PacificSci ~~~~~~~~~~~~~~~~~~~~~~~~~ FIFTH ANNIVERSARY OF A BUSINESS VENTURE WITH A SOCIAL PURPOSE

PREAMBLE: Fourth Sector Enterprises
Pacific Health & Development Sciences Inc. (PacificSci), a health systems consulting firm based in Canada, falls within a new class of organization known as “fourth sector” or “for benefit” enterprises. Such entities represent a new paradigm in organizational design, aiming to link two concepts which are held as a false dichotomy in other models: private interest and public benefit.[1]

Before telling the short story of PacificSci, we muse in this preamble on the emergence of “fourth sector” organizations. To place this in the contemporary context, consider the following observations regarding the conflicts confronting traditional organizations[2]:

• Private companies have always had to balance between achieving the largest possible profits for their shareholders and retaining trust and contact with their other stakeholders: the local community, consumers, sub-contractors, pressure groups, etc.

• The public sector for years now has faced enormous political pressure in favour of privatization of a wide range of functions - and then being forced to 'repurchase' the very same functions and institutions when private companies no longer find them profitable.

• Voluntary organizations: Due to fierce competition from other voluntary organizations and tight state financing, voluntary organizations are having to experiment with their independent income - the sale of services and new products. All of which - activities and financial priorities - can be at odds with the organization's main goals and mission.

As far as the private sector is concerned, one only has to look at the world financial crisis to recognize that some firms are simply too big to be allowed to fail, despite incompetent leadership e.g, even now the US is bailing out its once mighty banking industry. Clearly, western industrialized nations are capitalist when going up, and socialist going down!

Equally, it has become increasingly clear that neither public nor voluntary sector organizations really operate in the “pure” manner traditionally implied. Increasingly public enterprises compete with the private sector, while the voluntary sector has become more commercially oriented.

For example, the success of many voluntary not-for-profit organizations today is due to a fully funded core staff, supplemented by contract income, thus able to build handsome “working capital funds”, while remaining eligible for government grants, which conveys a competitive advantage over other types of organization. In effect, such non-governmental organizations or NGOs (once mostly charitable organizations) have actually become a good “business model”!

In the meantime, many public sector (government) entities have become so hollowed out that they simply must hire private contractors to deliver the expertise that actually belongs with their public mandate. In addition to consulting firms, much of that expertise (sometimes hidden) is obtained from universities, themselves having become “hybrid” organizations[3]. Even publicly funded universities now engage in industry partnerships while receiving government financing, and simultaneously contracting out services to government! For those wishing a more academic analysis, we refer to Claude Menard.[4]

In this increasingly complex scenario, for which the neat rules separating the traditional organizational forms seem increasingly less applicable if not actually quite murky, the emergence of fourth sector organizations is perhaps virtually inevitable: breaking with earlier conceptions of the relationship between the state, the private sector and the voluntary sector. Operating outside the world of grants, and inside the basic economic realities of surviving as a business, the bottom line is nonetheless one of social purpose: in many ways a modern renaissance of motivation to improve the human condition.

With this backdrop we now offer the short story of PacificSci as a fourth sector organization.

References:
1. FourthSector.net http://www.fourthsector.net/for-benefit-organizations.php Accessed Dec 5, 2008.
2. KaosPilot International - International School of New Business Design and Social Innovation. http://users.homebase.dk/~awi/Publications/fourth_sector.pdf Accessed Dec 5, 2008.
3. Lamb R. Hybrid Organization. University of Hawaii, Manoa. June 17, 2004. http://www.vfh.fh-brandenburg.de/vfh/gastvorlesungen/gastvortrag_05.pdf Accessed Dec 5, 2008.
4. Menard C. The Economics of Hybrid Organizations. Presidential address to the annual conference of the International Society for New Institutional Economics, MIT, September
27–29, 2002. Journal of Institutional and Theoretical Economics. JITE 160 (2004), 345–376 2004 Mohr Siebeck – ISSN 0932-4569
http://atom.univ-paris1.fr/documents/Menard_JITE_2004.pdf Accessed Dec 5, 2008.

