Reflections of an old Socialist (7)
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Claudio Schuftan wrote an eloquent and wonderfully provocative con-
tribution to this group earlier, revolving around the problem of
maintaining socialist convictions whilst surrounded by the harsh day-
to-day realities of health work in the developing world. I can only
manage 23 years of experience against his 25, but nevertheless I
share a number of his viewpoints as I have worked in the same areas
of health in Africa, the Caribbean and Asia. His article seems like a
kind of stimulus to further discussion along the same theme, so I am
taking the challenge in that spirit.
One of the tensions Claudio speaks of is between doing what he as an
employee of an outside agency thinks is wrong, and of doing something
relevant for health in the country. You look around you and see the
effects of the Great Step Forward of the Week, and, as Claudio and
others often remark, the effect is a shrug of the shoulders and a
sigh of weary resignation.
But he goes on to talk of the flaws in the staff motivation and dedi-
cation and their greater interest in economic survival, and I would
like to spend time analysing that aspect a bit more.
Probably the majority of the people I have worked with have been in-
credibly dedicated. They work hard, often late into the night, for an
almost total lack of regard still less any thanks. They also do stuff
on the side and profit commercially when ever they can. In addition
to the obvious monetary needs I see their problems in five areas:
1) the lack of time to focus or think;
2) the use of money to buy people;
3) the lack of support for thinking or challenging;
4) the lack of relevance of programmes to real lives;
5) the lack of any support in human or resource terms.
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1) The lack of time
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Most managers at district or national levels are plagued with the
problem of having to report on a variety of projects or programmes to
a variety of donors. A typical district might have, amongst many oth-
ers, a malaria control project, a safe motherhood initiative, a fam-
ily planning programme (sorry, several, if you include reproductive
health, contraceptive social marketing, female genital mutilation,
male involvement, sexual health and other compartmentalised FP pro-
grammes which will all be run by different donors), a diarrhoeal dis-
ease programme, an AIDS control programme, a TB control programme, a
nutrition project, a district management team programme, an essential
drugs programme, a human resources management programme, a management
information systems programme, a health education programme, a public
health environment programme, an occupational health programme. On
top of that they have to deal with the complex logistics of regular
hospital and health centres resource and personnel management. As has
been pointed out, each one of these programmes is likely to have
training and other workshops associated with it. Finally the same
people are likely to have clinical duties to perform as well. I have
not yet counted the full range at any particular district headquar-
ters, but you get the picture. Each one of these programmes have
their own reporting and budgetary requirements as well as a range of
different timetables.
We have a problem. Where is the concern for the health of the commu-
nity? Quite simply, there isn't the time even to think about it. It's
nice to do so in the comfort of a year abroad doing a masters', but
it simply does not relate to the nasty, sordid and corrupt realities
of programme management. Your interest in the programme? The next
visitor that comes along asking for reports on progress.
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2) Buying people
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There are two things to say about 'workshopitis'. One is that if the
workshops are truly workshops in which health planners or others are
working to solve a problem that is truly of relevance to their own
situations, I have nearly always found that the work is of a very
high order. If, however, the workshops are typical of the donor drive
to 'sell' some idea or programme or initiative, without having any
inkling of the local situations and without any kind of a context,
then I think people are perfectly right to approach such lavish
feasts with purely mercenary motives. I know that I do, as have done
all my colleagues in such situations when working from a country per-
spective. If we are to be treated like prostitutes, why then, we will
act like prostitutes. And the money *is* good.
The increasing tendency to 'buy' people with more and more lavish
gifts in order to ensure their attendance (rather than attention) at
workshops has now extended to buying people in communities to attend
and sanction community work. The situation is so bad now in some
countries, that the whole idea of community participation or involve-
ment has been reduced to a question of who will pay the most per di-
ems or allowances. In one African country, CBD agents now refuse to
work for communities and people refuse to attend meetings unless they
receive 'the going rate'. Whilst I believe that they are right in do-
ing this as long as the initiative is externally-led, the problem re-
sults from the competition amongst external agencies to establish
programmes that will receive more money from donors, and thus per-
petuate the salaries of the organisation's workers. Since their pro-
grammes are evaluated by the number of community meetings they can
hold, why, then, it is in their best interest to ensure as many meet-
ings as possible are held in the short time-frame of their pathetic
project.
It is this commercialism and the prostitution of organisations and
others working in the health field that I find the most disturbing
trend in the last 23 years. The bottom line is that finding funds
comes before finding the ideal for which you shall work. In fact the
funds now determine the ideals with which you work. Look at the
flourishing of NGOs for AIDS, or orphans, or women's rights -- for
the several that are motivated by a desire for change, there are many
more motivated by a simple and understandable desire to tap into the
necessary cash which will be spent with little follow-up as to its
value (or whose value is measured in self-fulfilling terms).
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3) The lack of challenge or thought
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This is related to a third area of difficulty with regard to the
ability of workers to be motivated: the link of the educational and
management system to the ability of people to challenge. There are
very few workers in the health field who have been brought up to
challenge the system of which they are a part -- to raise questions.
This applies as much to those workers from rich industrialised
countries as it does to those in 'developing' countries. The politi-
cal systems in most countries do not in general like questioning. A
very good example of this is the approach to 'AIDS' programming that
is current and almost impossible to challenge with any hope of a
thoughtful ear. So, combined with the lack of time to think about
things, we are all definitely encouraged not to think but to follow
programmes blindly. In one country recently a huge primary health
care programme was allowed to continue despite the knowledge of local
workers that it was a failure -- they simply had not felt able to
report the problems to their managers. It was easier to send the
usual glowing reports of efforts undertaken. The current plethora of
logical frameworks and strategic planning instruments testifies to
the gross compartmentalisation of thinking -- they are mostly geared
to the efficient management of pre-determined programmes rather than
the satisfactory long-term development of a set of answers to complex
societal problems.
