Friday, May 7, 2010

What to do to get better global health outcomes?

Dear Colleagues

What to do to get better global health outcomes is a very simple question ... and it deserves a serious understandable answer.

Better global health outcomes is a legitimate goal, and there are a very large number of legitimate alternative ways for the goal to be achieved ... and there are also a number of approaches that should be considered inappropriate. The data to choose between alternative approaches is not easily accessible, even if the data exist at all.

Recently I wrote the following on a listserve with a health focus in Africa:
From: Peter Burgess
Subject: [afro-nets] Global Health and Innovation Conference at Yale (2)
To: "African Networks for Health Research and Development (AFRO-NETS)"
Date: Thursday, April 22, 2010, 11:20 AM

Dear Colleagues

A few days ago ... Saturday, April 17 - Sunday, April 18, 2010 ... a lot of people gathered at Yale and a lot of people made presentations (see below). The occasion was the annual Global Health & Innovation Conference presented by Unite For Sight organized at Yale University, New Haven, Connecticut, USA. The key organizer is Jennifer Staple-Clark

Many people will probably look upon this conference as a celebration of progress and are impressed by the achievements ... but from my perspective, I am appalled at the amount of money that is available on this planet and in the health sector, and how little of it is being used to achieve great things that have a good impact of the totality of society.

When I look at the list of people below who are presenting, I see double. I see people who are respected and are considered to have been successful. But I also see people who are in a leadership in the sector and have considerable responsibility for system failure. Global health is a mess. Compared to what is possible, far too many people on the planet have a health status that the world should be ashamed of!

My specialization is analysis ... based on cost accountancy and new metrics about social value. The structure of the global health industry needs some serious rethinking so that the costs of health interventions do not bankrupt the societies where healthcare is needed. Profit and the economic market mechanisms are meant to be good ways to get efficient allocation of resources ... but this does not work for health where those who need healthcare are poor and cannot afford profitable pricing of the services.

Of course, there is a related question ... and that is what has profit got to do with anything where human life is at stake? Of course, the answer to this question is everything, when the only metrics used in the market and for the allocation of resources are the metrics of profit.

Why are there continuing difficulties in the global health sector? What are the issues? Why do they not get fixed? There are reasons ... but nobody wants to put them on the table and talk about them!

The Community Analytics (CA) methodology argues that value is another metric that should be in play ... and allocation of resources should be based on value as well as profit. With value and profit in the mix of metrics, the market system will allocate resources much better.

I did not attend the conference ... but my guess is that the issue of cost efficiency and cost effectiveness in the global health sector were not a big part of the dialog ... even if they were part of the dialog at all.

These are not petty scale questions ... but they are not in the dialog? This is dangerous!


Peter Burgess
I copied the speaker list associated with this conference into my listserve message, but it was deleted. The speakers represented many well known institutions and organizations ... universities ... hospitals ... NGOs ... government agencies. I have heard many of the speakers at other venues, and I know something of their work. In general, few, if any, of these speakers ever get close to answering the key question of cost effectiveness ... and how to get better health outcomes without the world going bankrupt in the process!
200 speakers , including keynote addresses by Seth Godin, Jeffrey Sachs and Sonia Sachs. Social innovation sessions by CEOs and Directors of Acumen Fund, Partners in Health, WaterPartners, Save The Children, HealthStore Foundation, and many others.

The Global Health & Innovation Conference convenes more than 2,200 participants from 55 countries. The conference challenges students, public health professionals, educators, doctors, scientists, lawyers, universities, corporations, nonprofits, and others, to develop innovative, effective solutions to achieve global goals.