Feature Story - FIFTH ANNIVERSARY OF PacificSci
Pacific Health & Development Sciences Inc. (PacificSci), was incorporated precisely five years ago, on December 8th, 2003, as a health systems consulting firm. Our mission is “seeking solutions to health and social impacts of economic development”.

PacificSci is a joint venture of principals Franklin White (FW) and Debra Nanan (DN), President and Vice-President respectively. It was conceived primarily as a vehicle for our continued involvement in the field of public health, within which we had accumulated some 50 years professional experience. FW having worked outside Canada for the previous 15 years, and DN also experienced in both developed and developing countries and now a new resident of Canada, it was clear that –having been out of sight and out of mind for so long – one way to sustain our involvement in mid-career at appropriate levels of philosophy and responsibility would be to set up a private entity with its own mission.

The act of incorporation was carried out without professional legal assistance, using a simple “how to” guide. Within the first year, we became listed on various public sector registries in Canada, and launched our first website using freeware. In 2006, "PacificSci" was approved as our registered trademark. We upgraded our website in 2007 using the basic package from SiteCube.com, again without assistance[1]. See http://www.pacificsci.org/

Since incorporation, PacificSci has engaged in a blend of contractual and pro bono activities, mostly with an international focus, and with an expanding domestic portfolio. Without attempting to be comprehensive, the following is a selection from our portfolio.

Revenue Generating Activities
As a fourth sector organization, contractual work has been our primary source of corporate income. In this we have had reasonable success in attracting both international and domestic assignments, all of which reflect our social mission. In carrying out this mission, we commit to the same level of rigour and professionalism as we previously applied to our former careers in both academia and government service.

International Contracts
Foremost in this category has been Health Project Monitoring in Pakistan: In 2004 PacificSci participated with Universalia Management Group to bid for this Canadian International Development Agency (CIDA) role. A 5-year contract was awarded in 2005. Since then we have conducted M&E tasks in relation to four CIDA-supported initiatives:

- Family Planning Association of Pakistan (FPAP)
- HIV/AIDS Surveillance Project (HASP)
- Systems-Oriented Health Investment Programme (SOHIP)
- Lady Health Workers Programme (LHWP)

We are currently engaged in continued monitoring of both SOHIP and the LHWP. In addition, at CIDA’s request in 2006, FW carried out a review of a World Bank evaluation on a primary health care initiative in Pakistan, duly acknowledged by the bank.

We were also contracted by Sweden’s International Development Cooperation Agency (SIDA) to represent them in a joint donor evaluation of the African Medical & Research Foundation (AMREF). From October 2005 this entailed site visits to headquarters and field operations in Kenya, Uganda and Tanzania; the assignment was completed in March 2006.
NOTE: Links to each of these projects are supplied on our website: http://www.pacificsci.org/

Domestic Contracts
Domestic contract have also been a significant source of revenue, compatible with our mission. Over our first 5 years, PacificSci has engaged in several contracts, the most significant of which have been:

. Royal Roads University, Centre for Health Leadership & Research (CHLR): In April 2008 DN, PacificSci, contracted to support CHLR research; concluded Sept 2008. In July 2007, both principals delivered a review of process evaluation for population health initiatives. In Sept 2006, White co-developed with Dickson of CHLR a concept paper to support the ActNow-BC initiative, Ministry of Tourism, Sports & the Arts.

. EDS Canada: From December 2005 to February 2006, PacificSci was retained for our technical expertise to assist EDS in developing disease surveillance and management solutions, in response to an RFP to develop a Pan Canadian system. While EDS did not win this competition, out of 10 bidders it ranked second in a final run-off with IBM Canada, and ruled eligible if IBM did not complete the initial contracting requirements.

. British Columbia Ministry of Health: in 2004 PacificSci developed (complete draft) the Provincial Health Officer's (PHO) 2003 report. "Every Breath You Take..." This cites ~200 references and presents original analyses of air quality and morbidity data, including the first analysis of health services impact of 2003 forest fires. It was presented by PHO Dr Perry Kendall to the BC Legislature.

