• Lowan Lee

An Interview with Professor Uli Locher on the Hierarchy of Healthcare

Professor Locher has been teaching at McGill since 1974. His research interests include internal and international migration, social change in the Caribbean and social and economic development. Prof. Locher has been a frequent consultant to the World Bank, USAID and the Interamerican Development Bank, particularly on issues concerning the educational systems in Haiti and West Africa, municipal development in sub Saharan Africa and social and economic development in the Caribbean. Interview:

L: Professor Locher, it’s good to have you here, let’s start with a question about your research and interests, taking a particular emphasis on health.

U: I’ve been at McGill since 1974 and much of my research goes into two particular areas: one I am no longer involved with, which is language behaviour in Quebec, and the other I am very much involved with, which is international development that particularly emphasizes migratory exchange and how international development aid works.

L: So you have been involved in health care project evaluation?

U: I’ve evaluated projects with a health component, and once I evaluated a project focused on community health. Many evaluations that I have done include health projects, so I can compare their success to the success of other projects.

L: Tell us a bit about hierarchy in health care.

U: It’s a vast subject. Let me start with this: most modern healthcare is organized in very hierarchical ways. There is a health ministry that is connected in finances, health departments, faculties of medicine, etc.…Training is also top to bottom. Then, there is a whole health delivery structure that involves clinics, hospitals and a personnel structure. Everything is really organized from top to bottom. This structure is to control expense while ensuring the respect of procedural and technical guidelines.

L: So this approach is very formal, with the general assumption of a hierarchy and clear lines of authority. Are there other alternatives to this type of structure?

U: Yes absolutely, such as community health programs. These programs channel resources in order to function more efficiently. For example, you can look at modest efforts by development projects with little infirmaries, clinics and only part time employees. They are the first defenses, the first contact with beneficiary populations, and most importantly, resources are channelled through them. For example, a health ministry structured in a top to bottom fashion has decided to run vaccination campaign. It can do this by itself or through community resources by mobilizing people who have a lot of interest in the community, rather than just in health. Most importantly, these actors know each other, they are organized and have lived in the community their whole lives.I call this the network approach, it produces much higher success rates.

L: How would an official body implement this?

U: The higher order of government will want to set certain standards. For example, in the case of a vaccination campaign, vaccine refrigeration. However, technical standards are only one part of the story; socio-economic political factors enter into the game. An instructed government will decide that anybody respecting these minimal standards can participate in the campaign.

L: How would the government work with the different actors such as NGOs, the local community and the municipal government?

U: It is important to always tap on a number of actors. For example in Santiago, Dominican Republic, the community health project will be implemented in an impoverished part of the city. Local actors from the community will participate such as the soccer club, youth club, religious society, choral society… Anybody with will and organization can make a contribution!

L: So the government recruited groups and gave directions?

U: Local meetings are organized, the local groups closest to beneficiaries state their priorities, and then in a consensual way, decide who does what according to priorities and what type of success they desire. The initial investments, like a small health outpost, some furniture, equipment, a couple of personnel and networking mechanisms (phones, radio) are provided by the organization in charge. However, all of the actors involved have their say, making everybody very much interested. This transforms low-level community organizations into monitoring agencies. For example, the soccer club participates, so if they have an accident, quick service will be delivered. If the service does not work they will report it, creating a self-reporting mechanism. The community approach is a very social approach, but with a higher efficiency of medical resources.

L: Impressive, so this ensures that everybody wants to make it work efficiently?

U: Monitoring mechanisms report on project success, to see if they are satisfactory or not satisfactory. Several databases, notably the Inter American Development Bank, have performance reports with fixed labels: “yes” or “no” and reasons. I ranked all of the reports of the Inter American Bank, and out of 149 projects under implementation in 2002, the success rate was more then twice as high with a participatory structure. On the other hand, government-to local level systems were performing much worse.

L: This seems like the way to go! Any idea of the percentage of local aid projects using the network approach?

U: This is difficult to assess, my own data are limited, but I also used other data sources such as the best practices used by UN habitat. These data are sampled so I am not sure if they are representative. But I can affirm that a better half are trying to use the network approach. This is not the case in health projects, as health project use strict hierarchies.

L: Why do they continue to stick to such a model?

U: Most importantly, governments want to keep their hands on these projects as they are expensive. It is also important to note that programs in Western modern medicine and health organization is hierarchical. Therefore, the discipline in originating countries exports something in its own image.

L: Are there advantages in having such a structure?

U: Yes, is absolutely essential sometimes, and occasionally quite successful. Development work can be so complex and so large that no developing countries can carry them out. For example, building major airports and seaports where a technocratic top-to-bottom approach is needed requires a hierarchical structure, so as to ensure proper monitoring and control. In certain cases, this is essential in large-scale health projects, for example, worldwide measles extermination.

L: To conclude, what are the best practices?

U: In my opinion, there are not that many requirements, but make sure others are involved. As an evaluator, this is the single most important contributor to program success.

L: Could you give us one last example of a successful program?

U: The Dominican example. Why was it so good? Beneficiaries were involved from the beginning. It started small and had a trial phase, in order to scale it to a bigger scale. Use of community contacts or “promodoras de salud” was important. Healthcare promoters who weren’t nurses nor professionals but just committed community women counseled people in their homes. They are the first line of defense, the first ones to detect something important. If newborn babies are underweight or have excess diarrhea, they will signal this to the nearest clinic. Why do these projects work so well? Overlaps of motivations, or common interests, are the foundation to make sure health results are actually achieved.

L: For our readers interested in learning more, what do you recommend?

U: The internet is full of best practices; make your way through many organizations that provide examples. Use Google! Youtube is a great resource as well, go look at health projects. Videos can be very revealing as organizations want to put their best front to the international audience. It is also very revealing in videos whether key roles are played by foreigners or locals. If it’s foreigners that's not bad, but it’s inherently unsustainable.

L: Yes, the problem with health projects is they have to be independent on themselves, otherwise, when foreigners leave, the whole thing breaks apart.

U: Something home grown, even if modest and not up to our standards, is vastly preferable from something brought from outside.Conclusion: The network approach in healthcare is perhaps the best practice, meaning that such an approach is effective at significantly impacting targeted outcomes. To summarize interview in three points : One, the network approach is more efficient, as participant’s motivations and interests are connected to their contributions, making them directly involved in the project. This creates an incentive to work harder. Two, partners are important, as they watch over resource allocation and procedural effectiveness. Since they have a direct stake in the project, the partner system facilitates monitoring and prevents inefficiencies. Three, such networks are flexible and have greater knowledge of the serviced community, allowing them to adapt with greater facility to changes in available resources and the working environment.

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