Packard on History of Global Health: devastating first chapter (we need to do better)

While i intend to write more about Packard’s new book (delightfully if uncomfortably subtitled, interventions into the lives of others) once i am through with it, a paragraph in the opening chapter seemed both so important and accurate as to merit sharing immediately — particularly given the lessons it may hold for the Universal Health Coverage (e.g.) movement. It is not that what Packard has to say here is necessarily new but rather that he sums it up in a neat, indicting list of trends, on which we would all do well to reflect:


There have been remarkable continuities in how health interventions have been conceived and implemented over the past century… [that] have worked against the development of effective basic-health systems to address social determinants of health:

  1. Health interventions have been largely developed outside the countries where the health problems exist, with few attempts to seriously incorporate local perspectives or community participation in the planning process…

  2. Health planning has privileged approaches based on the application of biomedical technologies that prevent or eliminate health problems one at a time.

  3. Little attention has been given to supporting the development of basic health services.

  4. The planning of health interventions has often occurred in a crisis environment, in which there was an imperative to act fast. This mindset has privileged interventions that are simple, easy to implement, and have potential to quickly make a significant impact…

  5. Global health interventions have been empowered by faith in the superioity of Western medical knowledge and technology…

  6. Health has been linked to social and economic development — but this connection has focused primarily on how improvements in health can stimulate economic development, while ignoring the impact that social and economic developments can have on health. The social determinants of health have received little attention.


Packard notes that these trends have faltered a few times, such as with the rise in interest in learning about the “social and economic causes of ill health” in the 1920s and 30s and in the Alma Ata / health for all movement at the end of the 1970s. We seem to think of ourselves as standing at a new trend-breaking moment. Hopefully we can do better.

data systems strengthening

i have been saying for some time that my next moves will be into monitoring and vital registration (more specifically, a “poor richard” start-up to help countries to measure the certainties of life: (birth), death, and taxes. (if village pastors could get it done with ink and scroll in the 16th c across northern Europe, why aren’t we progressing with technology??! surely this is potentially solid application of the capacity of mobile phones as data collection and transmission devices?).

i stumbled onto a slightly different idea today, of building backwards from well-financed evaluation set-ups for specific projects to more generalized monitoring systems. this would be in contrast to the more typical approach of skipping monitoring all together or only working first to build monitoring systems (including of comparison groups), followed at some point by an (impact) evaluation, when monitoring is adequately done.

why don’t more evaluations have mandates to leave behind data collection and monitoring systems ‘of lasting value,’ following-on an impact or other extensive, academic (or outsider)-led evaluation? in this way, we might also build from evaluation to learning to monitoring. several (impact) evaluation organisations are being asked to help set up m&e systems for organizations and, in some cases, governments. moreover, many donors talk about mandates for evaluators to leave behind built-up capacity for research as part of the conditions for their grant. but maybe it is time to start to talking about mandates to leave behind m&e (and MeE) systems — infrastructure, plans, etc.

a potentially instructive lesson (in principle if not always in practice) is of ‘diagonal’ health interventions, in which funded vertical health programs (e.g. disease-specific programs, such as an HIV-treatment initiative) be required to also engage in overall health systems strengthening (e.g.).

still a nascent idea but i think one worth having more than just me thinking about how organisations that have developed (rightly or not) reputations for collecting and entering high-quality data for impact evaluation could build monitoring systems backwards, as part of what is left behind after an experiment.

(also, expanding out from DSS sites an idea worth exploring.)