NOTE: Links to each of these initiatives are supplied on our website: http://www.pacificsci.org/

Pro Bono and Academically-Associated Activities
PacificSci’s voluntary activities have included many hundreds of hours in mentoring individuals and groups abroad and in Canada, participating in e-communities and in health policy groups, and reviewing for scientific journals.

We have also engaged in communications work. In 2006 the firm launched this monthly blog (PacificSci Global Perspectives) to present an independent view on current affairs, emphasizing the social determinants of health and social well-being. We were also a Communications Partner for the World Urban Forum (WUF) 2006, Vancouver.

On January 10, 2006, we launched PacificSci GLOBAL HEALTH DATA LINKS [2], a free subsidiary website developed primarily for students of international and global health providing annotated links to the following sources:

. UNDP Human Development Statistical Reports
. WHO Statistical Information Systems
. US Census Bureau International Database
. Population Reference Bureau Data-Finder
. WHO's Global Health Atlas.

Academically, PacificSci has been active in various (mostly honorary and voluntary) roles with: the Aga Khan University (Community Health Sciences), Dalhousie University (Community Health & Epidemiology), Kuwait University (College of Medicine), Royal Roads University (Centre for Health Leadership and Research), and others. The roles have included serving as: thesis supervisor; research advisor; external examiner; visiting speaker; curriculum design advisor; co-grantee; and co-author. In addition, Franklin White serves on an Advisory Board at the University of Victoria, Faculty of Human and Social Development, and Debra Nanan recently held a research post under a PacificSci contract with RRU. In May 2008, Franklin White was an invited by the University of Wisconsin to help launch the Survey of the Health of Wisconsin (SHOW), supported by the Wisconsin Partnership Fund for a Healthy Future.

Since incorporation, PacificSci principals have reviewed various scientific and professional articles for the following leading international journals:

. Anthropology & Medicine
. Archives Medical Sciences
. Canadian Medical Association Journal
. Evidence-based Complementary and Alternative Medicine
. Globalization & Health
. Medical Science Monitor
. International Journal Quality Health Care
. Journal of Public Health
. Qualitative Health Research

Since incorporation, as an expression of ongoing commitment to the population health sciences, PacificSci principals (in addition to numerous contracted technical reports) have themselves authored or co-authored 19 articles in peer-reviewed journals, 2 book contributions, 4 conference abstracts and 1 on-line video. Franklin White served as an Associate Editor and Debra Nanan as a contributor in: Dictionary of Public Health. JM Last (ed) Oxford University Press 2007. [Oxford Reference Online Series.] We also completed a major book chapter: White F, Nanan D. International and Global Health. Chap 76. In: Maxcy-Rosenau-Last, Public Health & Preventive Medicine. 15th Ed. McGraw Hill 2008. Full citations are available on a free website PacificSci NEWS & REPORTS [3], where we maintain a cumulative public record of our work. Unlike the contributions of most of our university and government colleagues, these contributions are of a pro bono nature. We see this as essential in staying in touch with and maintaining leadership in our field, while growing PacificSci as a fourth sector organization.
NOTE: Links to many items noted above are on our website: http://www.pacificsci.org/

Discussion
The most significant discovery in growing our enterprise, is that, despite working outside the formal system, we are able to make a unique and valued contribution to the public good, perhaps even “above our weight”. While less personally remunerative than working in either the public sector or in a university, this is offset by more “intellectual freedom” than most full time academics, and more control over professional time than persons working in a health service. Our third party independence, especially in monitoring and evaluation roles, and in our greater opportunity to “think outside the box”, frees us to speak out and write on issues as we see them, and make pro bono contributions out of choice, according to our best judgment. A significant disadvantage however is that, not being part of collective agreements that provide for professional networking and development, we must either dip into our own pockets or be invited as a resource e.g., conferences. This is the price to be paid for a different way of working: the fourth sector approach – in striving towards our social mission, we must also deliver on our skills, or go out of business. As we enter our sixth year, so far this has not happened.

