Projects succeed, projects fail. The successes are reported on, the failures are filed away. Or, in the case of most ICT 4 Development or Mobile 4 Development projects, pushed under the proverbial rug.

Well, its time to bring out the failures, with a sense of humor, and with an honest look at ourselves. So we are introducing the first-ever FAILFaire : A place where it’s ok to talk about what didn’t work.

The FAILFaire idea has been getting alot of play since the New York Times picked it up after the 26th July FAILFaire meeting in DC on ICT4Development sponsored by the World Bank. Mahad Ibrahim, who blogs for Global Health Ideas, is featured in the Times article, and presented results of his research on telecenters in Egypt to increase access to the Internet.

Think FAILfaire is the coolest thing since sliced bread, and want to do it at home? How to Roll Your Own FAILfaire

In my survey of public health innovators, my thesis advisor asked me to consider analysing some projects that actually failed. Well, those are quite hard to find unless they fail publicly and spectacularly.

But maybe that will change soon - Celebrating Failure to Learn from our Mistakes by Sarah Arnquist over at the Global Health Blog is a great piece (see especially the graphic on learning from failure). If we only know about what works, we don’t have a balanced view and can’t apply reason to solving problems. Instead, we are likely to be caught out when cold reality strikes us as it has done to all those who went before who kept their mouths shut, and their failures silent.

This idea of looking at failure is part of good business practice and total quality improvement – analysing faults, looking at airplane crashes, figuring out what failed so we can learn together and make good. In medicine, it seems to be verboten to talk about failures as the practice of medicine is a life and death matter, and admitting error could possibly lead to a potential lawsuit or disciplinary action that could end your career. But we need to talk, as “Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous.” – Sir Cyril Chawlte

Lucian Leape started the conversation with the groundbreaking Institutes of Medicine Report – To Err is Human: Building a Safer Health System which spurred the creation of the 100,000 Lives Campaign by the Institute for Healthcare Improvement, which evolved into the 5 Million Lives Campaign, and also the Safer Patients Network in the UK.

However, talking isn’t enough – you actually need to change the culture. In March 2010, Leape released Unmet Needs: Teaching Physicians to Provide Safe Patient Care which gets to this issue of how to prevent and discuss errors in medicine:

“Leape and his colleagues expressed a desire to move medical education away from what I’ll refer to as the elaborate hazing ritual model, rife with examples of disrespectful communications and humiliations, and forward into a model of education that is informed by teamwork, communication, conflict resolution, mindfulness, and asking for help when help is needed. – David Harlow at HealthBlawg full article

Here’s an interview with Dr. Leape where he highlights an innovative approach to medical errors at the University of Michigan with Rick Boothman

Let’s turn now to medical research, where you might wonder – Where does the negative result get published? For a long time experiments with negative results were swept under the rug, and doomed others to repeat them and waste energy and resources doing so – but now there is a Journal of Negative Results in several fields (here’s the one for Biomedicine). So wonderful.. we’re beginning to open up the freedom of information on scientific results and move away from publication bias.

and to end on a philosophical note, here’s Paulo Coelho:
Avoiding problems you need to face is avoiding the life you need to live/ Evadir problemas que necesitas afrontar es evadir la vida que necesitas vivir.

Guest Post by Ewa Wojkowska, a former UN worker, is the co-founder of TheKopernik.org.
As the rubble is cleared in Haiti, as a measure of stability comes to Sudan, as Sri Lanka holds a bitter peace and as Burundi faces its first election in the wake of massive civil war, a new development opportunity presents in some of the world’s poorest and most troubled places.

Online social entrepreneurship for the poor is one of the most compelling ways to fight poverty—and to reshape our development practices. Examples like Kiva and Global Giving are already leading the way, linking people anywhere in the world to better assistance and real results. The internet has created the opportunity for a transparent virtual marketplace: communities in developing countries identify their local needs, individuals anywhere in the world directly respond. Today our site—www.thekopernik.org—joins the force, connecting breakthrough technology to the poor through an online marketplace. It’s a simple, direct idea for real assistance to people in need.

