Category Archives: global health

back (and forward) from ‘the big push forward’ – thoughts on why evidence is political and what to do about it

Posted on by hlanthorn

i spent the beginning of the week in brighton at the ‘big push forward‘ conference, on the politics of evidence (#evpolitics) which mixed the need for venting and catharsis (about the “results agenda” and “results-based management” and “impact evaluation”) with some productive conversation, though no immediate concreteness on how the evidence from the conference would itself be used.

in the meantime, i offer some of my take-aways from the conference – based on some great back-and-forths with some great folks (thanks!), below.

for me, the two most useful catchphrases were trying to get to “relevant rigor” (being relevantly rigorous and rigorously relevant) and to pay attention to both “glossy policy and dusty implementation.” lots of other turns-of-phrase and key terms were offered, not all of them – to my mind – terribly useful.

there was general agreement that evidence could be political in multiple dimensions. these included in:

  • what questions are asked (and in skepticism of whose ideas they are directed), by whom, of whom, with whom in mind (who needs to be convinced), for whom – and why
  • the way questions are asked and how evidence is collected
  • how evidence is used and shared – by whom, where and why
  • how impact is attributed – to interventions or to organizations (and whether this fuels competitiveness for funds and recognition)
  • whether the originators of the idea (those who already ‘knew’ something was working in some way deemed insufficiently rigorous) or the folks who analyze evidence receive credit for the idea

questions and design. in terms of what evidence is collected and what questions are asked, a big part of the ‘push back’ relates to what questions are asked and whether they help goverments and organizations improve their practice. this requires getting input from many stakeholders on what questions are important to ask. in addition, it requires planning for how the evidence will be used, including what will be done if results are (a) null, (b) mixed, confused or inconclusive, and (c) negative. more generally, this requires recognizing that policy-makers aren’t making decisions about ‘average’ situations but rather decisions for specific situations. as such, impact evaluation and systematic reviews need to help them figure out what evidence applies to their situation. the sooner expectations are dispelled that an impact evaluation or a systematic review will provide a clear answer on the what should be done next, the better.

my sense, which was certainly not consensus, is that to be useful and to avoid being blocked by egos, impact questions need to shift away from “does X work?” to “does X work better than Y?” and/or “how an X be made to work better?” this also highlights the importance of monitoring and feedback of information into learning and decision-making (i.e.).

two more points on results for learning and decision-making. first, faced with the assertion that ‘impact evaluation doesn’t reveal *why* something works,’ it is unsatisfactory to say something along the lines of ‘we look for heterogenous treatment effects.’ it absolutely also requires asking front-line workers and program recipients why they think something is and is not working — not as the final word on the matter but as a very important source of information. second, as has been pointed about many places (e.g.), designing a good impact evaluation requires explication of a clear “Theory of Change” (still not my favorite term but apparently one that is here to stay). further, it is important to recognize that articulating a ToC (or LogFrame or use of any similar tool) should never be one person’s all-nighter for a funding proposal. rather, the tool is useful as a way of collectively building consensus around mission and why & how a certain idea is meant to work. as such, time and money need to allocated for a ToC to be developed.

collection. as for the actual collection of data, there was a reasonable amount of conversation about whether the method is extractive or empowering, though probably not enough on how to shift towards empowerment and the fact that extractive/empowering are not synonymous with quant/qual. an issue that received less attention than it should have was that data collection needs to align with an understanding of how long a program should take to work (and funding cycles should be realigned accordingly).

use. again, the conversation of the use of evidence was not as robust as i had hoped. however, it was pointed out early on (by duncan green) that organizations that have been comissioning systematic reviews in fact have no plan to use that evidence systematically. moreover, there was a reasonable amount of skepticism around whether such evidence would actually be used to make decisions to allocate resources to specific organizations or projects (for example, to kill or radically alter ineffective programs). rather, there is a sense that much impact evaluation is actually policy-based evidence-making, used to justify decisions already taken. alternatively, though, there was concern that the more such evidence was used to make specific funding decisions, the more organization would be incentivized to make ‘sausage‘ numbers that serve no one. thus, the learning, feedback and improving aspects of data need emphasis.