Envoi: This has been a brief and candid account of the experience of Pacific Health & Development Sciences Inc., during its first 5 years or operation. During this period, PacificSci has managed to deliver reasonably well on its mission while being a “business venture with a social purpose”. Our “fourth sector” model has facilitated flexibility in what we, as principals, choose to do professionally. We can recommend this form of organization for anyone who wishes professional freedom of choice, within a strong social mission, and with the discipline to ride through lean inter-contract periods.

References
1. Pacific Health & Development Sciences Inc. MAIN WEBSITE http://www.pacificsci.org/
2. PacificSci GLOBAL HEALTH DATA LINKS http://www.webspawner.com/users/globalhealthdata/index.html
3. PacificSci NEWS & REPORTS http://www.webspawner.com/users/pacificsci/index.html

INTERNATIONAL & GLOBAL DEVELOPMENT - YEAR IN REVIEW 2007

LATE BREAKER: For a thought-provoking critical analysis of what the Bhutto assassination on December 27 means for Pakistan and the "war on terror", see the new addition in our sidebar.

PREAMBLE: This issue also completes our first full year of blogging. Drawing from topics covered during the year, we offer below: overviews views on three major issues for humankind, followed by paraphrases from our monthly themes in 2007.

THREE LEADING ISSUES FROM 2007: Flowers or Fertilizer?
1. GLOBAL STEWARDSHIP: In our view, the lead issue here is Climate Change (May, October), which is already displacing some of the world’s vulnerable populations, and ultimately threatening life on this planet. This is followed closely by global food security (February) and displacement by rich countries of grain for use as automotive fuel, thereby creating pressure on its use in food in developing countries, and even the price of food in developed ones, impacting on access and affordability. Flowers: to the European Community for its global leadership on climate. Fertilizer: To Canada’s Conservative government which has set the world’s worst example of procrastination on climate.

Note: At the recently concluded UN Climate Summit in Bali, Canada received a “Fossil Award” for its dismal performance on addressing climate change, while the tactics adopted by our Conservative government to undermine the developing global consensus on the need for binding targets now were described by numerous observers as "hypocritical" and “deceitful”.

2. INTERNATIONAL DEVELOPMENT: Viewed broadly, we consider the leading issue here to be Maternal & Child Health (April, November). The determinants include gender inequality, global poverty, and insufficient policy and program development at all levels. Even in developed western countries this is an issue: taking our own country Canada as an example, the “new” Conservative government’s reneged on the Kelowna Accord to improve conditions for aboriginals, and failed to ensure an adequate child care platform (March, April). Further, with the exception of the Nordic nations, official development assistance from wealthy developed countries is still far less than targets agreed decades ago. Flowers: Norway, whose 4.7 million people already contribute almost $4 billion a year to aid developing countries ($850 for each Norwegan man, woman and child). Fertilizer: The powerful G7 nations for allocating proportionally less Gross National Income (GNI) for international development: 0.30%, compared with .50% for non-G7 nations.

3. HUMAN RIGHTS ABUSES: Still topping the list continues to be the War in Iraq (January, August). Primary responsibility is shared between the Bush and Blair regimes (not equally) for promoting false rumours of weapons of mass destruction, unsupported by UN inspections led by Hans Blix. While insurgents share responsibility for the mayhem and catastrophe, the end results include over half a million Iraqis killed (a genocide?), massive numbers of refugees, and the undermining of Geneva Conventions that were born out of the worst excesses of World War 2. Flowers: Pastor Martin Niemoller (1892-1984). Fertilizer: George Bush (most dangerous US President in history).

Historical Notes:
1) For a revealing 2003 interview of Hans Blix, visit: http://www.truthout.org/docs_03/041203A.shtml
2) For an October 2006 update on JHU estimates of Iraqi deaths: http://www.jhsph.edu/publichealthnews/press_releases/2006/burnham_iraq_2006.html

2007 AS WE RECORDED IT:
 January: PEACE, SECURITY, HEALTH & HUMAN RIGHTS: In our first issue of 2007, we took note of the incoming UN Secretary General Ban Ki-moon, acknowledging the immense contribution of former Secretary-General Kofi Annan, focused on war and peace in the Middle East, and completed the transfer of reports and commentaries from our News & Reports site (as announced in our December 2006 posting).

