Global Health Watch 3
Examining the World’s Health from an Alternative Perspective
Call for Case Studies and Testimonies
Contribute to the Alternative World Health Report

The Global Health Watch provides a platform for activists  to share experiences and inform each other with practical examples and theoretical analyses  to strengthen local, national, regional and global campaigns towards  Health for All!

How you can voice your views:

The Global Health Watch is putting out a call for the submission of country or region specific case studies and testimonies. These case studies and testimonies will form part of the electronic platform of the alternative world health and selected case studies shall also be incorporated into the final document of Global Health Watch 3 – scheduled for publication in 2011.

Some suggestions:

•       Positive and negative examples of policies and actions to secure improved and equitable access to health care.

•       Examples of interventions to address public sector corruption and inefficiency.

•       Examples of effective, efficient and inclusive public health care systems.

•       Evidence showing the negative effects of commercialised health care on professional ethics.

•       Case studies on what is driving good and bad processes of decentralisation, with some analysis illustrative case studies of where deconcentration, devolution and delegation have worked, where it hasn’t worked and why.

•       The good and bad practices bilateral and multi-lateral donors on public health stewardship and on the performance of health care systems.

•       Examples of civil society resistance to the effect of privatised public water and electricity utilities on equitable and fair access.

•       Case studies of the positive and negative impact of multi-national corporations on health policy.

•       Case studies of the difficulty that country governments have in responding to the needs and demands of multiple international agencies (creditors such as the World Bank, traditional bilateral donors, relatively new institutions such as GAVI and the Global Fund).

All case studies, pictures and videos will be published on the website of PHM Global with pictures

Guidelines

We are looking for short and concise submissions of 1000 -2000 words with pictures
Please indicate:
•       your organisation
•       your locality/country/region
•       whether you want your submission to be anonymous and why
•       Ensure a clear link of your case study with one of the subjects covered by the course or issue mentioned above.
•       Pictures or videos

Looking forward reading your stories, experiences, analysis and observations!!

We should receive the first draft by 30th August, 2010.

Please write back to asengupta@phmovement.org

Why should you get involved

The Global Health Watch is a non-government initiative aimed at supporting civil society to more effectively campaign and lobby for ‘health for all’ and equitable access to health care. This is not a matter of finding a technical or economic prescription, but is one that requires political mobilisation to shift resources and attention towards the needs of the poor, and to reform the very political and social institutions that have generated the state of ill health today.

Promote the accountability of governments and global institutions that affect health (such as the World Health Organisation, UNICEF and the World Bank)

Identify policies and practices at the global and national levels that are unfair, unjust and bad for health

Highlight the needs of the poor and reinvigorate the principle of ‘health for all’

Shift the health policy agenda to recognize the political, social and economic barriers to better health and to advocate alternatives to market-driven approaches to health and health care

You can get more information about the Global Health watch at: http://www.ghwatch.org/

The answer is yes if you ask Carina Lupica.

Carina is Executive Director of Fundación Observatorio de la Maternidad (OM), an entrant in this year’s Healthy Mothers, Strong World competition. The competition, jointly sponsored by Ashoka and the Maternal Health Task Force, seeks to identify maternal health innovations from around the world. OM is a globally unique organization that is dedicated to using data as a policy advocacy tool for maternal health in Argentina.

Argentina’s maternal mortality ratio (MMR) – 44 deaths per 100,000 live births in 2007 – is much lower than high maternal mortality countries, but it is high when compared to other national indicators (Ramos et al., WHO Bulletin, 2007). In 2007, OM identified a lack of quality data focused on maternal health issues as a key gap in Argentina. OM has responded to this gap by aggregating data from various sources to develop a comprehensive understanding of the maternal health landscape in Argentina. OM maintains a holistic view of maternal health, including environmental factors and social issues, such as access to clean drinking water and the increasing frequency of single mothers.

As Carina writes by email, “This is brand new information that contributes to a complete diagnosis of the state of motherhood, which constitutes the necessary grounds for any public policy proposal.”