empowerment in the use of data (as opposed to its collection) was not as much a part of the conversation as i would have hoped, though certainly people raised issues of how monitoring and evaluation data were fed-back to and used by front-line workers, implementers, and ‘recipients.’  a few people stressed the importance of near-automated feedback mechanisms from monitoring data to generate ‘dashboards’ or other means of accessable data display, including alternatives to written reports.

a big concern on use of evidence was ownership and transparency of data (and results), including how this leads to the duplication/multiplication of data collection. surprisingly, with regards to transparency of data and analysis, no one mentioned the recent reinhart & rogoff mess, nor anything about mechanisms for improving data accessibility (e.g.)

finally, there was a sense that data collected needs to be useful – that the pendulum has swung too far from a dearth of data about development programs and processes to an unused glut, such that the collection of evidence feels like ‘feeding the beast.’ again, this loops back to planning how data will be broadly used and useful before it is collected.

here’s an idea — if they are trying to tell you something, make it easy for them to do so.

Posted on by hlanthorn

there’s been a good deal of press around the unfortunately insignificant results of a major HIV prevention trial with products for women in south africa, uganda and zimbabwe. the results had little to do with efficacy of the products (a pill and a gel) but rather with the fact that most of the participating women did not use the treatments as recommended – or at all.

one potential response is to improve our behavioral interventions to support adherence to treatment regimens (and prevention regimens) and integrate these methods more directly into medication trials. adherence and persistence with medication are global problems and we are just beginning to learn – with the help of health psychology and behavioral economics – how to tackle the challenge. efforts so far include high- and low-tech solutions, though not all the promises of the former, in terms of mhealth to facilitate behavior change and adherence, have yet been borne out.

another, not mutually exclusive, response would be to actually ask the women what they would like to see and use in the way of HIV prevention – a tool which should be empowering for them. the press seems full of comments like “the women are trying to tell us something!” why does it seem that, then, for a product made for them, they have to work so hard to tell us those things? why are we not hearing more sentences that start “the women told us…” that is, why, after such a big trial, am i not hearing anything about on-going qualitative and observational follow-up efforts to learn more about what exactly didn’t work about the methods offered to women?

there’s often a lot to learn from null results (that’s science, right?) but it doesn’t just come from brainstorming what went wrong. asking helps.

i don’t suggest that people are perfectly prescient about what they need or want. often, the innovations that we can’t live without now – smartphones, for example – weren’t a need or even desire that most people could have articulated 20 years ago. as such, directly asking people what it would take to get them to engage in X desirable behavior can’t determine the research agenda. but it should certainly be part of figuring it out.

targeting vaccine teams: and now nigeria

Posted on by hlanthorn

this seems to be the first time workers were killed in nigeria, despite previous opposition to vaccines.

on thursday, a controversial islamic cleric spoke out against the polio vaccination campaign, telling people that new cases of polio were caused by contaminated medicine.

more on targeting vaccination workers here.

‘where the streets have no name’

Posted on by hlanthorn

that’s the title of a short article in the jan/feb 2013 atlantic– and i couldn’t think of a better one.

i have written previously about the joys of getting and giving directions in lower-income countries – specifically for research and household follow-up, although the general taxi/auto/tuk-tuk stories of trying to reach any specific location purposefully are equally fun (in hindsight).

after reading my initial post, at least one friend reminded me that people at home (in the US) aren’t always so good at directions either, too familiar with a route to think about landmarks or to remember street names, and already too accustomed to google maps & similar being able to get the job done. the atlantic article from the title, about west virginia, re-emphasizes, for one, that a lack of street names, the use of landmarks, etc, is hardly only a poor-country phenomenon – rather, that “addresses have historically been an urban commodity” and one that probably belonged to highly literate urban areas with people who moved around the city a good deal.

formalizing addresses is more important than the inconvenience of trying to find a location or getting mail delivered. it is also essential for emergency services to find you and is presumably useful for tax collection and other basic services of the state.

which brings us to the second important part of the article: west virgina relied both on 911-services and a deal with verizon to get the mapping and road-naming word underway. knowing the power and visibility of mobile companies in many low- and middle-income countries, would this not be a reasonable way  to move the task forward? of all the potential projects for m-dev (e.g. and here, h/t tom paulson), it seems to me that mapping, paying taxes, and vital registration are some of the most promising and fundamental – as well as good public-private ventures. these would be fairly top-down and possibly foucauldian projects, and may be faulted for that, but i think we need more thinking about how the state can connect with its citizens.