Here’s our idea: Registered local organizations provide short proposals explaining their needs—simple water filtration in Freetown, Sierra Leone, self-adjusting eyeglasses in Manado, Indonesia. Any visitor to the site, anywhere in the world, can review the proposals and make donations to fund the plan of his or her choice. We connect these breakthrough technologies—water filters and drums, self-adjusting eye glasses, and solar lights, just to name a few—to the people who need them most.

What sets us apart is the focus on technology and a review mechanism for local organizations, or ‘technology seekers’, to rate the products. By including a feedback mechanism on the effectiveness of these technologies, Kopernik gives voice and choice to local communities and organizations – simple elements that are so frequently missed in international development efforts. We’re looking to take out the delays and to spark new ideas in international aid, one click at a time.We believe this is the new face of development.

If more people everywhere have safe, unfettered access to clean water, more efficient means of transporting that water, clear eyesight, and reliable light, how would their choices change? How would they see the world and their place in it? What could their empowerment achieve?

We now have the technology to improve everyone’s lives, and the internet is the window to get these life-changing technologies into people’s hands, directly and efficiently. We’re building a resource that those in need can access for themselves.

Ewa Wojkowska, a former UN worker, is the co-founder of Kopernik.org. The website launched this past week.

Related articles by Zemanta

• Kopernik Sells Technology To The Developing World (techstartups.com)
• Sierra Leone link to India medics (news.bbc.co.uk)

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.

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.

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.

Clinton Global Initiative – Making things happen through Commitments

Action speaks louder than words. At CGI, you’ve got to commit – and that has an amazing impact.

What will your commitment be?

CGI was the birthplace, in past years, of projects like Matt Damon’s water program (water.org, expanding this year to Haiti), the Goldman Sachs 10,000 Women Initiative, and so many more. In the five years of CGI, there have been 1,400 commitments made (participants are required to make commitments to existing projects or commit to creating new projects), valued at $46 billion dollars, and impacting the lives of 200 million people in 150 countries. This year’s meeting will give birth to 30 more of these programs – more by Andrew Mersman over at Passport Magazine/ Change by Doing blog.

Check out CGI Commitments here.

Innovation!

Business Week highlighted innovation as a top priority for the global economy, and President Obama announced a new strategy for innovation: A Strategy for American Innovation: Driving Towards Sustainable Growth and Quality Jobs. Download white paper.

Judith Rodin of the Rockefeller Foundation identified innovation strategies that could be applied to social problems – user-driven innovation, crowd sourcing and collaborative competitions reported here by Alexandra Cheney at Fast Company.  And Innovate Today: 8 Ways Business can End Poverty - superb post by Steve Enders over at tonic.

A few people – including Muhammed Yunus and Ngozi Okonjo-Iweala of the World Bank at CGI had an Innovation Wish List. Yunus talked about the edible yogurt pot, and Judith Rodin announced a new initiative to help the poor – the Global Impact Investing Network. This gets my vote for one of the most exciting developments to come out of CGI – read the Economist article.

Investing in Women and Girls

Women make up half of the world’s population, but do 2/3 of the world’s work, produce 50% world’s food, earn 10% world’s income, own 1% of world’s property.

Development aid spending around the world is failing to adequately account for women and girls’ needs, with less than one penny of every dollar allocated for girls, according to the Clinton Global Initiative. A lack of political will and failure to effectively tailor existing programs to local needs are some of the challenges associated with the problem – reported from UN Wire.

It’s a failure of will, says Zainab Salbi of Women to Women International here

I agree with Pamela Shifman at the NoVo Foundation, who says “a growing body of evidence [shows] that when half the population is oppressed and not able to participate in society, it hurts not only girls and women, it hurts everyone.” Read more of this article in Rebuilding the Global Economy – Will Women Lead the Way? for a thoughtful analysis by Katherine Gustafson at tonic

Some very interesting points from Lisa MacCallum of the Nike Foundation. Read more here.

