What’s driving the quiet revolution in basic healthcare?

This article by Romina Rodriguez Pose, ODI, is part of the Wikiprogress #health series.

Rarely a day goes by when the news is not filled with both warnings about possible epidemics and more encouraging tales of medical breakthroughs. And yet, while these often extreme perspectives occupy the limelight, more nuanced and in-depth understandings of how and why things are working in certain countries and not in others remains relatively unheard.

Health is a key component of ODI’s Development Progress project, which for the past three years has been documenting national-level case studies (on what is working in development and why), enabling us to reflect on how far we have come in addressing basic health issues around the world and uncover hidden stories of progress.

The project’s first-round health case studies explored progress in Bangladesh, Eritrea and Rwanda and were carried out between 2009 and 2011. The second round, currently underway, has two focus areas: maternal health (with case studies in Nepal and Mozambique) and neglected tropical diseases (NTDs) (Sierra Leone and Cambodia).

Maternal health is intrinsically important because people’s prospects in life depend on it to a large extent. It is also a proxy for the capacity and strength of health systems and government’s ability to deliver core services. NTDs are of particular interest as they disproportionally affect the world’s poorest and are dependent on and can accelerate progress in a range of other development areas (poverty, nutrition, water and sanitation, women’s empowerment, education).

Although these countries represent very different local contexts, we can identify clear and consistent factors driving progress across them all:

• Strong leadership and sustained political commitment have been key to pushing through reforms and engaging populations in development processes. Progress is not possible without the prioritisation of health within governments’ agendas.

• Bottom-up approaches invoking social mobilisation and community participation were the cornerstone for progress in all three case studies in the first round, and preliminary findings from Nepal and Sierra Leone support this trend. Community participation and involvement in health service delivery have not only helped alleviate staff shortages, but also proved extremely effective in accessing hard-to-reach populations, bringing services closer to the community while at the same time allowing for behavioural change. They have also transformed community members from being passive recipients to being active participants in their own development and wellbeing. Among other things, the empowerment of women and their increased decision-making power in health matters has been key in both Bangladesh and Nepal.

• The role of donors has been instrumental, not only financially but also through the provision of evidence of successful schemes in similar countries. All the countries studied are heavily dependent on external funding, but all have mechanisms to ensure funding is aligned with national planning (e.g.implementation of health sector-wide approaches has helped governments shape health policy, strengthen delivery and make health financing more predictable and flexible). Balancing government ownership of a development agenda with outside help can be challenging but is essential to ensure commitment and sustainability. Ownership varies across the countries studied, with some governments acting more strongly than others in responding to priorities on the development agenda.

• Both demand- and supply-side interventions have been put in place and contribute towards progress in health in these countries. Community health insurance schemes (e.g. mutuelles de santé in Rwanda) and removal of users fees (e.g. free health care for pregnant and breastfeeding women and children under five in Sierra Leone) have boosted demand for health services by removing financial barriers for underserved populations. From a supply point of view, rewarding health service providers for their performance incentivises them and enhances their commitment to working to higher standards in the delivery of services, although strong controls and quality checks need to be in place.

Despite the high levels of progress these strategies have attained, challenges remain. For instance, the provision of health services has relied widely on community involvement and voluntarism. Despite volunteers being rewarded in terms of respect shown by members of their communities and by the few incentives in place (e.g. provision of mobile phones, T-shirts etc.), keeping them motivated is becoming increasingly challenging. In the same vein, progress has been possible as a result of the financial flows provided by donor countries, which puts sustainability in question, as aid budgets in the developed world are under threat. As such, there is still a need for countries to mobilise internal resources in order to reduce their dependence on aid.

The bigger picture, however, should put a spring in our step. We can state, without doubt, that progress in health care is happening and reaching the most underserved populations in the poorest countries in the world. The increasing body of evidence documenting how progress has been achieved in some settings provides a great opportunity for policymakers from countries facing similar challenges to get inspired by successful strategies and best practices that have worked elsewhere.