finally, the atlantic article also points out the fun/difficulty of coming up with that many new street names. on absurd street names presumably combined by some random generator (although the linked article points to a single woman), i think my parent’s town has to take the cake.

drive-by truckers (highway 72):

“Don’t know why they even bother putting this highway on the map
Everybody that’s ever been on it knows exactly where they’re at.”

embracing local

Posted on by hlanthorn

a nice sentence, on which i will follow-up (from booth 2012, development as a collective action problem, citing kelsall 2008):

developing efforts have a greater chance of success when they stop treating cultural factors as a problem to be solved and try instead to harness them as a means to channel behavior in more positive ways.

thank you. water, sanitation, infrastructure, cholera.

Posted on by hlanthorn

someone said something helpful here. about cholera. but not about a new vaccine, a new super-antibiotic, or engineering a new vector that can be lulled to sleep by harp music, along with plans for a helicopter drop of harps or new ways to subsidize harps.

whenever epidemics of cholera occur, the global public health community is energized. experts meet, guidelines for control are reviewed and reissued, and new and modified interventions are proposed and promoted… [but]

the best intervention for long-term cholera control and, for that matter, for the control of the great majority of diarrheal diseases is the strategy that eliminated epidemic cholera from the united states and northern europe long before either marketed antibiotics or effective vaccines existed. the development and maintenance of water and sewage treatment systems assured safe drinking water and safe disposal of sewage for all, keeping contaminated sewage out of water, foods, and the environment. the strategy not only eliminated cholera but also dramatically reduced mortality related to diarrheal diseases of all causes.

among others, culter’s articles on mortality determinants are worth reading.

diwali and drugs – lessons from drug sales in india

Posted on by hlanthorn

as, you know, possibly from watching The Colbert Report, it’s dwali. as stephan and wikipedia note, diwali is the festival of lights or lamps. 

being in india – or at least chennai – however, one might be hard-pressed to think that it was not the festival of sound (also, sweet pongal).  firecrackers – or ‘crackers’ – play a large role. at all hours. regardless of any noise ordinances. regardless of whether my parents thought i was under assault when talking to me on the phone. seriously, if you know a war vet that still jumps at loud noises, please avoid indian cities during diwali. dr. dischord and the awful dynne would be so pleased.

so it was (ok, and because of a hard mattress) that i went out in search of sleeping pills. up till that point, i had not needed to actually purchase drugs in india. since part of my background is in private drug sellers, i was fairly confident i would be able to get something that would get me through the exploding nights of the rest of diwali. the private drug-retail market in india is fairly infamous for being unregulated – or, ‘the free-est market’ as (many) people thought was a funny joke. imagine my surprise, then, when at drug shop after drug shop, sellers heard my request, smiled sheepishly, asked for my presciption and, when i could not produce one, refused to sell the pills to me.

 i finally found one shop at which the vendor, after looking around furtively, cut off some pills for a blister pack, stuck them in a little paper bag, and sent me off. i didn’t actually know what i had been given, so worked to reconstruct the letters visible on the back of the blister pack with my dad over the phone (no internet in chennai apt – this was 2007). i had some sort of anti-anxiety meds.

i tried asking around after that as to why my mission had been much more difficult than expected. the few non-’i don’t know’ answers i got had nothing to do with fear of state regulation of pharmaceuticals but, rather, social censure. socially, people seemed to link sleeping pills, anti-depressents, and similar drugs with attempting to commit suicide. it was the community backlash from potentially being implicated in abetting a suicide attempt to which drug vendors were responding.

besides trying a few other times to buy sleeping pills and having difficulity, i haven’t researched this issue with any particular diligence. but, if true, it may suggest ways to work on getting drug vendors to behave appropriately, even if the formal regulatory system isn’t likely to catch up any time soon.

