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Post by Admin on Sept 10, 2021 12:25:34 GMT
Thank you all for being a part of module 2! Please respond to the prompt below. Have a great weekend everyone!
In our discussion on the strategic plan for malaria control in Zambia we identified multiple internal and external actors with influence on the system. Using this case or speaking more broadly, discuss how external actors (such as volunteers, academic institutions, NGOs) and funders (Global Fund, World Bank, PEPFAR, USAID, UNICEF, etc.) may insert themselves into the system, and the positive or negative impacts these have on other parts of the system or the system as a whole.
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Post by crobinson on Sept 11, 2021 19:52:05 GMT
In the case of Zambia, the opportunity for the external influence from the Global Fund and World Bank was present due to the country's large amount of debt. One of the most striking consequences of these large entities working with the government was that the structural adjustment programs enforced upon Zambia as part of the debt repayment ultimately worsened the economic performance of the country and drove them more into debt. This goes to show that countries can be worse off when engaging with these international groups despite their good intentions. It also shows how dependent a country in a large amount of debt is to the international community and susceptible to their outside influence.
As part of the structural adjustments, the health system was decentralized and services were no longer under the total responsibility of the ministry of health. Smaller external actors such as NGOs and volunteer programs were able to take hold in the country because of this decentralization and the private sector in many ways became a more robust influence than the public one. The World Bank and the International Monetary Fund touted Zambia as a model of decentralization for other countries in Africa. This again shows that the International funders in many ways dictated how healthcare distribution would happen within the country as opposed to possibly more internal influences.
The negative impacts this has is that the country's healthcare distribution has been largely dictated by the international community who may not know or understand the specific challenges in the country. The decentralization allowed for more international players to enter the country and help provide care but it also allows for the opportunity to become a disjointed, decentralized model which can lead to difficulties in distribution of basic services like medicines or equipment or financial coordination. With many healthcare entities there is more room for error or miscommunication. The benefit, however, of having these external players in the country allows for more money to be spent on healthcare and affect the population of the country than if only relying on the government of Zambia. It also allows for coordination between countries to have a greater affect than any one country alone on achieving something like malaria eradication. These players can transform something into a global effort with greater impact than a local country wide effort.
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Post by mattkynes on Sept 14, 2021 6:11:04 GMT
Fantastic insights here. The history of aid and development for many SSA countries is tied closely to debt, which continues to be a major issue. I find it interesting that the decentralization that you cite was developing at the same time that this malaria initiative focused its efforts on unifying the response.
This will be a common theme in development discussions during the course -- decentralized services allowing for increased involvement of external actors but also creating redundancy, inefficiency, 'vertical' programming, etc.
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Post by mollybrazil on Sept 20, 2021 16:04:14 GMT
As has already been pointed out, it's difficult to discuss global health without touching on how a country's debt impacts services, who is providing them and how they are implemented. The unfortunate reality is that often governmental corruption is also intertwined in this with hidden agendas and self-serving missions. This can heavily impact which external parties (NGOs, funders, etc) are allowed to participate. This can lead to varying degrees of in-country player involvement, and as we all know, the long term success of these initiatives is heavily influenced by local player buy in and a strong understanding of local societal/cultural institutions.
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Post by Eadjei on Sept 22, 2021 3:05:08 GMT
Very interesting prompt and discussions above. I believe the external actors such as NGO's, though often times do not engage in sustainable projects, and may come off as charitable agencies (where they can write off their "investments" in their tax returns), tend to have more positive impacts in influencing systems or other parts of the system. This is mostly because of their lack of heavy socio-political involvement. Thus, local players tend to welcome such organizations and are more willing to work with them.
However, the funders have gradually become the chief architects of policies in developing countries and are indirectly responsible for the worst inequalities and the explosion of poverty in these countries. As illustrated in the case of Zambia been driven into more debt when the world bank and other funding agencies tried to enforce their own structural adjustment programs. Most funders including World Bank and IMF have political power imbalances in their governance structures where, as a result of voting shares being based principally on the size and ‘openness’ of countries’ economies, poorer countries – often those receiving loans from them– are structurally under-represented in decision-making processes.