From the Bottom to the Top: One Step to Improving Global Sanitation

This article by Robbie Lawrence, Wikichild Coordinator, considers how global sanitation can be improved in the context of the International Federation of Red Cross’s ‘Getting the Balance Right’ report. This is part of the Wikiprogress #Health Series. 

"Communities in rural areas and urban settlements must be empowered to increase their resilience through access to safe water, improved sanitation and effective hygiene promotion." Getting the Balance Right, International Federation of Red Cross, 2013

This post follows on from Wednesday's blog on the dangers of diarrhoea by focusing on the disease’s chief causation: poor sanitation. Currently 3.4 million people die each year from water, sanitation and hygiene-related causes (Water.org). An estimated 2.5 billion do not have access to basic sanitation and 1.1 billion of those people practice open defecation. This is not only degrading but a severe health risk as fecal matter-oral transmitted diseases cause at least 1.5 million deaths per year in children under the age of five (Getting the Balance Right). As Gary White and Matt Damon so bluntly put it, by the time you’ve read this paragraph, another child will have died from something that is eminently preventable.  

In the same way that inequality has reared its head in the post-2015 discussions, forcing global leaders to consider how poverty reduction might be carried out more equitably in the future, it is evident that we need to address water and sanitation issues. The "Progress on Drinking Water and Sanitation 2012" report by the WHO and UNICEF highlights that, although the MDG target of halving the number of people globally without access to improved water source will be fulfilled by the MDG 2015 deadline, the target for sanitation is unlikley to be met.  

More often than not aid donors and development agencies have aimed at providing clean and safe water supplies rather than making sanitation a priority. As it stands, sanitation only receives 12 percent of global aid put towards combatting water and sanitation related issues. In the short term this trajectory make sense, since water is usually in more immediate demand, however, if diarrhoea and other hygiene related illnesses are to be dealt with, access to sanitation facilities must be increased. The ‘Getting the balance right’ report emphasizes that ‘neither water nor sanitations is more important: both elements are required to maintain and improve health and dignity.’

Water.org argues that the inability of philanthropic efforts to efficiently deal with the problem of poor sanitation has been a problem in the past. Even the money that has gone towards solving the issue has largely missed the goal of providing relief for those most in need. The organization recognized that if local communities were to make progress, independent of donors, then they must be viewed and view themselves as the owners of the project. Community ownership is the linchpin of Water.org’s philosophy. Without an active engagement from communities from the start of a project to its completion there is a strong likelihood that previously entrenched social norms such as public defecation will continue.

The ‘Getting the Balance Right’ report delivers a similar message, and uses a number of examples of community-based initiatives that have succeeded in improving sanitation. In Eritrea, a country where only three percent of its rural population has access to sanitation, the IFRC and the EU implemented a program focused on mobilizing and educating women in hygiene knowledge that reached a total of 145,000 people in 120 villages. By empowering these local women and providing them with  information, the program motivated them to become promoters of sanitation within their own communities. The Water.org website also lists various bottom to the top initiatives that have shown remarkable success rates. An Emory University review of a Water.org community based ventures in Lempira, Honduras reported that 100 per cent of the project sites were still operational after 10 years with 98 per cent of respondents satisfied with the system.

Since poor sanitation is now firmly in the crosshairs of policy makers and aid groups, it seems that the Water.org and IRFC have laid out a fairly effective framework for combating the problem. Changing intrinsic social norms from the routes of a community appears a far more effective means of catalyzing change than large, trickle down cash injections. The flow of international water aid must of course be rebalanced towards sanitation, but organizations, governments and NGOs need to go further and ensure that it reaches the right groups and individuals. The stark reality of IRCF’s report brings to light the vital role that sanitation plays in human health and dignity:  

"Let us speak clearly; the single largest cause of human illness globally is faecal matter. A society – regardless of how many clinics or water supply points it has – can never be healthy is human waste is not safely disposed of." Getting the Balance Right

Robbie Lawrence

Childhood Pneumonia and Diarrhoea KILLS!