1. Specific solutions for girls. The unique needs of girls are getting lost in the broader focus on women and youth, so we have to be specific about solutions for girls. For example, girls are five times more likely to die in childbirth than women in their 20s and they have less access to health and social services.
2. Invest directly. Investing in girls doesn’t mean investing only in girls. Take a look at your current programs and figure out whether they directly reach vulnerable adolescent girls. No matter your focus, girls can be a powerful part of the solution, or accentuate your problem.
3. It’s urgent: Get to her by 12. She arrives at adolescence in a pretty healthy state, and it goes sideways from there. If we don’t reach her by age 12, we will be investing in a treatment cycle rather than more cost-effective prevention methods.
4. Count her: Regardless of institutional size, ask for your reports and your data to be disaggregated by age, gender and marital status at a minimum. Girls will remain invisible in development efforts until we demand to see them.

Goldman Sachs says Women offer the highest Return on Investment, and here’s their 10,000 Women Initiative. 10,000 Women fosters economic development by providing high-quality management and business education, wrap-around services, and access to capital for underserved women entrepreneurs. The initiative involves more than 60 of the world’s leading academic and nonprofit institutions which are teaching in 16 countries that include Brazil, China, India, Nigeria, and Kenya. Read more of the article by Alice Korngold here at fastcompany.

And the Wall Street Journal says Investing in Women is Key to the Global Economic Recovery. The role of women took center stage at this week’s annual Clinton Global Initiative in New York with supporters such as Goldman Sachs Inc. (GS), Exxon Mobil Corp. (XOM), General Mills (GIS), Nike Inc. (NKE), and Jennifer and Peter Buffetts NoVo Foundation launching multi-million-dollar commitments toward business training, technology and ending abuse and trafficking of millions of women and girls.

UNAIDs with other partners launched a major campaign against sexual violence against girls and women. And the ManUp campaign will use hip-hop and soccer to tackle gender violence around the 2010 World Cup.

An Innovative Online Community to Support Girls and Women – In 75 villages in Malawi, Join My Village is setting out to drive measurable and long-term positive impact with women and families in Africa by tapping into the inherent power of women to connect with, and provide strength for, other women. Echoes of the Guardian.co.uk newspaper’s reporting on AMREF and Barclay’s work with Katine village in Uganda. And let’s not forget Jeffrey Sachs Millennium Villages

Interesting thoughts

Forget the Bottom of the Pyramid – Introducing the Global Majority.. How can you call 4 billion people the bottom of the pyramid? Diana Ayton-Shenker at change.org reframes our thinking in this interesting post

A Tool to Measure Sustainable Return on Investment - The SROI Decision Tool is a four-step process that allows public decision makers to measure an initiative’s sustainability by assigning monetary values to environmental, social and economic impacts, known as the “triple bottom line.”

Empty Gift Bags and Global Give Back Circle… Alice Korngold at 3bl MEDIA writes ‘Clinton said “This is the only conference you’ll ever attend where the gift bags are empty.” The idea is to GIVE BACK!

CGI in the Reset Economy.. Not sure whether he is coming down with a cold, or whether the mood of CGI has completely changed as a result of the seismic events of 2008 in the global financial and political spheres, Mitch Nauffts at PhilanTOPIC has some thoughts on the importance of CGI.

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• CGI: Investing in Girls and Women (one.org)

So I was thrilled to see recent developments in accountability – the Stop the Stockouts campaign, and the creation of the Budget and Expenditure Monitoring Forum in South Africa.

Power to the People: Stop the Stockouts

Stop the Stock-outs , a multi-country Africa campaign, is using text messages sent by activists and members of the public to expose stock-outs of essential medicines at public health facilities and put pressure on governments to address the issue. It was launched in Kenya, Uganda, Malawi and Zambia by Health Action International (HAI) Africa. During Pill Check week in June, facilities were surveyed, and a map of stockouts was created. The image below incorporates July 2009 data. It was found that many government health facilities were routinely running out of, or just not stocking essential medicines to treat common diseases such as malaria, pneumonia, diarrhoea, HIV and tuberculosis (TB).

“We were finding availability levels in rural, lower-level health facilities of 40 or 50 percent for essential medicines,” said Christa Cepuch, a pharmacist at HAI Africa. Read more from IRIN here

Show me the Money: HIV Policy AND the Budget and Expenditure Monitoring Forum in South Africa

With a new government in South Africa as of May, there have been some very positive signs. Celia Dugger of The New York Times reported that the new health minister, Dr. Aaron Motsoaledi, had accepted the strong critique of South African HIV policy reported in this Lancet series: Health in South Africa. He is a brave man, and needs all of our support as he tackles the challenge of rebuilding the healthcare system.

