Reflections of an old Socialist
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HEALTH AND DEVELOPMENT IN THE MID 1990s:
REFLECTIONS OF AN OLD SOCIALIST
I have been in the business of Third World Health -- with a capital
'H' -- for the last 25 years; mostly in the areas of PHC and nutri-
tion and in over 40 countries. I think I am ready to downgrade the
upper case 'H' to a lower case 'h' in health. After one repeatedly
hits one's head against the wall of hard realities, it behoves any-
body honest with him/herself to change his/her views. The trick for
me has been to do so without betraying my deep ideological convic-
tions.
I think I can be a dispassionate (though not an unbiased) observer
and analyst and I can share with you some of my pragmatist's points
of view and pearls of wisdom to let you in on some of the shifts in
my, actually, overall development thinking.
First of all, has it all been worthwhile? An overall balance would
prompt me to say yes. But it is a guarded 'yes'. In this business, we
really operate on the 'two steps forwards - one step backwards' mode.
The measuring stick for 'worthwhileness' has to be what is left be-
hind after foreign aid leaves. And of that that is left behind that
really counts, it is the intangibles that count the most; not the
half-achieved objectives of projects. Key among these intangibles is
changed attitudes of some of the people who worked with you. Note
that the idea of 'worthwhileness' is highly subjective and the latter
change in attitudes of our co-workers contributes to give us as indi-
viduals a partial sense of achievement.
The nature of my work over the years has been mostly in the realm of
ODA. I have, therefore, mostly worked inside and through government
(and international) bureaucracies. I have thus realised that rigidi-
ties in the minds and behaviour of senior national cadres is inherent
to bureaucracies -- transcending the North/South and the ideological
barriers. My latest experience took me from working in Kenya to work-
ing in Vietnam where I had hoped things would be different. But there
is something intriguingly common to bureaucracies in that they abhor
change with rewards rather coming from staying the course.
In the midst of all this, you find yourself as a long term adviser.
You are under pressure to move the project along, it takes you six
months to assert yourself in your new position (while your co-workers
are measuring you up), you experience your first frustrations of
things not moving, of deadlines passing with no glory, of you in-
creasingly taking the role of the doer rather than of the promoter
and co-ordinator, of the project not spending funds according to
plans to keep up a credible absorptive capacity, of the project
bringing in short term consultants that have never been in the coun-
try and are expected in three weeks to speak words of wisdom that
have never been spoken before, and so on...
And through all this, you try to keep your mental sanity and not to
hate yourself every morning when you look at yourself in the mirror.
The truth is that you get so caught up in the whirl of things that
you do not take time out to look at things overall, in perspective:
Is all this really helping? Helping who?
Further, I cannot emphasise enough the advice I have for you to take
every opportunity to escape the claws of the central bureaucracy to
do some work in the field. It has always proven to be rewarding, a
source of some satisfaction for a sense of accomplishment on small
undertakings. It is the string of such small victories that keeps you
in reasonable mental health, because development with a small case
does not have big victories in the realm of ODA.
In essence, what you have really become is another (more efficient
and well paid) bureaucrat. You have learned not to take a first 'no'
as a definite answer and know your way around to revert such a deci-
sion -- you have nothing to lose, you are not putting your neck on
the line.
Besides that, you have developed some relationships with one or two
more progressive senior officers in the organisation whom you consult
and carefully use as needed. Again, in the search of some long term
achievements on the fringes of the project you work in, I have found
it very rewarding to establish professional contacts and long term
working relationships with young faculty (in my case) in schools of
public health and/or departments of community medicine in the local
university; this includes project-related research being carried out
by them plus some involvement in staff development of the same young
faculty and the teaching of students. This is always an important
source of new inspiration.
But in your immediate working environment, in your own unit or de-
partment, things are tougher. You find that your co-workers have
their own parallel agendas -- as opposed to you who devote better
than 90% of your time to project objectives. The project does not ca-
ter to those parallel agendas and, therefore, (no wonder) you 'lose'
your colleagues to different degrees and get only very partial co-
operation. The sad truth is that often these parallel agendas are re-
lated to sheer everyday economic survival.
I think we have to learn to cater to some of those other needs of our
co-workers if we want them to be more committed strategic allies.
English language coaching and travel/training opportunities are often
high in the list for such perks.