Keynote Speakers

"Using The Power of Stories and Tribes to Spread Your Messages and Change The World,"

Seth Godin, MBA, Agent of Change; New York Times Bestselling Author of Tribes: We Need You To Lead Us; Founder,

Jeffrey Sachs, PhD, Director of Earth Institute at Columbia University; Quetelet Professor of Sustainable Development, Professor of Health Policy and Management, Columbia University; Special Advisor to Secretary-General of the United Nations Ban Ki-moon

Sonia Ehrlich Sachs, MD, MPH, Health Coordinator, Millennium Village Project

Leaders in Social Entrepreneurship Speakers

Gene Falk, Co-Founder, Executive Director, mothers2mothers

Scott Hillstrom, Chairman of the Board, CEO and Co-Founder, HealthStore Foundation

Kevin Jones, Co-Founder, Good Capital

"Creating Viable Enterprises For The Base of the Pyramid,"

Ted London, PhD, Senior Research Fellow; Director, Base of the Pyramid Initiative, William Davidson Institute at the University of Michigan

"From Ideas To Action Workshop: Creating Viable Enterprises For The Base of the Pyramid,"

Ted London, PhD, Senior Research Fellow; Director, Base of the Pyramid Initiative, William Davidson Institute at the University of Michigan

"Doing More With Less,"

Nancy Lublin, CEO, Do Something

Joia Mukherjee, MD, MPH, Medical Director, Partners in Health; Director, Institute for Health and Social Justice; Assistant Professor, Harvard Medical School; Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital

Ajay Nair, MBBS, MPH, Portfolio Associate, Acumen Fund

"Achieving Global Health Through Community Wealth,"

Billy Shore, Founder and CEO, Share Our Strength

"Investing in Local Social Entrepreneurship in Developing Countries,"

Jennifer Staple-Clark, Founder, President and CEO, Unite For Sight

"Solutions That Can Go Big: How To Think About Scalability, "

Kevin Starr, MD, Rainer Arnhold Fellows Program, Mulago Foundation

"WaterCredit: Driving Financial Innovation in Water Supply & Sanitation For The Poor,"

Gary White, Executive Director,

Andrew Wolk, CEO, Root Cause

Plus 200 Featured Speakers, including:

Ron Adelman, MD, MPH, Associate Professor of Ophthalmology, Yale University Eye Center

"HIV Medication to Empower Communities: An International Model,"

Jesus Aguais, Executive Director, Aid for AIDS

"Reconciling the WHO's International Classification of Functioning, Disability and Health with the Multi-dimensional Resilience Index,"

Astier Almedom, DPhil, Professor of Practice in Humanitarian Policy and Global Public Health

"Large-Scale Effectiveness Evaluations of Maternal and Child Programs in Low-Income Countries: A New Approach,"

Agbessi Amouzou, PhD, Assistant Scientist, Institute for International Programs, Johns Hopkins Bloomberg School of Public Health

Tom Arnold, CEO, Concern Worldwide

"Three Unique Models For Services For Orphans and Vulnerable Children: Worldwide Orphans Foundation in Ethiopia, Vietnam, and Bulgaria,"

Jane Aronson, MD, Director, International Pediatric Health Services; Founder and Executive Officer, Worldwide Orphans Foundation (WWO); Clinical Assistant Professor of Pediatrics, Weill Medical College of Cornell University

"Workshop -- How To Create an NGO That Does Community Work With Children Abroad: The Ins and Outs, The Ups and Downs,"

Jane Aronson, MD, Director, International Pediatric Health Services; Founder and Executive Officer, Worldwide Orphans Foundation (WWO); Clinical Assistant Professor of Pediatrics, Weill Medical College of Cornell University

Bob Bollinger, MD, MPH, Professor of Infectious Diseases and International Health; Director, Center for Clinical Global Health Education, Johns Hopkins University

"Meeting The Global Physician Shortage: The Contribution of Cuba's Latin American Medical School,"

Peter Bourne, MA, MD, Visiting Scholar, Oxford University; Vice Chancellor Emeritus, St. George's University; Formerly Special Assistant to the President of the United States for Health Issues; Chair, Medical Education Cooperation with Cuba (MEDICC)