The organization’s focus on policymakers is having a real and significant impact. In 2009, OM research helped to pass national law 1914-D-2009: Universal Payments to Children and Adolescents (link in Spanish), a conditional cash transfer program that aims to reduce poverty and improve family health. This program was based on OM research showing that poorer mothers are more likely to contribute a higher share of household income, 72.5% in the lowest income group.

Just this month the Lancet published a study that estimated that there were 343,000 maternal deaths in 2008. Included in this study were detailed estimates for individual countries, including success stories such as China, Egypt, and Bolivia. Study lead Christopher Murray remarks, ”Finding out why a country such as Egypt has had such enormous success in driving down the number of women dying from pregnancy-related causes could enable us to export that success to countries that have been lagging behind.” As with OM, this comment suggests that better data can result in better maternal and child health.

Can better data save the lives of mothers? Absolutely.

The important question now is this: Can the OM model be replicated globally?

The mission statement from Medicall’s site (chem’em out here):

Proveer atención médica de acceso inmediato, presencial y a distancia, a través de un sistema de membresías y una red de proveedores médicos, con calidad y descuentos garantizados, e incorporando conocimientos y tecnologías vanguardistas.

Translation (forgive my Spanish translation…it’s been a while): To provide immediate and live medical attention at a distance through a membership system and a network of medical providers with quality and guaranteed discounts and incorporating knowledge and advanced technologies.

The skinny:

- 1 million households subsribe

- 90,000 calls per month

- 62% of calls are resolved over the phone

- $5/month/household

Thanks Ashsish for passing along the info.

Vicky Hausman talking about innovative financing in frontier markets

Presenters and their presentation titles

* Bruce Au, Dalberg Global Development Advisers, “Franchising in Frontier Markets”

* Vicky Hausman, Associate Partner, Dalberg Global Development Partners, “Innovative Finance to Enable Access to Healthcare”

Ideas in this session

Franchising for health. Franchises in their basic form are simply contractual agreement between the franchiser and the franchisee. When we think about franchising we think of 7-11, Subway and McDonald’s. We can also think about franchising in terms of distribution as well (ex. Coca Cola has franchises their bottling in different countries).

Franchising can bring commercial sale (FanMilk in Ghana has got 8,000 micro-franchisees selling their products on bikes); local business ownership (Rickshaw Bank) and scalable social enterprise (Living Goods, “the Avon of rural health”, delivers public health products at low to no costs).

Observations and lessons learned from the corporate franchise world explains to us that:

1. Profitability comes first; growth comes second (The HealthStore Foundation provides medical care and sells essential drugs to BOP customers in Kenya by employing geometric scaling. In 2000 they had 11 units. By 2008 they had 59 units);

2.  Homegrown franchises enjoy better positioning (look at Nando’s Chicken compared Subway, KFC, 7-11 and McDonald’s in South Africa–Nando’s : 160 locations. McDonald’s : 0). By working with a customer base without much disposable income how are you going to sell your franchised product? In addition, franchisees need to have disposable income to invest in the franchise.

3. Good could be the enemy of great–If you spend your time trying to fundraise you’ll dissipate your focus on improving profitability. Good stifles innovation and subsidizes competition.  Vision Spring sells presbyopia eyeglasses to BOP customers. They pursue growth before having reached profitability.

Innovative financing. Within financing of global health there’s a lack of financial incentives for product innovation (i.e. the will to develop a malaria vaccine), volatility of donor funding for commodity procurement, limited growth capital for SMEs delivering at the last mile (this point is important because the majority of those the BOP receive private health care from SMEs), and prices are too high for poor customers.

In the case of funding product innovation, the World Bank and GAVI are willing to underwrite investments in innovative solutions to health problems in order to get the private sector to develop new products to improve the lives of millions.

Risk-sharing mechanism and platforms which lower drug prices have been enabled by Health Systems 2020, MicroEnsure and Affordable Medicines Facility.

A new form of financing

The Pledge Guarantee for Health enables health commodities to reach recipients more quickly, consistently and cost effectively.  Increase efficienty of existing resources for health commodities by leveraging existing financial.