Gap in Treatment Access and Re-estimating the Need

One of the most daunting challenges Dr. Motsoaledi faces is that less than 50% of people who need ARVs in South Africa have access to treatment. And this may be an understatement of the actual need. Why? The government uses the Actuarial Society of South Africa ASSA model to project need, but ASSA uses 10 years from seroconversion to the time of first AIDS definining illness, whereas research evidence now supports 7 years. Dr. Francois Venter and Dr. Pierre Barker created the HAART calculator which uses 7 year period to AIDS, and estimates a higher patient need for HAART at this point in the epidemic than that projected by the National Strategic Plan. So, the gap is even bigger than reported.

Budgeting Failures threaten HAART program

This week, the Treatment Action Campaign released a press release on the creation of the Budget and Expenditure Monitoring Forum. Read the IRIN report here.

The Forum plans to put pressure on the national departments of health and finance to provide better budgeting and oversight of health expenditure in the country’s nine provinces, and ensure that there are no further moratoriums on ARV treatment. Last year, the most visible of budget cut decisions was the moratorium on the initiation of patients onto HAART in the Free State from November 2008 through March 2009. The Southern African HIV Clinicians Society estimated that at least 30 lives a day were lost as a result of this decision.

Here’s an excerpt (with some editing by me) of the press release from TAC:

A further problem is that the quality of financial and programmatic information about the HAART and PMTCT programmes is poor. This makes it difficult to assess implementation progress and leaves civil society largely dependent on what we can find out from our own investigations and anecdotal reports. For example, there is no publicly available information of the volumes purchased against the antiretroviral tender. We have received a report that the volumes being purchased are substantially less than predicted. If this is correct, then the treatment target set in the HIV & AIDS and STI Strategic Plan for South African, 2007 – 2011 (NSP) is not being met.

The Minister of Health, Dr. Aaron Motsoaledi, has already confirmed that nationally, there is a billion rand shortfall ($135 million USD) in HIV programme budgets for the current financial year. We have received reports indicating that provinces are facing financial constraints which could lead to a cut-off or slow-down in putting patients onto HAART. This will lead to more avoidable deaths.

If I can get a .pdf of the TAC press release, I’ll post it.

This year’s Clinton Global Initiative takes place from 22 – 25 September 2009, where heads of state, government and business leaders, scholars, and NGO directors work together to analyze, discuss, and debate possible solutions to urgent global issues. Each participant is then asked to take action on one or more issues by making a Commitment to Action.

The Economist calls the meeting ‘an important part of the global elite’s calendar’, so join online and watch the live webcast!

As noted in our post on Girls Count: The Girl Effect, one of the major themes this year is Investing in Girls and Women. The four focus areas are Innovation, Human Capital, Infrastructure, and Equitable Futures.

Investing in Girls and Women:

CGI’s 2009 Annual Meeting will provide a forum for those interested in working on projects involving the various stages of a woman’s life – from infancy to adulthood – to come together to collectively address challenges and solutions. Proposed discussion topics include:

Reproductive, maternal, and newborn health

Access to health care and education for adolescent girls

Opportunities for women to obtain higher education, professional training, and capital

Innovation

I was particularly interested in their Innovation stream – forget tinkering, they are ready to change the world!

Challenges of poverty, unequal access to education and healthcare, as well as protecting the environment call for innovation on an unprecedented scale. To date, most change has focused on incremental greening strategies like eco-efficiency, corporate social responsibility, or treating the symptoms rather than root causes of global health problems. While well-intentioned, it is doubtful that such incremental strategies will be sufficient.

Organizations need to develop breakthrough strategies… that resolve social and environmental problems. In this regard, clean technology and Base of the Pyramid initiatives have burst onto the scene, each providing pieces to the sustainable development puzzle: next generation technologies with dramatically lower environmental impact, and bottom-up business strategies with a more inclusive reach. However, these strategies come with baggage and blind spots. If narrowly construed, they still position companies as outsiders, foreign to both the cultures and ecosystems within which they do business. Becoming indigenous or locally embedded, then, is another innovation challenge.