AMFm post over at CGD – a few thoughts on the conversation

Posted on by hlanthorn

here’s the series:

http://blogs.cgdev.org/globalhealth/2012/09/what-the-pre-post-evaluation-of-amfm-can-tell-us.php

http://blogs.cgdev.org/globalhealth/2012/11/the-future-of-amfm-making-sense-from-all-the-noise.php

http://blogs.cgdev.org/globalhealth/2012/11/the-future-of-amfm-realpolitik-and-realistic-options-part-ii.php

@altmandaniel pointed out that our position on what the Board should decide in the final post was not entirely clear. this is true – our goal was to lay out the positions and process rather than take a strong stance on the outcome. with regard to outcomes, the matching-based funding model would be the preferable option if you support facilitating private-sector delivery of drugs, while the integrated model represents a likely vote against intervention in the the private sector – at least absent a strong mandate for the TRP.

what @fanvictoria and i take a stand on is who and what needs to be considered by the Board. we further take a stand on the requisite transparency of the Board’s consideration.

this is a Big Moment for how evidence-based policy making plays out – and the decision at the end of the large-scale pilot period is neither as clear nor as technical as many people seem to have expected. both continuing AMFm and abruptly terminating it have strong implications for access to malaria drugs – but also in the political and policy spheres within implementing countries.

frankly, despite fast-paced and extensive evaluation efforts, what we learn about the AMFm is not really enough to say whether it is the ‘best’ approach to increasing access to malaria treatment. it is a reasonable proof-of-concept that the world does not fall apart when the private sector is used as a supply mechanism for increasing access to aid-subsidized drugs. beyond that, the debate remains both largely speculative and, in place of evidence about the relative impact on malaria morbidity and mortality, ideological.

given this, we step back in order to lay out the actual options and trade-offs that should be considered. some of these – how to improve dosing practices, how to encourage proper completion of doses by patients, how to strengthen in-country regulatory mechanisms and monitoring capacity, how to improve demand generation & information dissemination, how to include local pharmaceutical manufacturers – all often seem to be drowned out by either rancor over whether the private sector (in low and middle income countries) is an appropriate target for aid dollars or by discussions of specific types of subsidies and diagnostics. these are important moving parts in the bigger picture but they are not the only moving parts.

as a closing point on the Board’s decision, i‘d like to point out that many countries have already made a choice on whether it is right for ACTs to be sold in the private sector  because they have given ACTs over-the-counter status. this is not a decision about where people do seek treatment for fever and whether that is the ‘right’ place. rather, the discussion should proceed from the positive reality that the private sector is utilized for fever treatment. thus, the needed normative and positive discussions are about

(a) whether it is ‘right’ for aid-subsidized drugs to be distributed in the private sector;

(b) whether people in low- and middle-income countries should pay for medicine at all;

(c) how aid money can be used most effectively to strengthen front-line worker and patient practices across sectors, including learning lessons from experiments with community health workers, nurses and pharmacists in the public sector, and drug shop staff in private sector; and, finally,

(d) how we can better design, test, evaluate, and cooperate on an approach or combination of approaches to reduce malaria morbidity and mortality that also strengthens systems for supplying treatment more generally.

why avon and not tupperware? among other questions on micro-franchises for health (& beauty) commodities in low-income settings

Posted on by hlanthorn

sometimes there are things that you say about work-related topics that you think you should only say with friends at the bar and then it turns out other people are thinking about it. like, ‘why can’t haiti be part of africa?’ and then this happens. my growing feeling is that there shouldn’t be such a divide between what you talk about at the bar or in hushed tones at a conference because there a lot of lessons to be learned, even if some connections are wacky/wrong and some process information is sensitive.

anyway, another such of my comments that i feared was un-PC or not fully substantiated was about the similarities between BRAC’s shastya shibikas in bangladesh’s health system and Mary Kay or Tupperware women (I don’t know about many Mary Kay or Tupperware men but am happy to learn!) in the US.

i have a fairly limited understanding of Mary Kay and Tupperware: along with Discovery Toys and Pampered Chef, I went to some parties with my mom growing up and remember examining the catalogues. i also remember the woman with the pink car at the Mary Kay party and I recall the Pampered Chef party being somewhat an excuse for mimosas and chatter – but also getting a cool (and much-used) slap-chop precursor out of it and a neat-o cooking demonstration. my understanding of the 1950s, 60s, and 70s Mary Kay and Tupperware scene is almost certainly Norman Rockwell-ized but I have a vague sense of the role they might of played in burgeoning post-war female employment and empowerment in the US. i am sure there is an official study (or episode of mad men?) i should read and would be happy to be pointed to it. [the only tupperware-related TV show i remember was the short-lived eerie, indiana.]

