in development

Enough with the lazy advocacy.

Aid Watch recently posted a satirical send-up of African advocacy videos.  It may have come off as a bit too flippant for some and sarcastic for others, but that shouldn’t detract from its substance.  Namely, it highlights how predictable and ineffective campaigns aimed at engaging apathetic audiences in the aid and development of Africa have become.  And I’m not just piling conjecture on top of conjecture here.  This perspective is based on sound research.  Last year, I directed a national study, on behalf of The Gates Foundation, of US voter attitudes towards global health issues.  The key findings of our study challenged the historical, and still dominant, narrative framework of global health advocacy campaigns.  Much of which corroborates, albeit more dryly, the criticisms posted by Aid Watch.

The dominant narrative of global health advocacy campaigns employs a well-established script – it begins with the size and urgency of the problem, then tries to guilt the audience into caring, and concludes with possible solutions and a plea for help. During the past few decades, this narrative has helped increase awareness of several global health problems. However, it has also created crisis fatigue. In effect, this narrative has now run its course.  People have heard the same story for over 20 years.  At best, most audiences just tune out these campaigns today.  At worst, these campaigns promote skepticism as they implicitly suggest that there is nothing to show for all the aid we’ve sent to the developing world over the past quarter century. 

This goes a long way toward explaining the aid world’s current obsession with “success stories."  But simply providing evidence of successes may be insufficient in capturing the attention and interest of otherwise disengaged audiences.  Our analysis suggests the entire framework needs to be reconsidered.  In effect, we concluded the narrative for global health needs to stop emphasizing problems and despair and start highlighting progress and optimism.  The biggest challenge for most global health advocacy efforts today isn’t about recognition of the problem(s).  The biggest challenge is accountability.  Our research proved that the primary reason people are resistant to support foreign aid is because they do not trust that the aid provided is reaching the people it's intended for. Thus, in our estimation, effective advocacy campaigns need to start by immediately addressing the progress already underway.  Americans are desperate to hear of results.  And they showed a strong willingness to support further investment for proven interventions.  Of course, for those organizations with no progress to report, it's probably best if you devote your resources to fixing your product before you try to market it.  That trick may work with consumer products, but when it comes to issue advocacy disingenuous attempts to solicit support only make it more difficult for the efforts of legitimate initiatives to capture people's interest and involvement.

From there, our message framework recommends redefining what success means for global health in a way that mirrors the public’s definition of success – empowering people to build productive, self-sustaining lives.  Receiving a bed net is not an outcome.  Nor is being put on ARVs.  These are just means to an end.  And people rightly want to know about the end.  They want to know how our aid efforts are helping create a self-sustaining society not a culture of dependency.  This is much easier said than done.  Now that I'm working in the field I can fully appreciate the complexity of M&E (monitoring and evaluation) beyond basic health metrics.  Nonetheless, if aid organizations are serious about advocacy they should seriously invest in robust M&E programs to provide interested parties with the proof points they need to commit to their cause.

This is not to say that we can't continue to introduce audiences to the many problems of the developing world.  We just shouldn't begin by dwelling on the issue.  We should begin by demonstrating the progress already underway - whether that means lives saved, jobs created, or policies enacted.  Just as viruses become resistant to drugs, audiences have become resistant to the standard regimen for advocacy campaigns.  Audiences clearly aren't responding to these tired formulas.  So enough with the lazy advocacy and wasted resources.

As for those who contend that sensationalized messages using over-simplified statistics and celebrity spokespeople are the only way to get apathetic audiences involved, I wonder how long you think you can hold their interest.  Treating issue advocacy like fashion advertising will only subject your cause to the ruthless and ephemeral world of consumer trends.  Here today, gone tomorrow.  This style of advertising celebrates and exacerbates our disposable culture.  Which may (or may not) be good for the economy, but when applied to issue advocacy it compromises the sustained interest and involvement aid groups need from their supporters to help them reach their goals.  Naive supporters don't understand the consequences of their erratic involvement.  Then again you shouldn't expect them to when you sell yourself like any other shiny new object.

Rethinking the "big three" of global health.