Companies can find the right balance of profitability, environmental sustainability, and local legitimacy by learning to co-develop technologies, products, and businesses with local communities and their stakeholders. This session will examine these emerging innovation strategies as vehicles for addressing the global challenges of poverty, climate change, health, and education.

Break-out Session Topics:

Driving Disruptive Innovation from the Base of the Pyramid

Becoming Embedded: Co-Creating Business with the Community

Enterprise-Based Strategies for Health and Education

Check out their reading materials on Innovation here

Mayo Clinic, Global Health and Design Thinking. You might be wondering what those three terms have to do with each together. This is my partial recap on time spent at the Mayo Clinic this past week where I saw one potential vision of what the future of healthcare might look like. It was a great privellege to hang out at the Mayo Clinic for what was the best conference I have attended in a long long time or maybe ever (Amy Tenderich at Diabetes Mine also has a recap that I encourage you to read). The Mayo Center for Innovation hosted a TED style event – Transform, a collaborative symposium on innovations in health care experience and delivery, all the videos are online (highly recommended viewing). It is going to take me a few months to digest what happened there and wrap my mind around everything I heard. There were over 430 people from 23 states, 7 countries and over 1,350 tweets. The caliber and just genuine niceness of every person I interacted with was on some other level, the conversations were rich, deep and thoughtful. The conference organizers *created an open purposeful environment* that led to an incredible experience. The folks at Mayo certainly shaped and designed a great space to achieve the symposium goals (this all reminded me of the Winston Churchill quote – “We shape our buildings and afterwards, our buildings shape us”).  Let me stop before you think I have joined a cult. The direct connection to global health here – it was discussed by keynote speakers and my first tweet from Mayo was “this place reminds me of Aravind (Aravind Eye Care System). Jaspal, Mahad and I have written several articles and cases studies on Aravind and I continue to believe it is a premiere model for innovation and care delivery. More on this in a bit.

The Global Health Convergence: “Design Thinking” and Innovation
There were many things that made this event great, however, in terms of extending your horizons and making you think, one of the most refreshing things was to see some convergence of disciplines and people from a variety of backgrounds. This is very hard to do and cannot be underrated. We all live in a sea of fragmentation,  in systems, in professions and fragmentation in how we solve problems. This is even reflected on a micro level – look at the mainstream peer reviewed journals in healthcare where you see severe fragmentation amongst the physician, nursing and pharmacy focused journals (some of this is for good reasons and some of it’s not). This conference was in part about ditching that fragmentation and about a convergence of ideas, people and relationships working collaboratively. In addition to innovative projects, new models of delivering care and how the process of innovation can be conceptualized, managed, and enabled was discussed. Much of this was encompassed under the umbrella of Design Thinking (innovating and problem solving using various methods). Tim Brown, CEO of IDEO, was a headliner on this front and re-emphasized a call for design to big, an ethic of design for social impact/change, which Jaspal and I have covered on this blog before (see our previous post – 8 Links for Design and Global Health).

If you were too look at the methods of design thinking you would see an amalgamation and convergence of mostly existing methods from a variety of disciplines (from engineering to ethnography to epidemiology to psychology to health services research to name a few examples). As Tim Brown said in his talk: “Design thinking begins with integrative thinking which is the ability to hold opposing constraints and opposing ideas and from those create  new solutions…this means balancing societal needs (desirability) with what’s possible (feasibility) and what’s sustainable (viability)“. When Tim Brown said “Design should not be left in the hand of designers” he hit the nail on the head – design thinking can be incorporated by non-”designers” to help innovate and solve problems. What we do has to be a participatory, collaborative effort. Tim Brown wrote more about this participatory perspective (How to Design a Participatory System in a post crisis economy world). There are many critically important reasons why this is a key factor, one of which goes back to Paulo Freirean educational tenets – people who participate in their own education, become engaged in the transformation of their own world. The other reason is because even though as brilliant as Tim Brown is, (and all the people working at organizations like his) he doesn’t have all the answers, or even the correct ones (read his other piece at FastCompany on HSAs where his point is highly debatable about the solution and at best has over simplified the problem).