anyway, when teaching about the BRAC model of health care delivery in Bangladesh for ‘SW 25 Case Studies in Global Health: Biosocial Perspectives,’ it always struck me to have unexplored parallels with Mary Kay (we used mostly gated GHD case studies but some similar info here). but, this never quite seemed like something to state widely and we didn’t really read about the empowering aspect of giving women this earning opportunity. so, then, imagine my surprise when the article ‘the avon ladies of africa‘ made an appearance last week, also linked to BRAC. yay!

in bangladesh, this system includes ‘shastya shibikas,’ or ‘health volunteers,’ who have played an important – but perhaps somewhat controversial – role in treatment completion for TB (e.g. see here). more generally, these women receive  a brief, basic health training and then work part-time to sell medicines, etc, door-to-door. basic criteria for these positions include being between 25-35, married but having no children under the age of 2, and preferably being able to write (in order to limit turnover and improve availablity and effectiveness). not only was this mechanism seen as a way to overcome spread-out rural populations – as is also mentioned in the nytimes article about uganda and the US at the inception of avon - but also strictures such as purdah on females’ out-of-home movement.

i think there is scope for this franchise model to do a lot of good in not only delivering appropriate health-related products but following up on their appropriate use and customer satisfaction (bonus points if the sellers have a way of tracking satisfaction info and sending it back up the supply chain). but, i have a few questions.

five key things.

1. door to door v parties. why avon and not tupperware? of course, there is some reason why an avon (door-to-door model) might make sense in rural areas. but what about tupperware parties: bringing women together, learning about and discussing health issues, encouraging each other to obtain the necessary products. certainly there is evidence about the benefits (though not the necessity, here or here) of peer groups in changing behavior. has it been tried? what happened?

2. follow-up. i just want to re-highlight the important role of these workers not just in completing the supply chain of getting commodities to bodies but being able to help the right commodities to the right people and to follow-up on them being used correctly. it would be great to hear more about the incentive mechanisms for these services and how they are received by customers (repeat sales, appropriate use, etc).

3. empowerment and within-company upward mobility. i‘d like to hear more discussion of whether/what are career advancement opportunities within these models (and, slightly more peripherally, whether these employment opportunities are changing views of the importance of schooling and skills-acquisition for females.) about five years ago, i did some work with the then-newish Health Extension Workers in Ethiopia, a new cadre of workers (e.g. here) with high-school + 1 or 2 years of training that focused almost exclusively on health education and preventative services, also relying on a door-to-door rotation (in their place of residence or nearby, generally). an awful lot of the young women with whom we spoke saw this as a temporary role, which they hoped to use as a back-door stepping-stone to becoming a nurse (a position for which they were not otherwise qualified). i think this mindset needs to be accounted for when considering investments in training and also the importance of trying to offer continuing incentives and opportunities to increase pay and status. the nytimes piece mentions that the ladies get a snazzy blue t-shirt and I fully understand the power of branded t-shirts, tote bags, etc. not exactly that pink cadillac but similar concept. still, how long does this keep workers interested? nava ashraf has certainly done work on incentive theory, related to health workers such as this, but it’d be good to hear more about it in action. is being an ‘avon lady’ for an effort like Living Goods seen as a a long-term career? could it be seen as such? i hope there are some balanced qualitative studies occurring about the experiences of these women (i.e. not just the testimony for one enthusiastic woman, as happy as i am for her).

4. local goods. it’s great that companies like unilever and others that have been focusing on the near-BOP consumer are looking on getting in on the action, providing a range of products that help ensure the income for the “avon lady” and the overall model of something like Living Goods, which still requires a lot of donor funding. but, it’d be awful nice to hear a bit about links to local industry in this – say, shea butter lotion – in some of these efforts as a means of further stimulating income and female labor-force participation.

5. supply chain lessons. i hope the lessons learned about the scope for text messaging to be used for supply chain tracking and stocking will be widely shared.