The idea is that donors make pledges and commitments of money and with that money you can buy commodities. Letter of credit that recipients of funding can apply for which helps procurement ahead of grant disbursement. Without the PGH, customers pay premiums of up to 26%.  With PGH, premiums are reduced to ~6.5%.

Lessons learned from the PGH model for health financing: 1. We’re moving from an idea to execution; 2. Design choices to maximize impact and scale; 3. Planning for sustainability.

Read more about PGH in the link below:

Pledge Guarantee for Health Overview – Jan 2009

Q&A

How does PGH affect the tendering process? The PGH process allows the tender process to start early.  One way is to choose who to work with. Also make sure that if this letter of credit is going into your tender that the process meets specific milestones.

Where do I read about the best practices for franchises in any market? A lot of the research is not done in the context of frontier markets.  But you can find info at www.franchise.org.

Suzanne Rainey talking about online communities for global health

Speakers and their presentation titles

* Bobby Jefferson, Futures Group “IQCare Technology Innovation for Low Resource Clinics”

* David Alyward, mHealth Alliance, “mHealth: The Future Success of Health Care Delivery in Developing Countries”

* Ashifi Gogo, Sproxil.com, “Simple Solutions to Complex Problems: How a Text Message Can Save a Life”

* Suzanne Rainey, Forum One Communications, “2 Ways to Build Community Online for Better Global Health”

Some major themes

Data is stuck in silos. There’s lots of IT in the developed world but the different platforms don’t work together. Innovations are happening and are funded all around the world but they’re not integrated in any way. Data mining is good for the developing world–companies that data mine can figure out your needs and uses to improve the products and services you use each day.

Knowledge out. Data in. When we think geospatially, especially given the advances of mobile technologies, the idea that people have to travel to clinics and mega-million dollar health institutions to receive care is becoming less and less a reality.

Take a Creative Commons Approach. By using freely available, reusable tools you can reach the most people.

We’re at an inflection point. Right now we can use technology to have a big impact on human health. The impact of mHealth on shortages of skilled personnel and facilities are immense. Mobile phones are a force multiplier and extender for health especially given the deep penetration of mobile phones in the developing world.

Reach the Un-Reached. What’s interesting is that villagers and people at the base of the pyramid are already reached with deep penetration of mobile phones. With the use of mobile devices there is the possibility of reaching the unreached.

Access vs. Quality? Why not both? Sproxil has aimed to address this question by working to prevent counterfeit drug product use, with their “buy & scratch/text&check” mHealth system.

Online communities can improve global health. How do we use online storytelling and professional networks to improve global health? Build a community around sharing, avoiding duplication, discussion, networking: who’s doing what, where?, story telling, engaging in debate and connecting via online events. The Healthy Newborn Network pools resources from 60 different organizations about what’s been done in global health as well as bring together different stories and features the different partners working to improve newborn health.

Tell your story about your experience in global health. Story telling is the heart of our human experience. We tell stories each day about our coworkers the guy that was singing on subway, etc.. Let’s talk about what’s going on in health by telling stories about connections with people. One thing to remember is that leadership in an organization who tell their story with a cause can actually make the organization more real and connected with the people they work with–lead by example. Check out Charity:Water with an example of story telling (here).  (btw the visuals on Charity:Water are incredible).

Q&A

How do you get a grasp of the technology available and get started? Answer(s): It’s not easy. Ministries of Health need to a lead on this to catalyze the ICT4Health movement. Don’t use technology for technologies sake–think about who you want to reach and their needs.

I asked, how are you addressing the issue of security and privacy? Answer: Ashifi said that they’re taking the best practices from the corporate security sector and applying those practices to their application with Spoxil. Bobby said Futures implements a three day security course to teach local technicians how to fix security issues that may arise. From the patient side, there’s data encryption. Facilities also sign a document to ensure security from the district level manager on down the decision making chain.

How do you move from the grant-funded stage to scale? Answer: David said that the mHealth Alliance is bringing together the requirements to scale to companies that need to scale. Ashifi says that you need to bring value with your product.  The grant-funding model is not sustainable.  If you’re idea or product has value for those at the base of the pyramid, then people will pay for it.