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4) The lack of relevance to workers' lives
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This relates to a fourth area of difficulty concerning the motivation
of workers: the overwhelming technical focus of most interventions
nowadays in the health field. Although it is generally recognised
that most problems of health are deeply rooted in the ways in which
people live, and what is acceptable in a society, there are incredi-
bly few attempts to link this knowledge to practical work either with
health workers (who themselves form part of that same culture, and
will face the same difficulties and concerns) or with the communities
served. More and more, health services are being reduced to delivery
systems as purveyors of meaningless behavioural messages and simplis-
tic interventions with regard only for proven efficacy rather than
adequate coverage or relevance to a problem. The workers themselves
thus not only see directly the failure of these technical interven-
tions, but understand for themselves and the problems that they face
that the central problems are not being addressed. Small wonder that
they regard their work with a certain emptiness. The most obvious ex-
ample of this is in the sexual health field, which is still full of
twaddle about safer sex behaviour: the workers are supposed to de-
liver messages which they know don't work for their own relationships
or situations.
Where there are efforts at involvement of people (whether they are of
the health workers or of people from the communities they serve),
they are often either based on the premise that 'people ought to se-
lect concerns, priorities and strategies from a list that we have
thought of', or else the efforts at political community mobilisation
are carried out entirely independently from the health sector. Very
few indeed have coherent co-ordinated strategies for the development
of community and health service efforts side by side. Very few have
even conceptualised the fact that community efforts have an entirely
different framework and objectives to those of health services. Al-
most no programmes that I know of have spent time exploring workers'
conceptions of their own concerns, of their beliefs about the situa-
tions in communities or of their work.
A common rejoinder from those funding or providing health services is
that they have no time to do the people-intensive work that is neces-
sary for meaningful intervention. At this point we have come back
full circle to the question of time and its deployment. Just who is
in charge of a district or a national health programme, and who has
the time to think about the health of the communities they serve? And
whose fault is it if they don't have the time?
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5) The lack of support or resources
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I have recently co-ordinated an evaluation of 156 workers in 26 units
in one country. Only 30 or so had any supervision at all, and of
those only 5 said they felt their supervision was adequate. Some had
had no pay for months. This was agreed to be likely to be the truth
by all the managers. What passes for supervision is mostly a rap on
the knuckles. This is added to a terrible shortage of most of the
needs of a clinic. The fact that donors can expect people to work at
all given the woefully inadequate infrastructures and the competitive
nature of their programme imposition in most of the countries I have
worked in is truly astonishing. And yet in each of these units there
were staff who worked amazingly hard to try to get things right.
Which of our Great Step Forward Programmes has as a catch theme "Pay
and Support for All by the Year 2000?".
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Small, big or dropped 'h'?
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Against all this pessimism, I agree with Claudio's optimism. As I
have said, I much admire the selfless devotion of so many of my col-
leagues in so many countries around the world who try to do something
meaningful in such an abysmal situation. I also have luckily been
part of many approaches in the world in which both community and
health service efforts evolve side by side, and in conjunction with
other sectoral developmental programmes. They have worked. I love
continuing to support such people and efforts. Unfortunately, they
are generally allowed to work only for a short time as they never fit
the neat compartmentalised visions of what donors and multi-lateral
organisations expect of development. The major push is to spend all
of the budget in a three year period, which is set against harsh
short-sighted and short-term evaluations that mainly have in mind how
good the donor organisation (or government department) is going to
look at the end of it.
So all in all, this is exactly what you might expect from a commer-
cialised world in which the political aspirations for the least
served, most vulnerable etc are always subsumed to the short-term
needs of money and success -- the success of programmes that desper-
ately seek funds for their self-continuation in a competitive market.
I don't think it is a question of agreeing with privatisation -- it
is already rampant among the organisations who act as private and
competitive agencies rather than a commune of partners interested
primarily in the benefits for mankind.
However, my end-point is not to move to 'health' with a small 'h'.
There is now all the more reason to pursue with vigour the re-
establishment of the big 'H' in health. It may be a losing battle,
but it gives a constant stimulus to those in the world who have the
interest and the position to fight for it.
It is really interesting that over on the PRA discussion group, they
are having a parallel discussion about the gross failure of PRA to
have evoked any interest in participatory community development be-
yond empty rhetoric in the major donor and international agencies. It
is truly 'business as usual', but then I would have thought that any
other expectation is delusionary rather than visionary. I know. I
have stuck my head out several times and had it bitten off rather se-
verely. Hence the rather headless and rambling nature of this dia-
tribe. People love the vision, but hate the idea of taking the nec-
essary steps when they see the implications.
The existence of so many health problems (TB, Malnutrition, Diar-
rhoeas, Pneumonia, Malaria, AIDS, STDs) at such shocking levels re-
main potent indicators of under-development. They do not reveal the
inadequacies of individual programmes. They reveal continued abysmal
under-funding and under-support, as well as a pathetic reliance on
whatever the Great Step Forward of the Week is this week. They reveal
an over-reliance on a multiplicity rather than integration of techni-
cal programmes propounded by a cynical self-sustaining market.
Any takers?
--
Anthony Klouda
London (UK)
mailto:anthonyk@aklouda.demon.co.uk
or CompuServe: Anthony_Klouda@compuserve.com
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