monitoring) and community monitoring of diseases (Maes, E. and S. Zimicki (2000), http://www.aed.org/Publications/upload/GhanaCBSEvalrep_3-00.pdf). In both cases lay community members are trained to participate in the monitoring process. The first reference is an RCT which showed significant results in improving the quality of care.

It’s obvious that for an approach like this to work, whatever is being monitored needs to be objectively measurable. What I also assume, though, is that it is also important that whatever is being monitored needs to matter to the people doing the monitoring. In the first example, things like waiting times, availability of health care personnel – I’m pretty sure they matter. In the second example, the specific diseases being monitored were fairly common and “felt”, so I reckon they mattered too. 

On the other hand I’ve seen a few community monitoring projects where communities are encouraged to monitor things that they probably don’t really care about. Things like immunization rates or mosquito net usage rates (as opposed to the positive outcomes of these). And because they don’t care, they have to be given some other sort of externally provided incentive to do the monitoring like, for instance, a community party being thrown for them if they hit their targets. I understand the importance of incentives and of using them creatively but I reckon, as much as possible, it is probably preferable to try and find incentives within the positive impacts of what people are doing (i.e. my incentive is that I get better care) rather than relying too much on unrelated ones (i.e. I worked to improve health care so that I could get a free t-shirt). 

The other thing is, a lot of discussions of this problem focus on a particular issue: the notion that “national” or “donor” priorities are imposed on communities and that as a result communities are forced to monitor things that are not important to them. (See for instance O’Meara, W. P., B. Tsofa, et al. (2011). “Community and facility-level engagement in planning and budgeting for the government health sector–a district perspective from Kenya.”, http://www.hubmed.org/display.cgi?uids=20888061). This is a problem, but it’s also a reality that sometimes, a national point of view can reveal things that a community one cannot. Patterns of HIV infection, with its long latency period and its tendency to affect marginalised groups and behaviours, are more easily picked up in national surveys than in local conversations. It doesn’t make the problem any less real.