 February: GLOBAL FOOD SECURITY – A MATTER OF SURVIVAL: In 1996, the World Food Summit set a target to halve the number of undernourished people by 2015. However, in 2007, it appears unlikely that this target will be met. This issue focused on the conflict between grain for fuel or for food, the stalled Doha round, and food security.

 March: COLONIZED MINORITIES IN DEVELOPED COUNTRIES: Colonized racial, cultural or religious minorities exist throughout the world, within powerful societies eg., Tibet in China, Japan's Ainu, India's Dalits, Amerindian enclaves in the Caribbean, tribal minorities in Africa, Boznian Muslims, the Kurds of Iraq, others in all continents and among the Pacific islands. The issues apply to several economically advanced western countries where it is sometimes said that one may find “3rd world conditions in 1st world settings”. Because these countries claim leadership for human rights, they also must live up to these principles.

 April: EARLY CHILD DEVELOPMENT – POLICY SHIFTS, GLOBAL VIEWPOINTS, AND THE EVIDENCE BASE: This issue focused on Canadian policy shifts of global interest. Sadly, Canada’s reputation for enlightened social policy is being undermined by a neo-conservative ideology. Over a million Canadian children live in poverty and cannot access child care. In support of child-friendly interventions, we included evidence reviewed by the US-based RAND Corporation showing that childhood intervention programs yield benefits in behavior, educational progression and attainment, delinquency and crime, and labor market success, among other domains.

 May: CLIMATE CHANGE, KYOTO ACCORD, EUROPE RESPONDS & CANADA REMAINS CHALLENGED: The European Community (EU) takes Climate Change seriously, and is making progress towards its Kyoto targets. On April 26, 2007, Canada’s Conservative government released its first “climate-change plan”. Despite Canada leading the world in reducing ozone destroying chlorofluoro-carbons (Montreal Protocol 1987), signing the Kyoto Protocol (1997), and hosting its ratification (2005), this plan is incapable of meeting Canada’s Kyoto targets. Ranked 27th of 29 by the OECD on Greenhouse Gas (GHG) emissions, Canada remains among the most environmentally delinquent industrialized countries.

 June: OFFICIAL DEVELOPMENT ASSISTANCE & GLOBAL HEALTH TRENDS: This issue reviews the vexing issue of development assistance from wealthy developed countries such as Canada, references a report on global social and economic trends, then selects reports from a discipline essential to understanding global health trends: Health Situation Analysis. Selected examples included Africa, the State of the World Children, and Projections of Mortality and Burden of Disease to 2030.

 July: CELEBRATING THE AFRICAN MEDICAL AND RESEARCH FOUNDATION: In 1957, three surgeons in Kenya had a vision that could revolutionize health care in Africa. They launched a Flying Doctor Service (FDS). Over the next 5 decades, men set foot on the moon, satellites explored our solar system, the universe was probed with powerful orbital telescopes, robots explored the surface of Mars, and shuttles began servicing an international space station. In the meantime, with poverty and ill-health still pervading the planet, FDS became Africa’s largest indigenous health organization: the African Medical and Research Foundation.

 August: FIRST THEY CAME... VIGNETTES IN THE DISMANTLING OF DEMOCRATIC MYTHS: In this issue we offered a selection of extracts from reputable sources that focus on the disastrous trajectory of the current US administration in undermining the beliefs that underpin western democracies. We dedicate the issue to Pastor Martin Niemoller (1892–1984), whose famous poem “First they came…” about the inactivity of German intellectuals during the Nazi rise to power and the subsequent purging of their chosen targets, group by group, most devastatingly to German Jews.

 September: THIRD WORLD AID TO FIRST WORLD COUNTRIES: This issue featured the "brain drain" from sub-Saharan Africa, citing a report from Juan Ramos of ProCOR (website listed in sidebar). Practical responses re examined: striving for better compensation for indigenous health professionals, attention to policies that determine recruitment and retention of health professions in low income countries, fixing the ethics of western firms that raid poor countries to meet the service demands of rich ones, and finding ways to compensate third world "donor" countries for their loss of human resources. Through official inaction, "first world" countries benefit from a massive subsidy from the "third world", equal to the direct and indirect costs of their investment in this health human resource, and the opportunity costs entailed by its loss.