Interoperability? Answer: David says the the mHealth Alliance is asking what global stakeholders need and answer the question of interoperability.

David Alyward from the mHealth Alliance

If there’s two things I’m most passionate about its food and global health.  This session was packed with presenters and innovative ideas about how to re-invent food to improve population health.

The Presenters and their Presentations

* Robert Lawrence, MD, The Center for a Livable Future Professor, Professesor of Environmental Health Sciences, Health Policy, and International Health; Director, Center for a Livable Future, JHU Bloomberg School of Public Health, “Food security and the right to health”

* Amy Lockwood, MBA , Exec Director, Project Healthy Children, “Development of a national food fortification program in Rwanda”

* Bonnie McClafferty, Head, Development & Communications, HarvestPlus, “Breeding better food: an agricultural innovation to improve public health”

* Obidimma Ezezika, PhD, MEM, Senior Fellow, McLaughlin Rotman Center for Global Health, University of Toronto and University Health Network, “Factors in the adoption and development of agro-biotechnology in sub-Saharan Africa”

Food security is important to the social determinants of health

With 6.8 billion people in the world and over a billion malnourished, food and food security is important to the social determinants of health. Dr.Lawrence spent time to explain that food is a basic human right. The basic idea of human rights in the context of human health is so eloquently put as:

My right to be me not interfering with your right to be you

The more we communicate the rules that govern relationships between states and oversee the obligations of states to their citizens, the more opportunity we have to advance the human rights of people everywhere.

When it comes to food security, however, economic and social rights have not been ratified.  The International Covenant on Economic, Social and Cultural Rights which was last signed by President Carter has still not been ratified by US Senate. The Covenant gives people the right to education, housing, food security, health, gainful employment, potable water, trade unions, benefits of scientific advances.

In Article 11, the Covenant exclaims that people have the right to food. Specifically interpreted as requiring, “the availability of food in a quantity and quality sufficient to satisfy the dietary needs of individuals, free from adverse substances, and acceptable within a given culture.”

The right to adequate food means that food must be accessible, affordable and nutritious.  If these are the metrics to have the right to food, then 25% of the school children in NYC lack food security.

When we think about the rights that humans have to adequate food we need to redefine the beneficiaries of food as rights holders (not just ’starving’).  The duty bearers, i.e. the suppliers of food, must be held accountable and and fulfill their responsibilities to the rights holders.

The Hidden Hungry

When we talk about food security and not having enough food, we need to think about it from its short and long term consequences.  In the short-term, not enough food implies starvation. In the long-term, not enough food implies lower productivity of countries.

While the supply of food is important to the harsh realities of food security, it is the hidden hungry that we worry about most. Children and adults, today, are not only receiving adequate quantities of food but also the quality of food.  Take for example the following medical conditions:

* Neural Tube Defect (NTD)- Women with a deficiency of folic acid have a higher chance of having a child with NTD.

* Night blindness- Caused by a deficiency of vitamin-A. Vitamin A deficiency alone is responsible for 250-500,000 events of blindness in children worldwide.

* Goiter- Caused by not having enough or too much iodine. You ever wondered why they iodize your salt?

How could you prevent the above medical conditions through food?

1. A balanced diet: this requires access and being it affordable.

2. Suppliments (ex. vitamin pill): This mode of nutrition expensive and not sustainable.

3. Fortification (ex. adding directly into foods): On the one hand, the downfall of fortified foods is that it only reaches those who eat fortified foods. On the other, fortification is cheap and could prevent losses of national GDP up to as much as 6%.  The cost on average to fortified foods is USD 0.02-0.80/person/year.

Food fortification is obviously not the only means and must be integrated with other modes of nutrition and agriculture.

Lockwood and her team at Project Health Children have been working with the Rwandan government to combat the issue of malnutrition. With 22% of children underweight, half of the children born stunted, and half of the children born anemic, nutrition is a clearly a problem in Rwanda. By enabling nutrition through policy and legislation, food fortification standards, industry implementation and government regulation, the Rwandan government has begun to fortify salt, oil, sugar and maize flour to improve the lives of hundreds of thousands.

