We believe that systems thinking and complexity science can be transformational in global health by increasing local capacity and shared learning, and minimizing unintended consequences.
As I have introduced the idea of GHSIAs to colleagues and friends, 3 criticisms have been mentioned:
1. “The cost is too great. GHSIAs would only add to the cost of global health programs that are already scraping for funds.””
2. “This yet another example of increasing bureaucracy. We don’t need more complicated programs. Simplify!”
3. “Assessing and evaluating health systems is much too uncertain and complicated. We should not start such an assessment until we are sure that it will work.”
As I have thought about these criticisms (which, I think, are legitimate concerns that merit careful consideration as we move forward), the following analogy, it seems to me, puts the need for GHSIAs into perspective, and addresses those criticisms (assuming, of course, that the need is real; more on that in upcoming posts):
Imagine a community in dire need for basic shelter. Most of the dwelling units are very simple lean-to structures exposed to the wind and rain. There is little to no knowledge about how to construct homes, and little to no organization to improve the situation. The community suffers daily from exposure, and life expectancy and productivity are greatly decreased.
Word of the condition of this community and its needs reaches people near and far. Concerned activists, humanitarians, and others consider what they can do to help. A neighboring community has been using straw for its houses roofs for years, and gives some to our community.Window builders from a far-away land come periodically to donate and make windows. The owner of a large roof-making company donates his trainers to help locals learn how to make the roofs. The response is tremendous; thousands of dollars are invested, hundreds of volunteers from all over the globe, and from dozens of churches, universities, and other organizations donate their time. No one had ever witnessed such a response.
The surprising final result, all agreed, was a disaster. The window makers had not coordinated with the size of the framing, so most of the windows that were donated were useless. The roof making company volunteers would come sporadically to help, often without warning, resulting in some roofs that were partially finished, and the majority of the houses were left without a roof. Some of the houses that did have roofs had roofs that were much too big. Perhaps most significant was the number of local roof builders that were put out of business because they could not compete with the well-financed, though unpredictable, company from afar. There was a door-bell specialist from a neighboring country that installed functioning door bells on all of the houses. That, however, did not address the community dwellers’ real need: protection from the elements. A framing organization did a respectable job at mobilizing the community. However, every time that they would come to help, they would pay considerably more than other other employers, so workers would abandon their other jobs that were just as important as the roofing jobs. The lack of communication and coordination, stemming from the lack of a common goal, resulted in what many considered a worsening housing crisis: lack of local capacity, dependence on unreliable outsiders, and houses that are, at best, only partially effective at keeping out the elements.
Improving health is much like building a house. While responding to specific threats (polio, malaria, AIDS, etc.) is important and necessary, all involved in global health would agree that the final, ultimate goal is not an increase in vaccinations, or an increase in the number of people on AIDS medications, or an increase in the percentage of people using mosquito nets, just as home builders would agree that the ultimate goal is not an outstanding window, door bell, door, etc. The ultimate goal for home builders is a house that keeps the temperature bearable, and keeps the elements out. Our ultimate goal as citizens interested in global health is to improve health. And, long-term, that will only happen when the health system is functioning effectively and efficiently.
Home building contractors all agree that a blueprint is needed prior to starting their particular contribution to the final house to consider how their activities impact and improve the final product. I have never heard the claim that home blueprints are too expensive, or involve too much red tape, or that they are too difficult or complicated. Indeed, it would seem foolish to embark on some aspect of home building without considering how your activity might impact other activities or products, or the house itself.
It is time we in global health perform a similar impact assessment on all of our activities. In response to the critics: we cannot afford NOT to perform GHSIAs!.