This article, by Ousmane Aly Diallo, Wikiprogress Africa Advisor, is part of the Wikiprogress Health Series. Wikiprogress Africa aims to  provide a platform for knowledge sharing on measuring progress and well-being in an Africa context. 

“We know what works against pneumonia and diarrhoea – the two illnesses that hit the poorest hardest. Scaling up simple interventions could overcome two of the biggest obstacles to increasing child survival, help give every child a fair chance to grow and thrive”, Anthony Lake, UNICEF Executive Director.

The Lancet recently published a series of papers on Childhood Pneumonia and Diarrhoea in collaboration with the Aga Khan University of Pakistan, in April 2013.  The series demonstrates that it is possible to eradicate the prevalence of these two diseases among children through a comprehensive strategy involving all the stakeholders and highlights the barriers that have enabled children’s death from it.

Pneumonia and diarrhoea are low in incidence in the developed world but remain serious health concerns in the developing world. Childhood Pneumonia and Diarrhoea are particularly lethal in the developing world; nearly 90% of the children who died from these diseases are from Sub-Saharan Africa and South Asia, according to a recent World Health Organization report.

Assessing  the global burden of childhood pneumonia and diarrhoea in the world,  Walker and Alii’s paper show that these two diseases remain the leading infectious causes of death in children younger than 5 years, and caused an estimated 700 000 and 1·3 million deaths, respectively, in 2011. 

According to the study, more than half of the burden (56% of severe episodes of diarrhoea and 64% of severe episodes of pneumonia) is upon 15 countries and among this category, 10 of them are Sub-Saharan Africa’s ones: Angola, Burkina Faso, Democratic Republic of the Congo, Ethiopia, Kenya, Mali, Niger, Nigeria, Tanzania, and Uganda. Most of these deaths could have been prevented through vaccines and other means of prevention according to this study. Besides, undernourishment constitutes another obstacle to these children’s survival. Any program to tackle childhood pneumonia and diarrhoea should include a facet on improving child nutrition.

Lack of national leadership in the fight against these diseases and a lack of financial resources are important bottlenecks. This, coupled with the inadequate training of health workers, and a lack of health indicators, are key obstacles that need to be addressed to lower the morbidity rate of pneumonia and diarrhoea among children and to improve their survival rates, for these authors.

The second paper on “Interventions to address deaths from childhood pneumonia and diarrhoea…” shows that scaled interventions could save 95% of diarrhoea and 67% of pneumonia deaths in younger children (under 5 years) by 2025. But to reach that goal, the emphasis must be put on community-level healthcare as it is the best way to reach the most exposed populations. 

This series show that childhood pneumonia and diarrhoea are serious health concerns in many developing countries, particularly in Sub-Saharan Africa, but that they could be eradicated through prevention (immunisation campaigns) and effective intervention. In its subject and objectives, this series echoes the recent publication by the World Health Organization and UNICEF, the Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea. This plan aims to reduce by 75% (with 2010 levels as reference) the incidence of severe pneumonia and diarrhoea, as well as the death from both these diseases among children under-five. It also aims for a 40% reduction in the global number of children under five who are stunted since undernutrition is one of the key risk factor for children suffering from pneumonia and diarrhoea. There’s a global commitment to ending child death from preventable diseases and these two Lancet publications show that this objective is reachable if all means are galvanised.

Childhood diarrhoea and pneumonia are deadlier in low-income countries of Sub-Saharan Africa and South Asia than in the developed world. Closing the gap is one of the ultimate aims of the Lancet series as shown through different models, it is an objective that is within our reach.

To find out more about Wikiprogress Africa, click here. 