"Medical Innovation in Humanitarian Situations: The Work of Medecins San Frontieres,"

Jean-Herve Bardol, MD, Former President of MSF-France; Former Board Member, MSF-USA

Kathleen Casey, MD, FACS, Director, Operation Giving Back, American College of Surgeons

"The Latin American and Carribean Initiative for the Integration of Prenatal Care with the Testing and Treatment of HIV and Syphilis,"

Arachu Castro, PhD, MPH, Assistant Professor of Social Medicine; Academic Director, Program in Infectious Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School / Partners in Health

James Clarke, MD, Ophthalmologist and Medical Director, Crystal Eye Clinic, Ghana

Luz Claudio, MD, Associate Professor of Community and Preventive Medicine, Chief of the Division of International Health, Mount Sinai School of Medicine

"Challenges and Opportunities for Improving Health Care Systems,"

Paul Cleary, PhD, Dean of Public Health, Chair, Epidemiology and Public Health; Anna M.R. Lauder Professor of Public Health, Yale University School of Public Health

"Diagnosis and Treatment of Glaucoma For Persons on Medical Missions,"

Gustavo V. de Moraes, MD, Research Assistant Professor, NYU School of Medicine, Department of Ophthalmology, New York Eye and Ear Infirmary

Prabhjot Dhadialla, PhD, Program Director of Health Systems, Development and Research, Columbia Center For Global Health and Economic Development, Community Health Worker Advisor, Millennium
Village Project

"Building a Distributed Village Model,"
Zoravar Dhaliwal, CEO, Community Lab

"Partnerships - Are We There Yet,"

Amir Dossal, Executive Director, UN Office for Partnerships

Margaret Duah-Mensah, RN, ON, Ophthalmic Nurse, Crystal Eye Clinic, Ghana

"America's Vital Interests in Global Health,"

Harvey Fineberg, MD, PhD, President, Institute of Medicine of The National Academies

Susan Forster, MD, Associate Clinical Professor, Department of Medical Studies, Department of
Ophthalmology, Yale School of Medicine; Chief, Ophthalmology, Yale University Health Services

Kevin Frick, PhD, Associate Professor, Johns Hopkins Bloomberg School of Public Health

Pape Gaye, President and CEO, IntraHealth International

Ilene Gipson, PhD, Senior Scientist, Schepens Eye Research Institute; Professor, Department of Ophthalmology, Harvard Medical School

"Simple Solutions To Complex Problems: How A Text Message Can Save A Life,"

Ashifi Gogo, Co-founder, Sproxil; Holekamp Family PhD Innovation Fellow, Thayer School of Engineering at Dartmouth

"Workshop: How To Advance Global Health Through Technology and Social Entrepreneurship, "

Ashifi Gogo, Co-founder, Sproxil; Holekamp Family PhD Innovation Fellow, Thayer School of Engineering at Dartmouth

"Obstetric Fistula - The Ultimate Indignity, Gender Inequality, and Poverty,"

Kate Grant, Executive Director, The Fistula Foundation

Laura Herman, Managing Director, Social Impact Advisors

Christopher P. Howson, PhD, Vice President for Global Programs, The March of Dimes Foundation

Marcelo Jacobs-Lorena, PhD, Department of Molecular Microbiology and Immunology, Malaria Research Institute, Johns Hopkins School of Public Health

Kaveh Khoshnood, PhD, Assistant Professor in Public Health Practice, Division of Epidmiology of Microbial Diseases, Yale School of Public Health

Norman Kleiman, PhD, Director, Eye Radiation and Environmental Research Laboratory, Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University

"Siyajabula! The Challenges of Developing Empathic Care Intervention Methodology for Children and Guardians Affected by HIV/AIDS in Southern Africa,"

Jamie Lachman, Clowns Without Borders

Robert Lawrence, MD, The Center for a Livable Future Professor, Professor of Environmental Health Sciences, Health Policy, and International Health; Director, Center for a Livable Future, Johns Hopkins Bloomberg School of Public Health