It has been my own personal rewarding experience that you can always
find at least one (young) cadre in your unit with whom you can work
more closely and who is eager to learn and do with you; someone who
has not yet been caught by the negative influences of the prevailing
'system'. Seize such opportunities and develop them as intensely as
you can. You will gain a strategic ally for life.
There are two more aspects I would like to highlight among so many
other that come to mind.
All projects have training components, and working in the bureauc-
racy, you see an array of workshops being organised for staff by many
donors or by the government itself. An unwarranted faith has been
placed on this entity: the workshop; workshops are our prescription
to inform and upgrade people's skills. But although it may achieve
the former, it certainly does not achieve the latter: Staff returns
from workshops and goes on with their routines as if nothing had been
learned.
Moreover, training is atomised into different components by different
single-track donors with each one doing his thing in an uncoordinated
way; the result is multiple workshops for the same staff every year,
with the hope that the (poorly qualified) staff will do the integra-
tion and co-ordination in their own heads... Failing to recognise
this is costing billions of dollars around the world. People have
called this epidemic "workshopitis". As it stands, workshops are more
a source of sporadic extra income for staff than of changed behav-
iours. No funding is thrown in to follow up on workshops' medium or
long term impact. Donors like workshops, because money is spent and
quickly written off against the budget.
On the other hand, institutionalised support supervision of field ac-
tivities of programs and projects is virtually non-existent. The time
has come to make a bold move.
Continuing education and support supervision activities have to be
merged. The budget available for workshops should be used instead to
fund multi-disciplinarily trained support supervision teams (one by
province?) to go around at least two times a year to visit peripheral
units. They will stay 4-5 days in each place before moving on to the
next unit; they will work with the staff in their every day chores
and routines, correct mistakes, introduce new procedures, educate on
the job on technical and managerial matters, on reliable information
systems, etc. Workshops are to be kept to a bare minimum.
The second aspect I want to highlight hits me more directly, because
it brings into question some of the lifelong held principles of my
socialist ideology. I have by now seen too many well intentioned,
well planned, well executed, culturally sensitive, balanced top-
down/bottom-up interventions in primary health care that have still
failed to bring about and sustain desired changes. There are deeply
ingrained flaws in the public sector staff's system of motivation and
dedication that no amount of outside intervention can affect.
My change of view relates to the greater openness I now have for ex-
ploring options that include the privatisation of certain functions,
at least in health, in even the poor rural areas. The truth is that
privatisation has already occurred, but is 'under the table'. Staff
is charging fees, is doing private home visits and/or is selling
drugs on the side for profit. Given this 'fait accompli', one might
as well stop the farce and stop this unhealthy mix which, in a way,
is costing the country double: by keeping up the bottom heavy public
sector payroll and by the beneficiaries using the private services of
the same staff, because it perceives it gets more personalised atten-
tion (let alone all the over-prescribing we see as private practitio-
ners try to make more money).
I remain firm on calling for close controls once selected privatisa-
tion is given the green light; I think controls will be cheaper than
keeping a highly inefficient operation in an environment of ever fal-
ling public resources. I have developed some more ideas on this, but
this is not the time to elaborate further. (The same is true for the
whole new window of opportunity represented by the increasing role
NGOs are playing in development work).
With all this (...and so much more), is development work in health
still exciting to me? I think yes. But again, a qualified 'yes'. I
think the Western model of development has, so far, miserably failed
to endorse a realistic conceptual framework of the causes of under or
mal-development that has the courage to put the political and eco-
nomic causes of world-wide poverty, ill-health, high morbidity / mor-
tality and malnutrition in the proper perspective so as to give those
causes the needed priority for more determined actions. In that
sense, I continue to feel guilty of being part of this system. As in
the "Gatopardo", I feel I'm being instrumental in changing things
just to leave them the same way. But I want to think that, over the
years, I have contributed my small grain of salt to expose, demystify
and correct some of the flaws of a technocratic (H)ealth model over-
sold (not always in good faith) for its potential impact.
On the other hand, having now been working in a genuine socialist
country, I cannot but see that some of the problems and obstacles in
the path of development are the same, and much work is still needed.
I now settle for (h)ealth work with less grandiose expectations, not
missing any opportunity to raise awareness about its contradictions,
always trying to stay faithful to my ideological convictions. In this
way -- despite alternating between depression and (small) euphoria --
every day continues to be a challenge to me.
Claudio Schuftan, MD
I.P.O. Box 24
Hanoi, Vietnam
Tel./Fax: +84-4-823-6401
mailto:aviva@netnam.org.vn
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