 

finally, will blue t-shirts ever get memorialized as songs as have pink Cadillacs (though i don’t think any of the songs have Mary Kay ties at all)? are there any incentive lessons to be learned here?

magic bullets are bad and silver bullets are hard to come by (agenda for approaching resistance to malaria treatments)

Posted on by hlanthorn

i have previously discussed the bizarre origin of ‘magic bullets’ as a phrase used positively and aspirationally in public health – as well as the folly it represents: relying on a single approach to a public health problem rather than doing multiple, hopefully coordinated, activities.*

my feeling is that something silver-bullety is going on right now in discussions about addressing malaria treatment and parasite resistance to that treatment.

there is a big push — both to wisely spend malaria-treatment resources and to stave off parasite resistance to ACTs (artemisinin-based combination therapies, the current WHO-recommended first-line treatment for uncomplicated malaria**) — towards using rapid diagnostic testing (RDTs); further, towards coming up with incentives for people to choose a treatment commensurate with those test results (and to incentivize drug vendors to encourage clients to choose treatments that correspond with the diagnosis).***

diagnosis is awesome. those issues need attention. but…

there are other big components in effectively treating malaria and fighting resistance that seem to be getting too little attention because they lack a fancy acronym and cool technology aspect? because they are unsexy? and/or because they are hard to do and measure?

in any case, counterfeiting and improper dosing and usage of ACTs are also important issues and i just don’t hear them getting the same buzz.

first, whether it is the public sector or the private sector that ultimately delivers the drug to an end-user, ‘health systems strengthening’ needs to include increasing government (or private?) monitoring, testing, and regulatory — pharmaco-vigilance – capacity to test drugs and check prices at port and mid-way through the supply chain, not just with the front-line workers. companies like sproxil offer one way to approach this problem, though monitoring and regulation seems like the sort of thing you might want a state to be able to do.

second, just because good drugs get to front-line workers, it doesn’t mean the end user is getting the right drug for his/her body weight. but that’s actualized access: affordable, available, acceptable, adaptable, AND USED. there’s evidence that workers with even limited training can make the right decisions about diagnosis and weight-class (including here and here).

but there is not a lot of evidence that most front-line workers possess this information, say, via regular government trainings. certainly my experience in northern ghana suggests that many vendors do not know about weight classes for drugs (preferring, if anything, to assign treatment by age) these private vendors are a major interface with the population seeking treatment for fever.

i recently heard someone promote pediatric formulations – syrups or enemas – to help guide vendors and users toward the right dosing decision even without understanding weight-classes (‘syrups are for kids’ is a relatively easy message). this seemed like very sage advice from shunmay yeung.

third, even though ACTs are only a 3-day (6-time) course of meds, people don’t finish them for all kinds of reasons.**** i was surprised at this problem when i first started looking at malaria after much more work on behavior around TB and chronic diseases – it seemed like such a short treatment course! but, it turns out a lot of people (including ex-pats!!! looking at you, JoT) don’t finish their malaria treatment course: like, 30% of people, in some endemic countries. there have been efforts at addressing this, for example here and again here, using follow-up text messaging. but, again, this just doesn’t seem prominent on the malaria agenda.

the last mile isn’t just getting affordable drugs into remote areas: it’s about getting good, affordable, and appropriate drugs in the right amounts into the bodies of the people who need and want them.

i have become quite fond of the ‘silver buckshot‘ metaphor to use in place of ‘silver bullets.’ in this case, treating malaria and protecting the effectiveness of malaria treatments requires looking at diagnosis, pharmaco-vigilance, and appropriate dosing and use. (and that’s without opening the prevention can of worms!)

keeping this bigger, balanced, and un-acronymed package of items on the malaria treatment agenda is difficult — but i hope it can be done.

*recognizing, of course, the problems with ‘planning’ and ‘coordination’ without allowing for ‘searching’ in terms of design and implementation.

**”it’s complicated” may be less-than-ideal as a relationship status on facebook — but it is definitely no good as a status update on your malaria.

***also, there is the tricky follow-up question of what to do if someone tests negative for malaria (moreover, what else to do if someone tests positive for malaria, given the potential for co-morbidities; these are topics for another time).

****too many pills, feeling better, saving the pills for the next illness, feeling nausiated from the pills, and so on