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Post by crobinson on Oct 4, 2021 16:11:09 GMT
Another good perspective above. A lot of the countries similar to Zambia are at the mercy of large funders like the World Bank and IMF where the large power imbalance really does not give the country any other option other than the one they provide them. With large amounts of money comes external influences and questions who is to really benefit. At least with NGOs they may have the community's interest at heart and be more in tune with what support is needed if done well.
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Post by ajmata on Oct 4, 2021 18:35:23 GMT
I worked for USAID|Deliver Project Madagascar for a year, which oversaw the supply chain management of USAID-purchased bednets, rapid diagnostic tests, and treatments throughout Madagascar. Madagascar at that time had a unique context that really highlights the impact of internal and external factors on public health program implementation. In 2009, there was a coup and the US government did not recognize the new president. In response, the US placed restrictions on interaction with Madagascar's government, which meant any USAID funded program was restricted in working with the ministry of health. Imagine organizing a bednet distribution for half the country in this context. At the national level, we had all sorts of workarounds for this, so while some of the rules were inconvenient, we ultimately had sufficient collaboration. I think the people who were ultimately hurt by the restrictions were the communities. Rather than being able to use community systems already in place like public schools, government buildings or clinics as distribution points for bednets, each community had to find a private distribution centers, which honestly just did not function as well.
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Post by mollybrazil on Oct 7, 2021 11:21:58 GMT
This is a perfect example of decentralization allowing external players to participate but also leading to inefficiency. It highlights the importance of creating sustainable solutions with local governments (realizing bureaucracy and politics influence this greatly).
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Post by nishmav on Oct 11, 2021 13:17:13 GMT
I went on a week-long medical mission trip to Peru with an NGO in college. Once I got to medical school, I reflected on the true impact of this trip and actually felt guilt at going, especially since my individual participation was not sustainable. The organization itself was arguably sustainable, they had feet on the ground year-round. During that trip, we built a staircase up a mountainside that would undoubtedly help in some ways but I wondered how much say the community had in location, etc (the leadership team had mentioned nothing was done without the permission). In an ideal world, community members are engaged every step of the way and are the forefront of these organizations and their leadership. However, most times, external organizations are housed outside of the country and have occasional meetings with community leaders.
Funding is an entirely different issue. I do believe that the large funding organizations (WHO, Unicef) have the best intent when designing large projects and goals. They usually utilize employees that live in the country where these projects are implemented. However, at the core of external funding is a conflict of interest. You will have discrepancies between what community leaders and what these organizations want to do; and when those discrepancies exist, the funder usually has the last word.
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Post by tylerjmurphy on Oct 13, 2021 20:32:17 GMT
A mentor to many of the general surgery residents (and faculty since he was one of the most influential general surgery PDs at VUMC) is Dr. Tarpley. He has spent greater than thirty years in various regions of Africa and is now president of the pan-african academy of christian surgeons and he recently gave a talk on this very subject. He commented that many of the individuals he works with on his board have welcomed any and every project/initiative to help the inhabitants of their various countries because they are by and large behind in the grand scheme of development and innovation. There have been short stay involvement on a local level as well as prolonged expansive involvement in the structure of the countries. Although the latter may have more expansive and meaningful impact for countries, there is an impact for the shortened visits as well. Whether it be by exposure to new cultures, acknowledgment of another human beings struggles, or even just buying small trinkets at the local shops to help boost the economy, many of the shorter projects have important local influences. Similar to the prolonged projects, many of these smaller week long trips also have an expansive employment by local actors that although my individual stent was short, the local influence remains long standing.