The aim of CSIS's Mission to Kenya was to identify models of successful global health programs to help inform the Obama Administration's policy on international development (i.e., how to spend Obama's $63 billion budget for global health). Thus, my posts on CSIS's blog focused on two of the most unique features of AMPATH's model.  My first post (from yesterday) focused on how AMPATH works within the existing framework of Kenya's government. My second post focuses on the interrelationship between health and socioeconomics. Again, you can read it in context by clicking here (note: they posted it as one long entry rather than the intended two separate posts).  Or you can just read it right here:

When most people think of "global health" they think of disease.  Specially, they think of the big three:  HIV/AIDS, malaria, and tuberculosis.  But the model AMPATH has developed to respond to the health crisis in Sub-Saharan Africa demonstrates a much different understanding of global health.  AMPATH makes it clear that health can not be viewed as a medical condition alone.  In fact, most determinants of health are socioeconomic, not medical.   For example, antiretrovirals (ARVs) are largely rendered ineffective if a patient is undernourished.  ARVs are free in Kenya.  But food is not.  So HIV+ patients can get the drugs they need to stay alive, but without food the so-called Lazarus Effect can not commence.  Which is why AMPATH not only prescribes ARVs to its HIV+ positive patients, it prescribes food to patients who are undernourished.  Through it's network of vegetable farms, AMPATH  now provides over 40,000 patients with food per month.  Of course, to simply provide medicine and food to a patient population would just create a model of dependency - a pandemic in and of itself.    Enter FPI - AMPATH's robust portfolio of income security programs.  These programs help ensure that AMPATH is providing a hand up to those in need, not just a hand out.  Everything from microfinance to agricultural training, a handicraft workshop to a juice factory, and business consulting to a seedling nursery are designed to provide AMPATH clients the help they need to become self-reliant citizens capable of building a better life for themselves, their families, and their communities.  At AMPATH, health lies at the intersection of medical care, food security, and income stability.  Perhaps those of us in global health need to rethink what we mean by the "big three."

A Model for Smart Global Health Policy.

CSIS's Commission on Smart Global Health Policy just completed their fact-finding mission in Kenya to investigate the successes and challenges of U.S. funded global health programs.  They visited us here at AMPATH on Tuesday and kindly asked me to contribute to their Kenya blog.  You can read my thoughts on the CSIS blog here, alongside some far more interesting posts from Commission Co-Chair  Admiral Bill Fallon, CSIS Director of Global Health Policy J. Stephen Morrison, and many others.  Or you can just read my first CSIS blog post right here:

AMPATH is widely recognized as one of the largest and most effective responses to the HIV pandemic in Sub-Saharan Africa.  Which is why CSIS Commissioner Mike Merson and Deputy Director Karen Meachem were quite surprised to learn that "AMPATH doesn't actually exist."  Contrary to popular opinion, AMPATH is not an NGO.  There are no AMPATH employees.  Rather, AMPATH is a name that symbolizes a partnership between Kenya's Ministry of Health, Kenya's Ministry of Education, and a consortium of North American Institutions led by Indiana University.   In other words, AMPATH is the name of an alliance formed within the existing framework of Kenya's government.  And the model AMPATH has developed through this alliance demonstrates how health system strengthening can happen within that very framework.  It's a unique and often misunderstood approach to international development.  But in the view of AMPATH field director Dr. Joe Mamlin and program manager Dr. Sylvester Kimaiyo it is an approach that is both scalable and sustainable.  As evidence, AMPATH now provides treatment to over 90,000 HIV+ patients - up from just 1,000 in 2003.   And with the launch of AMPATH's household counseling and testing (HCT) program, their patient population is expected to increase dramatically as they go door-to-door across their entire 2 million person catchment area in western Kenya.  It's an aggressive initiative that will not only save the lives of those unknowingly living with HIV but it will reduce the number of new HIV infections.  In the absence of an HIV vaccine, HCT appears to be the most effective means to roll back the pandemic.  And deployed through AMPATH's model, the HCT program can not only stem the spread of HIV but it will further expand the reach and strength of Kenya's national health system.