 October: IS CLIMATE CHANGE AN ACT OF AGRESSION?: In this issue we abstracted an article carried by The Economist (on-line Sept 24th, 2007) that reported on Ugandan President, Yoweri Museveni's declaration that climate change is an act of aggression by the rich world against the world’s poor. We also noted a statement from the Church World Service (CWS): "The issue... is how climate change frames development and justice", said Rajyashri Waghray, CWS director, education & advocacy.

For stark contrast we noted Canada’s uncertain posture, quoting from a Globe and Mail Editorial (September 26): “Prime Minister Stephen Harper’s progress from a climate-change skeptic to an environmental convert has been a perplexing odyssey. After a half-hearted attempt to tackle greenhouse-gas emissions late last year, his Conservative government hurriedly introduced new regulations and incentives, which made a good start in fostering reductions. Earlier…(in September), in Australia, he even announced his personal commitment to ‘careful environmental stewardship’. That seemed heartfelt. Now it is fair to question the sincerity of that conversion. On… (Sept 24), at a UN climate change conference aimed at saving the Kyoto Protocol, Mr Harper announced that Canada had asked to join a rival climate-change pact, the Asia-Pacific Partnership. The six members of that pact include nations that have refused to ratify the protocol, such as the United States, and others among the world’s worst polluters, such as India and China. Together they account for nearly half of all greenhouse gas emissions”.

 November: MATERNAL MORTALITY: WHAT DO SOUTH ASIA, THE UNITED STATES, AND AFRICA SHARE?: Maternal Mortality represents the largest rich-poor disparity tracked by the World Health Organization. On the heels of a study released by the United Nations (UN), the Women Deliver Global Conference in London, 18-20 October, assessed high levels of maternal mortality round the world. Little progress has been made in reducing maternal deaths in many countries. Areas of major focus were South Asia, parts of Africa, and even the United States, as it lags the developed world in its maternal health performance. The conference was supported by non-governmental, intergovernmental and development agencies as well as private sector and philanthropic entities aiming to create the political will to improve the health of pregnant mothers and their children, and to strengthen health systems around the world to prevent the deaths during pregnancy or childbirth of "one woman every minute of every day ".

“The eradication of poverty and hunger… cannot be achieved if questions of population and reproductive health are not addressed”. Kofi Annan

HOLIDAY GREETINGS: We extend to readers our best wishes for the holiday season and the New Year. We hope you found our selections during 2007 thought provoking and factually informative, and that you will continue to monitor this report.

CELEBRATING THE AFRICAN MEDICAL AND RESEARCH FOUNDATION (AMREF)

PREAMBLE: On cloudless nights in 1957, children lay on their backs searching for a small red object traversing the sky: the Soviets had launched “sputnik”, the world’s first satellite. Although this also led to accelerating the “space race” and intensifying the “cold war”, imaginations everywhere were captivated by our common primordial fantasy: reaching for the stars. In the same year, three surgeons in Kenya, Michael Wood, Archibald McIndoe and Thomas Rees had a vision that could revolutionize health care in Africa. Sharing in the romance of Africa, its needs, its potential and sense of destiny, they launched a Flying Doctor Service. Over the next 5 decades, men set foot on the moon, satellites explored our solar system, the universe probed was probed with powerful orbital telescopes, robots explored the surface of Mars, and shuttles began servicing an international space station. In the meantime, what began as the Flying Doctor Service became Africa’s largest indigenous health organization: the African Medical and Research Foundation.

Yet, even as we make progress in solving the riddles of the universe, there remains extreme poverty and ill-health throughout Africa, and injustice throughout the world. In this, its 50th anniversary year, we celebrate the AMREF story which continues to unfold. In doing so we have drawn from our opportunity to view the organization at work during a joint donor evaluation in 2005-6, and from their anniversary book A Very African Journey (URL at foot of this article).