With that being said I think many of the positives of both external actors and funders comes from when they have local actor involvement. It is impossible to send VUMC residents to AIC Kijabe Hospital every year without having locals that remain within the hospital year round and the positive impacts of these players comes from many of the ideas that originate from locals. The negative impacts of many of these players and funders come when the local individuals and their viewpoints are not considered and instead hold the local system "hostage" knowing their reliance on external forces for progress and success on the world stage. When an actor or funder goes in with a plan without involving locals it is not only negative, but it is commonly unsuccessful. In addition to getting buy-in I think that the involvement of local individuals also helps offset the risk many of these external actors/funders have where they are extremely narrow sighted. Rather than having all of the funding or all of the effort go to one project (i.e. HIV prevention, malaria prevention, expanding availability of clean water), local influence can help dictate where the project can go to best serve the system which the external actors/funders are trying to succeed within.
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Post by strainsk on Oct 14, 2021 2:15:57 GMT
Organizations like the World Bank International Development Association have made significant strides to address inequity by providing access to lower and middle-income countries. Such support can arise in the form of grants or little-to-no-interest loans that are made to provide an impetus to some economic growth, access to specific needs, such as the COVID-19 vaccine, or to improve the general infrastructure of a country. The program is set up in such a way to provide stratified and appropriate loans according to the countries financial situations, and in essence, not providing "hands outs". However, the negative influence comes from the fact that they are one of the largest funders for the poorest countries in the world. If they do not deem a project worth funding, a significant amount of potential money is withheld. As an external actor, they have significant say in some of the poorest countries' infrastructure and growth.
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Post by strainsk on Oct 14, 2021 2:28:14 GMT
PAACS is such a unique external influencer. They have an interesting mix of local buy-in and "short-term" visiting faculty to sustain their residency programs. Their global aim is to train safe, spiritually sound, surgeons to serve in Africa so their overall mission to positively impact the continent as a whole but they cannot achieve this goal, as you said, without local buy-in. Unfortunately, at this time they still do rely heavily on visiting faculty to train their residents and do not have sufficient long-term faculty to full train their residents at this time. Those who are able to dedicate their time, whether local or out-of-country, will have significant influence on the training of residents and thus the availability/number of surgeons in Africa. A mentor to many of the general surgery residents (and faculty since he was one of the most influential general surgery PDs at VUMC) is Dr. Tarpley. He has spent greater than thirty years in various regions of Africa and is now president of the pan-african academy of christian surgeons and he recently gave a talk on this very subject. He commented that many of the individuals he works with on his board have welcomed any and every project/initiative to help the inhabitants of their various countries because they are by and large behind in the grand scheme of development and innovation. There have been short stay involvement on a local level as well as prolonged expansive involvement in the structure of the countries. Although the latter may have more expansive and meaningful impact for countries, there is an impact for the shortened visits as well. Whether it be by exposure to new cultures, acknowledgment of another human beings struggles, or even just buying small trinkets at the local shops to help boost the economy, many of the shorter projects have important local influences. Similar to the prolonged projects, many of these smaller week long trips also have an expansive employment by local actors that although my individual stent was short, the local influence remains long standing. With that being said I think many of the positives of both external actors and funders comes from when they have local actor involvement. It is impossible to send VUMC residents to AIC Kijabe Hospital every year without having locals that remain within the hospital year round and the positive impacts of these players comes from many of the ideas that originate from locals. The negative impacts of many of these players and funders come when the local individuals and their viewpoints are not considered and instead hold the local system "hostage" knowing their reliance on external forces for progress and success on the world stage. When an actor or funder goes in with a plan without involving locals it is not only negative, but it is commonly unsuccessful. In addition to getting buy-in I think that the involvement of local individuals also helps offset the risk many of these external actors/funders have where they are extremely narrow sighted. Rather than having all of the funding or all of the effort go to one project (i.e. HIV prevention, malaria prevention, expanding availability of clean water), local influence can help dictate where the project can go to best serve the system which the external actors/funders are trying to succeed within.