Ousmane Aly DIALLO
(Wikiprogress Africa Advisor)

Yes We Can and Yes We Must! Measuring Well-being and Progress in Developing Countries

This article, by Salema Gulbahar is part of the Wikiprogress series on the Global Forum for Development 2013 and post-2015, it reports specifically on the “Measuring Well-being and Progress in Developing Countries” session at the Forum.

Martine Durand opened the session and outlined the key questions to be addressed by the three panellists (full profiles below):

1. Does it make sense to talk about a more holistic approach to development when millions of people in developing countries still confronting extreme poverty and have unmet need for basic services including food, shelter and basic health care?
2. What is the relationship between concepts such as poverty, social cohesion and progress?
3. Can well-being be measured in countries that have less developed statistical systems, and what have been the specific challenges for Morocco and Mexico as they endeavored to do this? 

Photo by OECD/Christian Moutarde of  Mr. Olusegun Obasanjo, Former President, Federal Republic of Nigeria

“Yes we can and yes we must” measure development using a more holistic approach insisted Allister McGregor. There is a need for a common framework to assess and measure development for well-being in developed and developing countries as the boundaries between the two are becoming blurred.  The OECD provides a conceptual framework that can be taken and applied to individual country context. People’s well-being and aspiration can be expressed in most languages. 

Conceptually what is happening?

Income has been substituted for well-being and it was assumed that growth will deliver well-being for everyone but this is not so. To deliver well-being for everyone a  multi-dimensional approach is required. This does not replace existing measures as people still need food, shelter and water. Well-being is achieved though relationships, thus one needs to understand that well-being is a social concept. Methodological innovations are important as previously we suffered from ‘one size fits all’ idea.

"If people are what development is about, why do we not put them at the heart of our thinking and our measurement of development? "Allister McGregor.

Decision makers need to take the voices off the poor into consideration.  We need systemized, regular consultation, to include these voices in the global conversation – a bottom up approach. But everyone wants something different, so political systems need to be able to integrate the voices of people that are never heard, with a vision of where we are going ultimately. We should use human well-being as a focal point as it goes beyond income.

Gerardo Leyva Parra addressed the challenges for Mexico in developing well-being measures.  The first challenge was convincing people within the institution that measuring well-being beyond GDP and happiness in Mexico was possible and not only for developed countries.  They realised the potential for using well-being as a key tool in the measurement of development in Mexico.

Finding specific indicators was a challenge and thus the discussions were taken outside the walls of the institutions, involving government officials, think tanks, civil society and the private sector.  This continuous dialogue is essential and the need to be able to communicate that going beyond GDP and measuring happiness does not mean forgetting about basic material needs. The next step is to ensure that the new indicators are integrated and taken up by decision makers.

There is also a need to look at subjective well-being statistics from a positive rather than normative perspective. The micro data of subjective well-being surveys can provide valuable insights about the drivers that allow some people to live happy, more satisfactory and meaningful lives than others.

Mexico: Key learning from the process: 

1. Develop relevant indicators, with all stakeholder involved in the decision
2. Communicate the measuring progress beyond GDP concept
3. Keep in touch with relevant stakeholder with continuous dialogue to ensure indicators stay pertinent.

Providing decision maker with the data necessary to allow them to make informed decision about people’s well-being.

Khalid Soudi discussed the Morocco experience. Since the 1990s, the country has developed qualitative questions and found a divergence between the indicators and the perspective of the population. Thus a gap emerges between the finding of objective and subjective well-being responses, this highlights the importance of capturing people’s views.  

Morocco has three elements in its approaches and the global objective of providing decision maker with the data necessary allow them to make informed decision about people’s well-being:

  

• Social economic indicators – it has developed pallet of indicators on different dimension of well-being (the choices were dependent on the population – legitimized by people).
• Quality of life measurements - taking into account the affects and constraints people face and how this contributes to people’s well-being generally.
• Subjective well-being with different domains.

