The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. This is the sixth and final in a series of posts from the conference.

It’s now been a month since Forum 2009, so it’s time to wrap up any remaining thoughts from the meeting. My intention with these posts was never to provide a comprehensive view of the conference. If you’re looking for that, or simply additional insights into the meeting, I recommend the following resources:

1. Priya Shetty’s coverage of Forum 2009 for the SciDev.Net blog, five posts
2. TropIKA.net comprehensive coverage of Forum 2009, including daily reports and session reports

On my Cancún-bound flight out of Havana, on the morning of the 20th, the woman sitting next to me asked me for help with her Mexican immigration forms. As I was helping her, I asked what she did. “Terapista”. She asked what I was doing in Cuba. Attending “un congreso de investigaciones de salud pública”. She was a Cuban physical therapist going on a three month medical mission to Tecate in the Mexican state of Baja California, via Cancún, Mexico City, and Tijuana. I spent most of the short flight asking about her experiences on previous missions, all to Mexico, and probing for more details about the Cuban health system. Most memorably, she was quite proud of a unique surgical treatment the Cubans have developed for Parkinson’s disease.

I spoke about the medical assistance Cuba lends to other countries in an earlier post. The photo below of the 20 convertible peso note reinforces this. It touts Operación Milagro (Wikipedia link in Spanish), a joint program between Cuba and Venezuela with official aims similar to Cuba’s other medical mission efforts.

While I was speaking to this terapista on the plane, it occurred to me how important the setting of the conference was given the innovation theme. I don’t think that this was lost on many of the conference participants given external interest in the Cuban system, Cuban participation on panels, and various site visits. Still, there were three circumstances that limited knowledge exchange between the visitors and the Cubans:

1. Language barriers. There wasn’t very much communication between the several hundred Cuban participants and the external participants, especially those from outside Latin America. This was due in no small part to language barriers. Simultaneous translation took place during the larger sessions (UN-style headsets), but the smaller sessions didn’t have any and the informal exchange was visibly limited between the two groups.
2. An apparently flawless system. The Cuban health system may have been the talk of the week, but it was presented without fault. Even though it may be one of the best systems on the planet, it is not immune to needing improvement. Without a realistic understanding of the challenges, it was hard to understand the true effectiveness of the system. (In comparison, Minister of Health Chen Zhu was frank in talking about elements of the Chinese health system that need improvement, for example indicating in his plenary talk that many public clinics in China operate like private clinics.)
3. No U.S. government employees in attendance. There were certainly Americans at Forum 2009, but because of the restrictions associated with the U.S. embargo – it’s a bloqueo the Cubans said, since an embargo implies wrongdoing – there were almost no representatives of U.S. government institutions. I didn’t realize this myself until a colleague from the WHO pointed it out to me. He cited the example of his colleagues from the CDC who were not permitted to attend. Looking through the participant list, I only spotted one, someone from USAID. It’s unfortunate because there was a big opportunity for learning in both directions. In any case there were strong suggestions that we are months away from ending the embargo/bloqueo. Time will tell.

And here’s a post Aman wrote for Global Health Ideas about the Cuban health system two years ago: Lessons from Cuba: Healthcare Infrastructure and Information Systems.

We are really glad to have another guest blogger. Kriti from Epidemiology Tales: Stories Exploring Public Health & Life
is the author of the post below. We look forward to more posts in the future, be sure to check out her global health blog for more information.

Female Feticide: from Motherland to Diaspora

Up- country: Diya, an activist who educated women on female feticide, was recently married. She was 20 years old, and about to give birth. She was riding in a car hurtling over potholed roads toward the town hospital. Although at home, they claimed they would be happy for any child, “We like girl-children as much as boy-children,” her father-in-law would say, but she knew the reality was far different. Her mother in-law was next to her, looking tense with anticipation. She lived with her in-laws, customary in rural India, and did not have good relations with them: they were angry she had a love marriage with their son and a mind of her own.

“You had better give birth to a boy,” her mother-in-law hissed to her, as Diya’s labor pains intensified.

City: Jassi, the wife of a successful, well-known Bombay businessman, and already mother of two beautiful daughters, was pregnant with a third child. The women in her society (apartment complex) were anything but congratulatory. They admonished her, “why don’t you have a test done?” implying that she should make certain not to have yet another girl.

I was shocked to hear these stories. Both of these women, loosely based on women I’ve known, had healthy baby boys. But their problem is real, and getting worse: the number of girls for every 1,000 boys (sex ratio) went from 962 in 1981, and with the improvement of sex-testing technology, dropped to 927 in 2001. It was as low as 814 in Delhi.

At first glance, it seems like this is an economic issue, as some middle class families claimIn Spite of the Gods: The Strange Rise of Modern India, he talks about a woman from such a wealthy family, that her dowry included a Mercedes and Switzerland vacation. Even she was forced by her husband’s family to abort her baby girl, although many women themselves believe in this practice.

Shockingly, this practice continues in the US. Census data shows that for every child born subsequent born after the first in Chinese, Indian, and Korean families, the likelihood of that child being a boy increases.

Female feticide is because of many traditions and perceptions, as well as economic and social factors coming together. Girls are seen as economic liabilities destined to leave their homes, as they traditionally go live with their husband’s family after marriage. Male children, who never leave their parents (and doing so would raise eyebrows), support them in old age. Male children earn money for their parents through jobs and dowry. Female children, however, do not. Many are not allowed to work nor offered education, and dowry continues, even among educated, well-traveled, urban elites – furthering an already insidious gender bias.

There are some successful interventions, like empowering women through education, economic power, and allowing them to take greater control of their lives – and this is where I’d like my life to focus. Before translating and preparing training materials at CORD, I never realized how deeply rooted this practice is in Indian culture. To me, Indian culture is laced with quirks, visible and invisible, but I always felt some pride and loyalty in my heritage. But this level of hypocrisy and brutality is astounding. A sign in Mumbai reads, “It is better to pay 500 Rs now than 50,000 Rs (in dowry) later”.

Though the topic makes periodic appearances in international news, and many interventions are taking place, ultimately it rests on changing social norms: At weddings, including mine, there is a prayer to bless the new couple. It states tellingly, “May you have sons”. But Babaji (my grandfather-in-law), the eldest person at the event, added “or girls, because everyone is equal now.”. Andhra Pradesh, a more progressive state, offers hope with a girl-favoring sex ratio, closer to natural patterns. – but female feticide is rising fastest among wealthier couples. In Edward Luce’s

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Thanks for checking back to this blog after a long time! I’m getting re-started, and continuing to explore issues in public health that pique my interest (or deeply sadden me, like this one). You’ll notice some changes in the look and layout, all to be easier for you. Would love your feedback, or forwards this if you know someone interested!

The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. This is the fifth in a series of posts from the conference. Only one or two more after this one.

My reason for attending Forum 2009 was to participate in a session title “Innovation for Remote Populations”. This post is a about that session. What follows is taken from my recent report to the Global Forum for Health Research – edited only slightly.

Innovation for Remote Populations

Thurs-19-Nov-2009, 14:00-15:45, Global Café, Palacio de Convenciones, La Habana, Cuba

Coordinators/Facilitators:

• Patricia Mechael, mHealth and Telemedicine Advisor, Millennium Villages Project, Earth Institute, Columbia University, USA & Egypt (organizer & facilitator)
• Tim Hurson, Facilitators Without Borders (facilitator)
• Charles Gardner, Global Forum for Health Research (focal point)

Speakers (alphabetical order):

• Simon Adebola, NEPAD Council Global Health Commission, Geneva
• Najeeb al-Shorbaji, Director, Knowledge Management and Sharing, WHO
• Caren Serra Bavaresco, Student, Epidemiology, Universidade Federal do Rio Grande do Sul, Brazil
• Karl Brown, Associate Director, Rockefeller Foundation
• Arul Chib, Assistant Professor, Wee Kim Wee School of Communication, and Assistant Director, Singapore Internet Research Center, Nanyang Technological University
• Dziedzom Komi de Souza, Ph.D. Student and Research Assistant, Parasitology, Noguchi Memorial Institute for Medical Research, Ghana
• Bastiaan Hoefman, co-Founder, Text2Change
• Bernardita Labarca, Project Coordinator, Zoltner Consulting Group, Chile
• Claire O’Neill, Chairperson, Cell-Life-South Africa
• Ravi Ram, Head, Monitoring & Evaluation, African Medical Research and Research Foundation (AMREF), Nairobi Kenya
• Marco Salmen, OHR-GMCP Initiative for HIV/AIDS, Global Micro-Clinic Project, United States
• Jaspal S. Sandhu, Design Researcher, College of Engineering, University of California, Berkeley, USA
• Joel Selanikio, co-Founder and Director, Datadyne.org, USA
• Garance Upham, General Secretary, Direction, Safe Observer International, France

Additional participants – from the audience:

• Elmer Zelaya – Fundación Chica/Nicaragua
• Timothy Dye – SUNY Upstate Medical School/USA
• Jane Kengeya – WHO
• Oyewale Tomori – Redeemer’s University/Nigeria
• Lishandu/Zambia (full name/affiliation not available)
• Vargas/USA (full name/affiliation not available)

Summary:

1. Diverse users and uses: The speakers presented a variety of mHealth/eHealth applications involving a wide variety of users, including both the health workforce and community members, e.g. educating teenagers about HIV/AIDS in South Africa (O’Neill), Internet access in western Kenya to improve uptake of HIV VCT (Salmen), mobile emergency response systems in Aceh (Chib), electronic IMCI in Tanzania (Brown), text-based health education and health service promotion in Uganda (Hoefman), training for health workers as a downloadable game package for phones in Kenya (Ram), telemedicine to improve the skills of health workers at primary levels in Brazil (Bavaresco), delivery of health information to communities in Chile (Labarca), a general set of tools for mobile data collection being used worldwide (Selanikio), and handheld computers to support rural healthcare delivery in Mongolia (Sandhu).
2. mHealth/eHealth is about enabling access: A common theme across diverse applications was that information and communication technologies are being used to enable access to health information and services in places where access is difficult because of remoteness and/or cost.
3. Coordination among the various players: Coordination among donors and projects is necessary to avoid unnecessary duplication of effort and to share what works. This is the role of the mHealth Alliance, supported by Rockefeller Foundation among others (Brown). While there were questions from the program side as to what data donors want (Chib), there was a simultaneous sentiment that donors need “stepwise” guidance (al-Shorbaji).
4. De-emphasizing technology: The mHealth Alliance has recently been discussing development of an “mHealth Toolkit”, to provide a common technical architecture and platform for those planning to implement mHealth programs (Brown). The existence of free technology platforms – in this case DataDyne’s tool – enables programs to focus on developing health content (Labarca). It is important to have a generalizable tool, as DataDyne has done, that can be used by anyone; if individual governments must approve technology “you’ve lost the battle” (Selanikio). Programs must focus on understanding people and applications more than technology; in response to a question from Dye about the use of ethnography in this field, three examples were given: ethnography of teen chat rooms in South Africa (O’Neill), multi-year ethnographic fieldwork as the basis for the program in western Kenya (Salmen), and design ethnography of the information management practices of rural health workers in Mongolia (Sandhu).
5. Defining good evaluation: There are challenges to seeing change in population health outcomes (Chib). It is difficult to measure behavior change (Hoefman) and to evaluate systems that provide health content to people (Labarca). Ethnography should be considered more seriously as a complementary evaluation strategy in mHealth (Sandhu). In evaluation, the metrics should match the intervention – mHealth is another intervention; in addition, we want to see the unintended effects of technology (Ram).
6. New modalities of engaging people: Mobile phones enable fundamentally new ways of engaging with people. As opposed to mass communication that is often used in social marketing, phones allow for interpersonal communication that can be tailored and cost-effective (O’Neill). There are two modalities, moving messages out to people and demand-driven services, where people demand the information that they need (Ram). Salmen lent his support to the importance of demand-driven services and argued that phones will bring more equity. This is all supporting the shift to citizen-centered healthcare (Mechael).
7. Cautions moving forward: In natural disasters, the cellular network is the first to go (Zelaya). An open question: Who owns the data? (al-Shorbaji). Nobody is thinking about “real sustainability” (Adebola). Reliable phone networks are a challenge (Lishandu). We should be careful that we don’t become too dependent on one tool (al-Shorbaji).
8. Need to think more creatively: We should be bolder with approaches; if we are, poor countries “could leapfrog” in health and development terms (Upham). Many of the applications discussed focused on SMS and telephony capabilities; we should think about leveraging more advanced capabilities of mobile phones (Kengeya).
9. Who should design technology? There is an assumption that Africans cannot develop software, but that is not true (Adebola). DataDyne software was already developed by Africans (Selanikio). Africans should develop software, but they shouldn’t redesign what has already been built (Brown).

Conclusions/Recommendations:

1. There is a need for increased knowledge-sharing about mHealth/eHealth within the global health community. This should definitely include policymakers. As Prof. Tomori elegantly stated, while we are thinking about how to reach remote populations, we should think about “hard-to-reach” African leaders.
2. While there was discussion of both eHealth and mHealth, the discussion focused primarily on the latter.
3. There is a need for a continuing dialogue about mHealth. It is unrealistic to expect policy recommendations to come out of this meeting given the state of the field (many open issues) and the limited engagement at the meeting.
4. Major mHealth topics to be discussed at future meetings: definitions; standards, including how to conduct evaluation; and successes and failures from the field.
5. The value of the meeting was threefold: (1) it helped extend the network of those working in mHealth; (2) it provided those outside the field with an understanding of the opportunities and challenges of using mobile phones to improve population health; and (3) it placed a much-needed emphasis on prioritizing people and applications over technology.
6. Mechael suggested reviving the Mobile Metrics and Evaluation Group as a means of maintaining an active mHealth community discussion outside of official meetings.

Other observations:

1. The fishbowl format was successful in eliciting relevant commentary from a large group of speakers as well as from the audience. Time was an issue, though, as several invited speakers only spoke once and several audience members had comments or questions that they were unable to share.
2. One key issue that was not explored – as I stated at the end of the session – was the link between social entrepreneurship and mHealth. This is especially relevant to issues of demand, incentivization, and sustainability.
3. There is a need for an ongoing discussion of these issues at Forum 2010 and beyond – while the conversation will continue in other settings, the Global Forum for Health Research should continue to be involved because of its systems focus, its emphasis on actionable research, and the unique mix of parties (policymakers, donors, implementers) it brings together.

The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. I was in Jamaica the week following the conference and completely offline. Now that I’m back in the U.S., I’m planning at least two more posts about Forum 2009. This is the fourth in a series of posts from the conference.

In early 2009, Oxfam released a report Blind Optimism critical of the private sector’s role in healthcare in poor countries. It drew attention to the cause of those who believe that any private involvement in healthcare in these countries is harmful. The arguments, evidence, and position of the report were flawed in numerous ways; sound responses to the report were provided by April Harding and the World Bank:

• Oxfam — This Is Not How to Help the Poor
• World Bank responds to new Oxfam health report

The reasonable conclusion one would come to from working in the field and from studying health systems is that a mix of private and public approaches will be most effective – and that the need for different approaches should be dictated by local context. Ideological extremism – pro-private or pro-public – doesn’t serve anyone, most especially the people who need access to health.

At Forum 2009, there was much stronger representation of the private sector than at the previous meetings. In addition to pharma and biotech, there were several sessions and plenary speakers dedicated to talking social entrepreneurship. One of these speakers was Al Hammond, Senior Entrepreneur-in-Residence at Ashoka. Al spoke during Wednesday’s plenary - Enhancing national environment for innovation: perspectives on low- and middle-income countries (TropIKA.net post about the session) – about Ashoka’s Healthcare for All pilot Punjab, India.

During Q&A Claudio Schuftan of the People’s Health Movement criticized Dr. Hammond and Ashok [sic] for: (1) bringing electronics to people where there is no electricity or way to repair devices, (2) supporting the interests of multinational corporations, and (3) making people dependent on products. Dr. Hammond began his response by saying, “We are aware that there is hostility towards private sector approaches”. He explained that they use market approaches to achieve efficiency and that all the programs he presented are social enterprises started by NGOs. Based on the success of the three pilots so far, the Punjabi government has requested 600 additional units. “Take what you will from that”, he ended.

Dr. Schuftan’s comments are well-aligned with the Blind Optimism ideology. Such comments attempt to polarize policymakers, donors, and implementers. In doing so, they actually keep us from thinking critically about the private sector and social entrepreneurship. Fortunately, this was not the overall tone of the meeting.

At the end of a session examining the role of governmental policy in supporting social entrepreneurship, Julius Mugwagwa of the Open University (UK) asked a question about the “backlash” that might occur if something went very wrong with one of these social entrepreneurial models. This is the type of balanced discussion we really need.