THE AMREF STORY
AMREF’s Vision is to seek “better health for Africa”. Its Mission states… “In creating vibrant networks of informed communities that work with empowered health workers in stronger health systems, we aim to ensure every African has access to the good health which is theirs by right.”

Over the past half century, AMREF has truly evolved. Prior to the 1970s, most of its work was service delivery. Under then-chairman, Dunstan Omari (former secretary to the East African Community), the concept of community-based health care was promoted. Advocated by then-lecturers at Nairobi University, Roy Shaffer and Miram Were (now Chair of AMREF), and implemented by Revi Tuluhungwa, Chris Wood and others, a strategy of working more closely with Ministries of Health took root. Since then, AMREF has trained Africans to staff the organization, relying steadily less on foreigners to carry out its work, just as it has been training community health workers for many African governments. Its Flying Doctor Service is now a self-sustaining entity, while AMREF itself still delivers an outreach programme to support essential care and training to rural hospitals. AMREF initiated and now runs community-based programmes in Kenya, Tanzania, Uganda, Ethiopia, Somalia, Sudan and South Africa. Increasingly it has emphasized education, innovation and research, working in partnership with communities, grassroots organizations, governments and donors. It concentrates on finding ways to improve health through projects that address Africa’s unique problems, taking into account: culture, attitudes, economies, politics and environment as critical factors. Based on evidence supported by its operational research, AMREF’s programmes serve as implementation models for Africa, influencing policies and practices by sharing its interventions across the continent.

For decades, AMREF has applied ecosystems principles in the identification of health risks and piloting appropriate health system solutions in rural areas. On the dry plains, trachoma (leading infectious cause of blindness) persists among the Masaai in an environment of little water and swarms of flies; this contrasts with a farming community nestled between two rivers only 15 kilometres away: here trachoma is absent and malaria hyperendemic (where water is plentiful, mosquitoes breed more readily). Clearly, differing environments in conjunction with human behaviour combine to determine health risks. Overlaid on a traditional culture in which each wife shares a one-room home with her children and newborn animals, preparing meals on a contaminated floor, it is in these settings that conditions such as trachoma must be tackled. The WHO “SAFE” protocol was adopted: surgery, antibiotics, face-washing, and environmental improvements. From a primary prevention perspective, the underlying priority is the reverse of this, but one must deal with the most seriously affected first, as this gains immediate attention and promotes the credibility of an integrated approach. Attending to environmental and personal hygiene are also prerequisites to the prevention of a much wider range of conditions. Simple interventions like “leaky tin technology” (a large can of water with a small hole at its base plugged by a thorn), so that clean water can remain uncontaminated and used sparingly, have made the difference in reducing exposure and transmission of such diseases. Two decades ago AMREF realized that episodic clinical teams weres neither effective nor efficient, and that a community approach was needed, emphasizing the role of women. Adopting the WHO “PHASE” campaign (personal hygiene and sanitation education) in 1995, and in partnership with Glaxo Smith Kline, AMREF pioneered this approach in Kenya and Uganda; this has been replicated elsewhere in the world eg., Peru, Tajikistan, Nicaragua, Bangladesh.

AMREF’s operational activities reflect Africa’s disease burdens at the grassroots, including malaria and HIV. For example, the Malaria Partnership Programme in Uganda involves AMREF, Ministries of Health and local NGOs with funding from Glaxo, Smith, Kline. In Kiboga, Kanungu and Kumi districts, AMREF has trained over 1,000 “community medicine distributors” (CMDs) to promote insecticide-treated bednet use and home-based fever management in children who previously would have been treated with ineffective drugs purchased from roadside vendors. Population Services International has underwritten the distribution of nets, using a revolving fund. Within 3 years, 80% of children with malaria in these districts benefited from CMD interventions, supported by AMREF-trained clinical officers, nurses and laboratory technicians, and a marketing effort using radio broadcasts, drama and music, as well as posters in shops, schools and churches. In response to the HIV epidemic, the “Angaza Project” (Swahili: “shed a light”) in Tanzania has implemented 47 counseling and testing sites (more in development), and almost 1,000 counselors trained, supported by a marketing effort using peer educators, music and sports: 0.5 million people have already been tested.