For several years, the HCP has been collecting and analysing qualitative data on public perceptions of their economic and social realities by:

• Including modules and subjective questions, of quantitative nature in regular surveys
• Conducting qualitative surveys (business, household, economic, survey companies etc. on the perception of the development of living standards).
• Implementing several analytical projects combining objective and subjective perceptions of the population data.
• Calculating and publishing the quarterly index of consumer confidence.

Morocco carried out a national study that included:

• a sample of: 3,200 people aged 15 years and older (including 2,080 in urban areas),
• a household questionnaire on socio- demographic characteristics of its members and living conditions,
• an Individual questionnaire on well-being (given to one adult per household) and
• a classification of fields and factors of well-being that were developed and validated on the basis a pilot survey.

Three groups of well-being dimensions were identified (see slide): 1) material well-being -  housing and income, 2) social domain - employment, health and education and 3) societal domain - family life and social environment including cultural, spiritual and recreation aspect of life.

See the full presentation, here.

Read the full background paper: Measuring Well-Being for Development

The session was moderated by: Ms. Martine Durand, Chief Statistician and Director of Statistics Directorate, OECD

Panelists included:

• Mr. Khalid Soudi, Observatoire des Conditions de Vie de la Population, Haut Commissariat au Plan, Morocco (Download PPT)
• Mr. Allister McGregor, Institute of Development Studies (IDS), United Kingdom
• Mr. Gerardo Leyva Parra, Deputy Director General for Research, National Institute of Statistics and Geography (INEGI), Mexico  

Watch the video broadcast of the Forum, here.

Salema Gulbahar

(Wikiprogress Coordinator)

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Health Week in Review

This Week in Review by Robbie Lawrence, Wikichild Coordinator, is part of the Wikiprogress Health Series.

Hi everyone and welcome to another #Health related Week in Review. This week we are focusing on an array of health related topics, ranging from social progress to reports on nutrition.  Highlights include: The Social Progress Index, the IFPRRI’s Global Hunger Index, a look back at World Water Day and UNICEF’s recently released Child Nutrition report.

*This year, the Social Progress Imperative released its now annual Social Progress Index, a tool that ranks national, social and environmental progress across 50 countries representing three quarters of the world’s population. The Index will display how well countries provide for the non-economic needs of their citizens, enabling leaders in different sectors to effectively target a country’s social and environmental challenges. SPI hopes to expand the index each year so that 120 countries will eventually be included.

*As we reported last week, The Institute of Development Studies’ has issued its new Hunger and Nutrition Commitment Index, a measurement of political commitment to tackling hunger and malnutrition in 45 developing countries. This tool follows on from the International Food Policy Research Institute’s Global Hunger Index, published in January. The GHI is put together to comprehensively measure and track hunger globally by country and region and highlights successes and failures in hunger reduction. It also provides insights into the drivers of hunger in a bid to raise awareness and catalyze action.

*On Monday, UNICEF published Improving Child Nutrition: The achievable imperative for global progress which revealed that significant global progress has been made in tackling stunting – the long-term effect of hunger and malnutrition. The evidence laid out in UNICEF’s report and the momentum generated by their successes shows that improving child and maternal nutrition is an achievable necessity for global progress. If you haven’t read it already, check out our blog on the report.

*The OECD Mental Health and Work Project has launched a new series of reports focusing on how mental health and work is being tackled in a number of OECD countries including Belgium, Denmark, Norway and Sweden. According to the OECD, tackling mental health of the working age population should become a key feature of future development frameworks. .

*A recap on World Water Day, as access to clean water is so fundamental to health. The event is held around the world as a means of focusing attention on the importance of freshwater and advocating for the sustainable management of freshwater resources. As climate change and political and social conflicts reduce fresh water supplies, nearly 800 million people are without clean or safe water and almost 40% of the world’s population do not have access to sanitation. Next to pneumonia, diarrhea is now the biggest killer of children between one month and five years old. Follow the #igiveashit feed to find out more.

We look forward to more #health related articles next week!

The Wikiprogress Team