Bill Livermore, Executive Director, Somaly Mam Foundation

"Changing The World While Keeping Your Day Job,"

Nicholas Lumpp, Cofounder, Somaly Mam Foundation

Pamela Lynam, MD, Country Director Kenya, JHPIEGO - Johns Hopkins University

"An AIDS Vaccine: Progress To End The Epidemic,"

John McGoldrick, JD, Senior Vice President, International AIDS Vaccine Initiative (IAVI)

Carole Mitnick, Sc.D., Instructor, Department of Global Health and Social medicine, Harvard Medical School

"Society, Migration, Culture and Women,"

Mini Murthy, MD, MPH, MS,MPhil, CHES, Assistant Professor, Department of Health Policy and
Management, Global Health Program Director, New York Medical College School of Public Health

Ron Nabors, Chief Executive Officer, Christian Blind Mission-USA

Cliff O'Callahan, MD, PhD, FAAP, Pediatric Faculty, Family Practice Group; Director of Nurseries, Middlesex Hospital; Chair, AAP Section on International Child Health

Rebecca Onie, JD, Co-Founder and Chief Executive Officer, Project HEALTH

"Role of Inflammation in Retinal Degeneration, "

Santa Ono, PhD, Sr. Vice Provost for Undergraduate Education and Academic Affairs, Emory

David Oot, Associate Vice President for Health, Save The Children

Sung Chul Park, MD, Glaucoma Fellow, New York Medical College, New York Eye and Ear Infirmary

"Global Health Partnerships - Critical Success Factors and Lessons Learned From A Private Sector Perspective, "

Steven Phillips, MD, Medical Director, Global Issues and Projects, ExxonMobil Corporation

Maryse B. Pierre-Louis, MD, MPH, MH/HSA, Lead HNP Specialist, Human Development; Coordinator, Booster Program For Malaria Control in Africa, World Bank Africa Region

"Vision 2020/USA and The Future of Collaborative Efforts in Blindness Prevention,"

Louis Pizzarello, MD, MPH, Secretary General, International Agency for the Prevention of Blindness

"Online Innovation and Trends in Global Health,"

Suzanne Rainey, Forum One Communications

"Leveraging Advances in Nanotechnology and Consumer Electronics to Detect Infectious Diseases at the Point of Care,"

Rebecca Richards-Kortum, PhD, Stanley C. Moore Professor and Chair of Bioengineering, Rice University

"Partnership Models in International Health, The Yale Experience,"

Majid Sadigh, MD, Associate Professor of Medicine, Yale School of Medicine

"How To Develop a Sustainable Eye Care Plan For Rural Regions,"

Sarang Salam, Kalinga Eye Hospital, Orissa, India

Sarwat Salim, MD, Assistant Professor of Ophthalmology, University of Tennessee-Memphis

Georgia Sambunaris, Senior Advisor to the Director, Office of Economic Growth, US Agency for International Development

"Avoidable Blindness and Eye Care in Latin America and the Caribbean,"

Juan Carlos Silva, MD, MPH, Regional Advisor in Prevention of Blindness, PAHO-WHO

"Integration of Surgery Into Population-Based Healthcare in Learning Models of Integrated Care,"

David Spiegel, MD, Children's Hospital of Philadelphia; Assistant Professor, University of Pennsylvania School of Medicine

"Where There Is No Light: Using Solar Power to Reduce Maternal Mortality in Nigeria,"

Laura Stachel, MD, Bixby Center for Reproductive Health, UC Berkeley School of Public Health; Founder, WE CARE Solar

John E. Tedstrom, PhD, President and CEO, Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (GBC)

"Trabeculectomy Glaucoma Surgery: Clincal Pearls,"

James C. Tsai, MD, Robert R. Young Professor and Chairman, Department of Ophthalmology and Visual Sciences, Yale University School of Medicine; Chief of Ophthalmology, Yale-New Haven Hospital

Seth Wanye, MD, Ophthalmologist, Eye Clinic of Tamale Teaching Hospital, Ghana

"Can We Eliminate Blinding Trachoma by 2020?"

