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Friday, November 12, 2010

Root Solutions

We often talk about root causes of poverty and health issues because tackling root causes can be more economical, can result in less suffering, or both. Many (like me) are of the mindset that we must address both problems and their causes because there is a moral imperative to both prevent suffering and to help those that in the end are affected. In the health world, medicine is often criticized for not focusing enough on prevention and public health is often criticized for not valuing treatment. This dichotomy between treatment and prevention is overly simplistic - ultimately there are many steps along a pathway of risk factors and negative outcomes that can be targeted for interventions. Significant amounts of research have gone into elucidating these causal pathways of risk factors and problems, and now many problems are well-understood.

Other research has focused on interventions that specifically target various points along the causal tree of risk factors and outcomes for health and poverty issues. Here again, our research has provided us with many products and services that we now understand to be efficacious. We know that if you take an individual or a community with A, B, or C and give them X, Y, or Z, that they will be better off.

But knowing the XYZs isn’t enough. The important next step is understanding how to deliver these interventions, how to get them to the people that would benefit from them. Given that we have arsenals of health-improving and poverty-reducing interventions that are proven efficacious yet often lag in reaching or never reach the populations that would benefit most from them, many people are now talking about the so-called delivery gap. To tackle this we will need to focus on, and study, this gap in implementation much more than advocates, researchers, practitioners, policymakers, funders, and the press have in the past. These groups have often framed the discussion on problems (to show that we must act) and their direct solutions (to show that there are things we can do). But with the delivery gap in mind, in addition to focusing on the problem of, for example, malaria and the solution of bednets, we must realize that new focus is required on the systems that are successfully and unsuccessfully delivering bednets. We can’t just focus on bednets, HIV drugs, microcredit, crop-rotation, and other products and services. Knowing the solutions that work is great. But if we truly care about impact, then knowing how to get them to people that need them is required. Therefore, just as it is important to not solely focus on end-problems but also root causes, so must we not only focus on end-solutions, but also focus on their root solutions.

Most proximal to end-solutions are the platforms that offer products and services used by government and non-government service delivery organizations. These platforms consist of things we often take for granted, like hospitals, clinics, schools, and stores. There has been, and still is, often very little evidence for the efficacy of these platforms. This analysis is often difficult to do. One reason is that analysis of platforms cannot be removed from the context of the products and services that they offer nor from the context of the clients and communities to whom interventions are delivered. You can imagine a medical record system making a huge difference in health outcomes for chronic diseases that require the use of historical information, but offering much less benefit for acute emergencies. The reverse is also true - typically we take the platform for granted when analyzing the efficacy of interventions. We regularly do this by holding the platform constant between intervention and control groups. This is similarly misguided. Often an intervention, which would be effective if delivered by a frontline healthcare worker, is ineffective at the population level when delivered by a clinic. Therefore if a clinic-based platform were used for both control and intervention, a good intervention might appear worthless.

Community health workers play a major role in global health task-shifting and service delivery.

Other root solutions are more distal to service delivery organizations, but are also extremely important. These are things that enable and support service delivery organizations to do produce the most impact and might include new roles for academia in global health and development, the development of impact metrics, improving accountability mechanisms, attracting adequate levels of donor and investment capital, and many, many others.

I am certainly not the first to recognize the importance of these issues, and I am very glad to see that in the last few years many have focused on the issue of improving delivery. Some of my favorite examples: The field of social enterprise has been working on business models and impact evaluation metrics that can support these solutions. Academics and policymakers have begun to focus on the nascent field of health system strengthening. Jim Kim and Peter Pronovost have called for NIH to have not just basic science and clinical science divisions, but also one focused on delivery or implementation research. The Doris Duke Charitable Foundation has funded 4 large primary health care scale up implementation studies in Africa. The US stimulus package included funding for comparative effectiveness research. There is emphasis on task-shifting and community health workers to address human resources gaps. New funding mechanisms, like the Global Fund, with potentially better accountability mechanisms, are emerging. Advocates for neglected tropical diseases, surgical disease, and chronic diseases have replicated the model that HIV advocates used to build movements which create awareness and policy changes and ultimately yield funding for research and programming. There is heavy support for mobile technologies that are being developed and piloted to improve a variety of health and poverty initiatives. All of these efforts are part of a complex web of root solutions that will ultimately enable the successful delivery of proven interventions to the people that would most benefit from them.

These trends are very positive, but the delivery gap is immense. In my future posts I hope to provide analysis of what is being addressed and what needs to be addressed for improved global health and development delivery. With a systems view, I will not just examine delivery organizations themselves, but also the global ecology that enables or distracts delivery organizations from making an impact. I will also look to other fields and sectors for models that may be relevant to improving delivery in global health and development. These are just a few of the topics I hope to write posts (or series) about:

- Frontline health and development workers
- Academic roles in global health and development for the 21st century
- The anti-poverty value chain
- Successful models for social impact

I am really looking forward to reading everyone’s posts on this blog and any comments that people have. Please be in touch with any stories or ideas!


  1. I helped run a conference on campus here at UM last Friday (Student Global Health Day) and in the afternoon panel one of the big points the speakers emphasized was the need for health systems research. I see that as an area where economists have a lot to contribute: we know a lot about how to structure incentives, and also about how to study stuff that can't be captured by an experiment. There's also a lot of scope for us to learn interesting stuff about people's decisionmaking behavior from doctors and public health experts; people frequently make strange choices when they interact with healthcare systems, and models of economic behavior more generally can benefit from learning why.

  2. I remember an NGO director in Rwanda telling me that he could walk into a clinic and tell immediately if it was going to run successfully or fail. He said if he saw the nurse doing clerical work, it was an indicator of failed division of labor and boded poorly for the clinic. While the plural of anecdotes is not data, I have found the same thing to be true here in Botswana. There are simply too many patients and too few health care workers for the system to run smoothly without adequate support staff/task-shifting.


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