Global Health Council 2: “Small is beautiful, but big is necessary”

Cross-post from THDBlog:

Yesterday’s plenary session The First Mile: Setting the Framework for Effective Community Health Systems was a global health conference experiment.  The session linked the Global Health Council Conference (Washington, D.C.) to the Geneva Health Forum by video conference.  Keep in mind these were sessions attended by hundreds of people on both sides.  Louis Loutan, who modertated from Geneva, a self-professed “technical skeptic”, was so impressed by the technical success of the video conference that he proposed it as a model that we need to consider for future meetings.

Both meetings had complementary themes this year: “Community Health” and “Strengthening Health Systems and the Global Health Workforce”, respectively.  This session brought together these themes in the context of community health systems. 

Here’s who was involved from each side:

Geneva:

• Sigrun Møgedal, HIV/AIDS Ambassador, NORAD, Ministry of Foreign Affairs, Norway
• Frank K. Nyonator, Director, Policy, Planning, Monitoring, and Evaluation Division, Ghana Health Service, Ghana  
• Halfdan Mahler, Former Director-General WHO, Switzerland
• Moderator: Louis Loutan, MD, Head, Service of International and Humanitarian Medicine, Department of Community Medicine of Primary Care, University Hospitals, Geneva, Switzerland

Washington, D.C.:

• Fazle Hasan Abed, Founder and Chair, Bangladesh Rural Advancement Committee (BRAC)
• Gretchen Glode Berggren, MD, MScHyg, Consultant, International Health and Nutrition
• Molly Melching, Founder and Executive Director, Tostan
• Moderator: Nils Daulaire, MD, MPH, President and CEO, Global Health Council

I’m really happy that I attended this session because of the shift in thinking that it seems to represent.  Key quotes from each of the 6 people on the panels (tried to get quotes verbatim, but will be off by a few words):

• “Health must not only be seen as a whole internally, but also externally as an integral part of social and economic development.” -Mahler [he had a beautiful metaphor involving kaleidoscopes, but I didn't capture it - he also quoted Mark Twain and Niels Bohr]
• “Maybe we can’t do great things, but we can do small things with great love.” -Berggren, quoting Mother Teresa who said this at the Global Health Council Conference in the 1980’s
• “Doing holistic healthcare was hard, it was messy … it lost its energy” -Møgedal
• “We need someone nearby, who tells us what’s wrong, what to do, and where to go.” - Nyonator, quoting an opinion leader from a community in Nigeria describing what is needed in terms of healthcare workforce
• “If 10 people dig, and 10 people fill, we have plenty of dust, but no hole.” -Melching, citing one of her favorite African proverbs
• “Small is beautiful, but big is necessary.” -Abed, describing BRAC’s village health worker system in Bangladesh

There were five themes throughout the session that stood out to me:

1. Revisiting Alma-Ata
2. Collective impatience
3. Listen to the people
4. Changing social norms
5. Community health workers

The issue of food security was a recurrent one throughout.  The overall message was that there needs to be an increased emphasis on holistic primary healthcare using community resources, that understanding social norms was critical to success in improving health, and that this will take time.

Revisiting Alma-Ata

• Why it came up: the WHO Declaration of Alma-Ata (PDF) is celebrating its 30th anniversary in September, Dr. Mahler directed the creation of the declaration, the WHO has recently recommitted to strengthening primary health care, and the theme of both conferences and this session were very relevant to Alma-Ata
• There was a “total betrayal of Alma-Ata within months” because structural adjustment programs (e.g. FMI) “sapped energy” from health systems and “made it impossible for developing countries to conduct experiments necessary to test the recommendations achieved by global consensus” -Mahler
• At the time, one of Mahler’s colleagues told him “It is not doable. We must only do what is doable.”
• Alma-Ata is about “bottom-up” approaches and “social justice” -Møgedal
• “It’s not about convincing your adversaries that they’re wrong, but it’s about uniting with your adversaries at a higher level of insight.” -Mahler

Collective impatience

• “It takes time.” “We suffer from ‘Instant Coffee Syndrome’.” -Berggren
• Møgedal spoke of an impatience that we have in addressing the problems of global health in the context of a “broad-based global health push”.

Listening to the people

• “Let’s go back and listen to the people.” ”Everyone deserves a home visit.” “We must return to be more in touch with people.” -Berggren
• We need to think “where people are” and “what makes a difference to people” -Møgedal

Changing social norms

• “We must change social norms.” -Nyonator
• Melching spoke of the role of social networks and testimonials (not her words) in effecting behavior change in FGC (female genital cutting) with Tostan in West Africa.  She called this the “organized diffusion approach”.  The goal was “widespread change of social norms.”
• We need “change agents and fieldworkers.” -Abed

Community health workers

• “How come we keep talking about community health workers without talking about the support that they need?” “Work at each problem … solution in each context.” -Møgedal
• “Community-based health workers need extra arms and legs.” “We must work with groups.” -Berggren