Sheila West, PhD, El-Maghraby Professor of Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins School of Medicine

"Innovation in Global Health Research,"

David Zakus, BSc, MES, MSc, PhD, Director, Centre for International Health; Associate Professor, Dalla Lana School of Public Health; Associate Professor, Department of Health Policy, Management and Evaluation; Faculty of Medicine, University of Toronto, Canada

Derek Yach, Vice President of Global Health Policy, PepsiCo

"The Global Fight Against Malaria: U.S. Strategy for Combating Malaria Around The World,"

Rear Adm. Tim Ziemer, U.S. Malaria Coordinator, President's Malaria Initiative
I got some friendly messages from Africa ... there are a lot of professionals who are anxious to address the question of cost effectiveness and the lack of resources that constrain programs. There was some suggestion that Community Analytics (CA) should become project focused and be Community Project Analytics (CPA). I responded along the following lines:

My work around the metrics of socio-economic progress and performance is ongoing ... whether of not I am doing well with it is not an easy question to answer. Maybe I am making progress ... maybe not.

I seem to have more "friends" than I have ever had in my life ... in part because there are a lot of people who sympathize with the idea that there should be more transparency and accountability, and more meaningful metrics about socio-economic progress and performance.

At the same time, I feel that the impact of my efforts is presently inconsequential. Most of the people who have decision making roles in modern society are well "protected" from the data and the metrics that would show performance accurately and be the basis for accountability.

I should share this caveat. My work has a tiny budget, which is obviously a serious constraint ... not to mention that I am no longer a spritely young man. I do well for my age ... but that does not necessarily say much! I failed to find a budget for your last malaria summit ... and that is likely to be the same again!

CPA ... Community Project Analytics ... is fine. It suggests a community focus and a project structure. At the present the project structure is widely used and getting community analytics into the project at the community level is absolutely required.

At the same time Community Analytics (CA) ignores the "structure" of implementation ... project ... corporate ... government ... informal ... etc and focuses only on the community and the activity. If the community is progressing, that is good. If it is progressing, what activities could make it progress better? What activities are constraining progress?

An activity may be implemented by a project ... or it may be done through other vehicles.

Community progress is measured by considering the "state" of the community in the past ... the state of the community in the present ... and the potential state of the community in the future. "State" is a bit like a corporate balance sheet, but about the community ... and uses not only money quantification, but also quantification of the values associated with quality of life. This is fairly complicated ... but value is important ... and critical to an efficient allocation of resources in society.

The CPA concept you have and the CA concept I am using are complementary. I am already very much engaged with malaria as a health sub-sector that is important within the community. The way CA works means that there is a need for the CPA process for every project that is working in the community. I would observe, however, that both the malaria sub-sector and the project perspective have to address the issue of multiple interventions that have costs ... and impact that really is a function of a whole range of activities for the community as a whole.

With regard to an Abuja Presidential Malaria Review ... great idea. I have the constraints described above ... and I let you down last time, so do not want to let you down again.

As you may have noted I am continuing to be critical of the malaria community for the amount of money being used and the limited impact being achieved. Most of the actors in the sector want me to go away, and are doing their best to keep me away from their events ... so I am flattered and pleased that you are reaching out. As I mentioned above, I have a lot of friends who consider my efforts to be worthwhile ... and a lot of folk who wish I would shut up and go away!

You will not be surprised to know that I am fairly active with the accountability issue in the Haiti relief and rebuilding process. Everyone is willing to talk about transparency and accountability ... hardly anyone actually wants to do it!

Not sure what the next steps might be ... but within my constraints, I will happily do all I can to help.

Peter Burgess

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