The bottom line that I took away is that we need more of a participatory system, we should be open to new ways of approaching problems (“design thinking”) and we can provide some structure to the process of innovation. Besides design thinking the other major theme I want to point to is global health – as I said above in the keynote presentations global health made an apperance. Both Clay Christensen and Tim Brown mentioned the Aravind Eye Care System and Jaspal spoke entirely about global health. We have said on this blog before that there are many lessons that can be learned from outside our system where innovation is taking place due to extreme necessity, it’s not a choice (a lot of this is taking place over the web and with mHealth – mobile phones for health). In Global Health, there are hundreds, maybe thousands of innovative experiments going on using a wide area of technology (devices, drugs, the web, mobile phones, etc.), however, how we track these experiments, talk about failure, and share what has been learned seems to be highly inefficient and lacking.  We have covered a lot of this ground over the past three years, the easiest summary of examples can be found in this post:

42 “Extremely affordable” Innovations in Global Health

Clay C, Tim B, and Jaspal all pointed to global health as a place we can learn from. While there are some serious limitations, there is a ton to learn from the use of mobile phones in developing countries and how that might apply here – because overseas usage of phones is far beyond what is being done in the US. The other area to keep an eye on is chronic diseases. In some places, there is going to be an explosion of chronic conditions and new models will have to be devised to handle that tidal wave. I would love to see Amy Tenderich and her community do a brainstorming session on design for diabetes in developing countries. On this front see two previous posts:

1. Reverse South to North innovation – Borrowing innovation: health services, financial services, and clean tech
2. A massive wave of chronic disease in India and China

Let me leave you on a note of caution, a “design thinking” approach (remember using existing methods) can offer some powerful alternatives. However, there can also be something seductive about design thinking and a rapid approach (we’ve cautioned this on the graphics/visual side before). If you fall into that seduction, then this is just a fad for you, it’s on us to be rigorous, thoughtful and corrective when need be:

“The myth of innovation is that brilliant ideas leap fully formed from the minds of geniuses. The reality is that most innovations come from a process of rigorous examination through which great ideas are identified and developed before being realized as new offerings and capabilities.” IDEO website.

I have many more thoughts on this, if I get the time I’ll jot down a few more notes and quotes from the conference, in the meantime, it is well worth watching the videos from Transform.

The New York Times obtained hundreds of thousands of water pollution records through Freedom of Information Act requests to every state and the E.P.A., and compiled
a national database of water pollution violations that is more comprehensive than those maintained by states or the E.P.A. (For an interactive version, which can show violations in any community, visit www.nytimes.com/toxicwaters.)

In addition, The Times interviewed more than 250 state and federal regulators, water-system managers, environmental advocates and scientists.

That research shows that an estimated one in 10 Americans have been exposed to drinking water that contains dangerous chemicals or fails to meet a federal health benchmark in other ways.

Because most of today’s water pollution has no scent or taste, many people who consume dangerous chemicals do not realize it, even after they become sick, researchers say.

Ryan Massey, 7, shows his caps. Dentists near Charleston, W.Va., say pollutants in drinking water have damaged residents’ teeth. Nationwide, polluters have violated the Clean Water Act more than 500,000 times. Photo: Damon Winter/ NYT

Before you reach for that Evian, bottled water is also not regulated – the National Resources Defense Council did a study Bottled Water: Pure Drink or Pure HypeFull Report) which details the situation and has been putting pressure on Congress to pass laws to test bottled water for contaminants (Senate Testimony by NRDC Attorney Mae Wu). In July, the House heard testimony (New York Times article), and immediately afterward the committee sent letters to 13 companies requesting more information about the source of their water and how it is tested (

Ok, I don’t have any time to read an executive summary – just give me some FAQs like how can I find out where my bottled water comes from?

However, the scariest part of the Toxic Waters article for me – how money is getting poured into technological innovations at the expense of basic necessities of life being safe.

“How can we get digital cable and Internet in our homes, but not clean water?” said Mrs. Hall-Massey, a senior accountant at one of the state’s largest banks.

She and her husband, Charles, do not live in some remote corner of Appalachia. Charleston, the state capital, is less than 17 miles from her home.

“How is this still happening today?” she asked.