Concerns about food security and health

While impressive, most of these interventions have not been tackling the most paramount issue in food security, the price of food.  The Green Revolution believed that through science and technology we can feed the world abound. Adopted by multilateral corporations like Monsanto and DuPont, science and technology has not only helped ‘feed a billion people,’ so eloquently put by Norman Borlaug, but it’s also made a billion people go hungry and starving.  Food fortification and biogeneration of food through agriculture is another form of science and technology that is still not redefining the way in which food is accessed.

Food rebellions (not riots) are happening all over the world because governments cannot provide for its people affordable wheat, flour and maize. These rebellions are happening with or without fortified food and will continue to happen so as long as food prices remain in the hands of Wall Street and the aforementioned technology bearers. Investment banks on Wall Street have moved away from speculating on houses and mortgages to grain and food. The volatility of prices on food and grain is affecting the way people can access food through affordability.

I understand that in order to prevent the enormous amounts of deaths because of the quality of food we need to intervene with science and technology. But let’s not ignore the fact that if we really want to improve the health of billions through adequate food, we need to redefine access in the developing (and developed) world.

The room was packed, the debates and conversations lively and people left thinking about how to be a social entrepreneur in the space of global health using technology.

Presenter and their presentation titles:

Ashifi Gogo, Founder and CEO, Sproxil.com; Holekamp Family PhD Innovation Fellow, Thayer School of Engineering at Dartmouth, Workshop: How to advance global health through technology and social entrepreneurship

The first part:

Ashifi started out by explaining the value Sproxil, Inc (check’em out here) has giving the developing world.  What I appreciated most about Ashifi’s approach to this session was that he was teaching us how he and Sproxil did it. Going against traditional norms of business practice where you don’t share with ANYONE what your business plan, idea or process is in fear that the competition will devour you and steal your idea. Ashifi reminded me of Mario Batali from the Food Network. Batali goes on TV everyday and teaches the recipes he uses in his restaurant–how to make them, how they should taste, etc. The chances that you would take all his recipes he taught you, open up a restaurant right next door and compete against him is unlikely and silly. Thanks Ashifi for teaching us.

The workshop themes

1. Technology is an efficiency multiplier. If efficiency in your business is zero, adding technology to it won’t solve the problem (it might only exacerbate the problem). Technology doesn’t the solve the problem on its own.

2. Crowdsource your technology. If your idea has value, it helps to get your tribe/community to help you

3. Costs vs. Sustainability. Beware of costs and sustainability. KISS (keep it simple stupid) principle seems to work in the crowdsourced ethos of design. The more low-tech it is, the more it’s accessible.

4. Technology comes second to examining your health system. It’s important to examine your health system for what’s wrong before you even begin to insert technology–don’t use technology for technology’s sake.

5. Entrepreneurship is a useful model for global health. Too often the large sums of investments in global health are not bringing the results that we’d expect to see. By bringing entrepreneurship to global health can address the many challenges in global health (i.e. inefficiency, lethargy (from receiving funding to action takes a long time–sometimes the problem has changed), focus).

6. Social return on investment. The new metric on return on investment is to calculate social return on investments. While still fuzzy to quantify, if we can work toward metrics that can measure the impact of social investments then we’ll be on our way to improving health systems.

7. Who’s goin’ to pay for it? When we try to create value in global health, the million dollar question always comes up: ‘who will pay for it?’ People will pay for your service or solution if you bring value. When you have to answer this question as an entrepreneur you begin to focus, think about sustainability, rewards.

8. Some potential payers (in order of priority) for your value-added service/product:

• The end-user (private health professionals, patients, government)–Whoever you’re doing work for is your client. What about you yourself? There are no poor people when it comes to pay for value. Value will validate your concept.  Need to look at the incentives your product or service brings to different customers.
• Volunteers
• Crowdsourced funds
• Universities
• Grants
• Governments

9. Other things to think about
When is entrepreneurship not social? This is a tough question to answer. People who work in energy, oil, etc. all bring social value to society. The real point about social entrepreneurship is to be an entrepreneur, then add the social part.