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Post by danika on Oct 14, 2021 4:30:47 GMT
As demonstrated in module 2, it is important to consider the many external factors and sources of funding that can impact a national or multinational health system, as well as the benefits and disadvantages these types of relationships can have. In the malaria case, and in my limited personal experience, external organizations and volunteers can establish a connection with a health system through international organizations (ie WHO), a national government agency (ie MOH), NGOs, sister academic institutions or established national organizations with a similar health goal (ie malaria eradication). Longlasting relationships between institutions or individuals can then be built and expanded upon through networking and consistent interest/collaboration.
Funding is most commonly sourced from large international organizations (can be multiple, as in the malaria case) that have significantly more wealth and resources than the systems or countries to which they are being applied, which naturally sets up a power dynamic. Ideally, the funding organizations have the best interests of the smaller, local communities at the center of their mission, and in order to have optimal impact, relationships with leaders within those communities who have the best understanding of its inner workings are valued and maintained. Without understanding of how the current system works, what needs to be improved, the current infrastructure and how it can be expanded, the funding may not be meaningfully applied. The country or system receiving aid is at risk for becoming dependent on those external sources of funding and in turn risks losing its authority/autonomy in the progression of its own system.
There is also the question of which organization has the responsibility of conducting research to determine the impact of any interventions, and if this falls on the national organizations or funding sources due to poor infrastructure or capabilities of the native system, then there is risk for manipulation of data and possible withholding or inappropriate distribution of resources.
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Post by danika on Oct 14, 2021 4:52:28 GMT
I went on a week-long medical mission trip to Peru with an NGO in college. Once I got to medical school, I reflected on the true impact of this trip and actually felt guilt at going, especially since my individual participation was not sustainable. The organization itself was arguably sustainable, they had feet on the ground year-round. During that trip, we built a staircase up a mountainside that would undoubtedly help in some ways but I wondered how much say the community had in location, etc (the leadership team had mentioned nothing was done without the permission). In an ideal world, community members are engaged every step of the way and are the forefront of these organizations and their leadership. However, most times, external organizations are housed outside of the country and have occasional meetings with community leaders. Funding is an entirely different issue. I do believe that the large funding organizations (WHO, Unicef) have the best intent when designing large projects and goals. They usually utilize employees that live in the country where these projects are implemented. However, at the core of external funding is a conflict of interest. You will have discrepancies between what community leaders and what these organizations want to do; and when those discrepancies exist, the funder usually has the last word. I also went to Peru in college for a month with an NGO and had a similar reflection after the trip. I found the NGO through a posting on my school's pre-med program website and decided to go on the trip to gain medical exposure, learn about cultural differences in health care and try to help the local health communities however I was able. This NGO fortunately had local connections with multiple hospitals and schools, and I was able to observe/assist in clinics, procedures and teaching. Although I helped a few patients and health care providers I assisted, I came to realize my personal impact was short lasting and rather small and that I likely benefitted more from the experience than others I worked with. Honestly, the most sustainable impact my work had was to hopefully prevent disease by explaining to school age children the importance of washing their hands, brushing their teeth, and exercising. Ultimately, I realized the impact of the NGO as a whole was more significant, as multiple rounds of students participated in the program every month and the program continued to grow both in number of participants and connections with local facilities/organizations. I also promoted this organization on social media platforms and at my school after the trip, hopefully multiplying my impact on the NGO and its affiliated institutions in Peru. There exists an openness and desire to connect with external actors by countries/systems in need of assistance where the demand for quality care exceeds its supply, and establishing/maintaining connections with those willing to help, with service or with funding, can set up a mutually beneficial and durable partnership for all involved parties.
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Post by rachaelpellegrino on Oct 14, 2021 16:54:43 GMT
It is interesting to reflect on where funding sources come from and how that impacts which initiatives are undertaken in a country. These external actors are often closely tied to funders and have to shape initiatives in order to be financially sustainable. I think the challenge is involving communities in shaping initiatives on a local and country wide level that is not overly taxing and sustainable.
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