AMREF is intimately involved in health systems development in difficult urban settings. As stated by Director-General Dr Michael Smalley: “If health systems are robust then everything else works”. For example, in the Kibera slum nearby Nairobi, a squatter community of some 850,000 live in extreme poverty and overcrowding, in grossly deficient housing and poor environmental conditions. This situation is found in many cities throughout Africa, due to the rural to urban shift of populations. Such shanty-towns are becoming home to 2nd and 3rd generations, and are virtually a permanent feature of these cities. As migrants come from differing backgrounds and cultures, there is ethnic tension and little community solidarity. Nonetheless, it is precisely in this setting that AMREF has been working in close collaboration with the community-based organization Mradi ya Afya Msingi na Maendeleo (MRAMMA), to develop Primary Health Care (PHC), in a manner that reflects the spirit of the Alma Ata Declaration (1978), the most enduring set of principles for PHC development. In partnership for 11 years, the project has reached 100,000 slum dwellers, including such interventions as community organization and leadership development, stimulation of small enterprises, provision of safe water and sanitation, a core package of PHC interventions emphasizing maternal and child health, and a health centre to deal with a range of conditions responsible for the bulk of the disease burden. This community-based effort has succeeded so well that the City of Nairobi, the Ministry of Health and other partners have now joined to uplift the conditions of Kibera.

Among AMREF’s most important roles is the management of knowledge: building capacity through training, and introducing new learning systems. Since 1987, AMREF has run a 1-year diploma in community health, now offered in affiliation with Kenya’s Moi University. Through this rigorous programme have passed almost 500 students from 35 African countries. Innovative ways have also been found to exercise this role in a distributed manner, eg., almost 10,000 students have taken AMREFs correspondence courses. In 1998 the Maridi National Health Institute was started in southern Sudan with AMREF funding and support: this is a 3 year” clinical officer” course, through which over 130 graduates have been trained to become first line practitioners. New learning methods and technologies are being utilized: increasingly teaching is based on the PBL approach (problem-based learning), and an e-learning initiative has been launched in collaboration with the Nursing Council of Kenya with support (funding and technical) from Accenture: to upgrade 22,000 nurses from certificate to diploma level.

Much more could be told about the work of AMREF than is possible in the space of this short report. In South Africa, where the Ministry of Health accepts traditional practitioners within the formal health system (>60% of South Africans consult sangomas), AMREF is working to help determine “best practices”, and to promote the integration of sangomas within health priorities such as HIV counseling, TB treatment, oral rehydration therapy, and checking on immunization status, while also supporting safe and more effective traditional practices. Elsewhere in Africa eg., Kechene District, Ethiopia, AMREF is supporting microcredit schemes for families, simultaneously addressing poverty and health: helping women to develop economically viable small enterprises and to take care of their familes at the same time. In conflict zones eg., northern Uganda and southern Sudan, AMREF is working “to have health systems and informed communities ready to take control of their own lives and… health, once the fighting is over”.

Conclusion: AMREF recognizes far better than most health organizations around the world that 80% of health is made in households and communities; perhaps only 20% is repaired in hospitals and clinics. Redressing the imbalance in Africa requires empowering communities, teaching preventive measures in a way that can be understood, and narrowing the gap between health systems and communities. Priority must be given to operational and applied research: AMREF’s own priorities are development driven, and a research question embodied within all proposals to donors. From this research comes policy making: AMREF sees itself at the interface in this critical process. AMREF’s current 5 year strategy (2006-11) is to strengthen health systems and to provide the evidence. As stated by AMREF Chair, Professor Miriam Were: “In the past we just assumed that people would see how passionate and experienced we were and follow. Now we know it takes hard-nosed science to persuade others… we are beginning to produce the evidence to influence policy-makers”.

Reference: A Very African Journey is available on-line at: http://64.176.64.243/A%20Very%20African%20Journey.pdf
For more about AMREF, visit their website: http://www.amref.org/