10. Flaws in social entrepreneurship

• External market forces–people/organizations that don’t have global health at heart interfere with the deployment of your good/service
• Dual focus is challenging (social mission and organizational sustainability)

Workshop goals

We broke into small groups by interest (nutrition & infant health, HIV/AIDS, Malaria, [insert your favorite global health interest]) following these goals to present to the larger group: 1. state the problem, 2. come up with a solution using science and technology; 3. make it cost neutral.

One of the most interesting presentations was a small group who was thought about how to use technology to solve the problem of blood donations. The idea was to link a blood donation competition with the World Cup. Pretty cool stuff.

I’m happy to be writing to you from Unite for Sight’s Global Health and Innovation Conference 2010.

Key Note Presenter: Jacqueline Novogratz, MBA, Founder and CEO, Acumen Fund
Presentation Title: Patient Capital for an Impatient World

Some of my notes:
We in global health need to learn from lessons beyond how complex we are. Acumen Fund has learned that markets alone don’t solve the problems of poverty.  Instead market-based approaches to combat poverty are part of the answer. On the other end, charity and top-down development lead to dependence and not dignity.  Enabling dignity is the essence development.

Today, we are still having dysfunctional conversations by thinking things are zero sum games. Example:

It’s either health care for all or this won’t work -or-

The free programs don’t work, need to bring in the market

The Acumen Model believes in patient capital.  The patient capital model lies between the market and traditional charity. They invest, leave the investment for a long time and expect to fail, iterate, and try again.

We’re seeing a move from private sector innovations being integrated into the public sector.  Take for example some of the options low-income women have for child birth. They can either go: (1) go into the private sector; (2) home birth; (3) public sector hospital.

While there many public hospitals are good, their quality is not. Life Spring in India (check them out here).

From the site: LifeSpring is a network of Maternity and Child Healthcare hospitals that provide vital reproductive and pediatric healthcare to low- and lower-middle-income people in urban and peri-urban areas, with a focus on delivering high-quality, low-cost services to women and children in slum areas. What’s made Life Spring so successful?

• Transparency of prices
• Privacy for mothers
• Outreach–You can’t offer people low cost, high quality products and expect they will be picked up in a minute. Need outreach.

When we think about poverty it’s not just about economics. Poverty is about choice and freedom. Can an ex-prostitute with HIV choose to get health care when she wants?

The power of patient capital. When we invest in individuals close to us (in our tribe), we expect to get it back and give to others. When we invest outside the tribe we invest in people we don’t know and expect returns and profits. Investment in patient capital need to bring us closer. Let’s continue to talk about what works and how they work.

Question & Answer
What are the opportunities for growing patient capital? Answer: When Acumen started, they couldn’t get their non-profit through. Now we need to unlock some of the money in philanthropy for patient capital. Need to find partners that are interested in patient capital model.

Baby steps are being made to measure social capital. By using a crowd-sourcing approach, how do we believe an intervention is impacting a human life.

Investments in technology applications? Acumen just discussed in a board meeting about Aravind using telemedicine for eye care.

Related articles by Zemanta

• GoodCompany Ventures “UnPanel” Video Now Available (thegreenskeptic.com)
• The Blue Sweater (avc.com)
• GoodCompany: Can Venture Capital Change the World? (thegreenskeptic.com)
• Acumen Fund Announces Investment in Husk Power Systems to Provide Decentralized Power Generation to Remote Villages in India (prweb.com)
• Daniel Altman: A New Market for “Patient Capital” (huffingtonpost.com)

We last wrote about the Gates Grand Challenges Explorations in October 2009. The Explorations US$100,000 grants are again available, now for the 5th round. The four topic areas all deal with innovative approaches to priority health issues, three of them specifically focused on technology. One of the topic areas for the first time addresses mHealth: “Create Low-Cost Cell Phone-Based Applications for Priority Global Health Conditions”.

Here is the link to the Grand Challenges Exploration call.

Excerpt below from the Gates website: