Back to accountability on the local level

February 24, 2007 at 7:21 am (Sarah's Posts)

We had a lecture the other day from a woman from Hopkins who is working on a large-scale clinical trial in Indonesia on the effects of maternal micronutrient supplementation on infant mortality rates (IMR).  It is an area that has been looked at a lot, but with varied outcomes that have left open questions like when supplementation is the most effective and what composition of micronutrients is best.

One of the areas that she mentioned as particularly controversial was their policy of creating a certification program for all people involved in the project, including the local community facilitators (CFs).  They realized realy on that the local workers didn’t understand the larger focus of the project beyond their specific assigned tasks.  So, they started a program that evaluated everyone based on three categories: head (understanding of the project), heart (empathy and ability to communicate with the mothers), and the hands (ability to record and keep track of data).  If a CF fails three times, he is asked to leave the project.  Both the expat and the academic communities said that this wasn’t a practical, realistic or necessary expectation, but the program coordinators insisted.

When they started looking at the data, they found some interesting things.  Firstly, there was a 20% decrease in IMR with micronutrient supplementation, with the most important time being during the last trimester.  More interestingly, when they compared the IMR for women assigned to excellent CFs as compared to those who were rated as good, there was an additional 17% decrease in IMR.  Among women who were initially assigned to a CF who had to be dismissed due to failure to pass the certification, there was a 20% increase in IMR, essentially elimitating the positive effects of micronutrients.  If seems that there was a synergistic effect of having micronutrient supplementation and an excellent CF.

Sometimes in public health work here, I see the mentality that just because we’re doing good work, it means that we don’t have to do a good job.  Outcome measurements that look at numbers of people trained or number of women reached sometimes gloss over whether the project effectively trained/communicated/reached the target popultion.  Instead, these projects need foster the idea that everyone involved is going to be held accountable because they are all responsible to the community.  It is a method of empowerment, of telling CFs that their skills and understanding are valued, particularl if it becomes clear that these skills have an effect on health outcomes.

On a site note, someone brought up the point that all these programs are merely drops in the bucket, and that any given intervention-specific project is too small in scope to make any real difference.  This lecturer felt that the greatest increases in health have come from economic development, not from any health research or specific program.  How would we begin to address the question of whoether all the money that goes into health specific interventions and research could be used more effectively if directly invested in economic development of the community?


1 Comment

  1. msoule said,

    Your last point is exactly why I studied development. And why I encourage everyone to get a handle on some econ and some sociology and some political theory. The greatest improvements in public health have been driven by economic development. Poverty is known as a risk factor for ill-health in general. There is a website associated with the University of Illinois at Chicago’s medical center with some research that makes that connection explicit. I’ll post it soon.

    Yes, these efforts are all drops in the bucket. But what if we get more people adding drops? It’s why we need to work together with the politicians, the community leaders, the teachers, the lawyers to make a bigger movement out of this. We can’t make the big changes on our own, health folks. This is how we increase the rate of really invested community workers. And of course we have to have quality control, but the deeper and more comprehensive the reach into the community is, the better the outcomes ought to be.

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