We all know that working together to achieving health outcomes is vital — no one will deny it. But what may not be at the forefront of everybody’s mind is that working together is first and foremost about working together with the people whose health we’re trying to improve. Not just working for them.
At SNV, we’re dedicated to achieving a society in which all people, irrespective of race, class or gender, enjoy the freedom to pursue their own sustainable development. It’s a mission I’m personally deeply committed to — particularly in its emphasis on reaching all people and facilitating them to gain the freedom to make their own choices about what development means to them. Gaining this freedom may require support, guidance and regulation, as well as extensive work on achieving affordable access and informed choice — but freedom should always be the focus. Freedom of choice and the freedom to define what a healthy, happy life means for them as an individual, family or community.
This focus has a tension with shortcuts such as blanket approaches (for example food additives) to solving health issues for large groups of the population. Such shortcuts can appear easy, because they save us from the tedious process of going through capacity building, community engagement and supporting individual skill and knowledge development. But shortcuts also carry enormous risks. Not only the risk that we might be wrong in our solution, but also that blanket approaches rarely contribute to a meaningful engagement of individuals and families with their own health. This reminds me of a friend who avoided the inevitable toddler-parent food conflict by only feeding her 5-year-old son chicken nuggets in the shape of dinosaurs. It might have solved the problem in the short term, but did nothing to encourage him to engage in a meaningful way with food.
In water, sanitation and hygiene, informed choice activities in sanitation aim to make sure that families have information about different relevant toilet technologies and payment options, as well as to support their decision-making. Similarly, in water supply, demand-oriented approaches promote a dialogue with communities about their service level and tariffs before construction takes place. We find that very often rural communities will choose household connections over public tap stands, even though tariffs for the first option are higher. This stands in sharp contrast to what engineers and development workers have been thinking for years, namely that poor rural people should have access to water through public taps.
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Sustained good health choices need to be holistic and meaningful to the people whose health they concern. Therefore, when we aim at integration, it is ultimately people themselves who have to integrate different aspects of their health in their daily lives. This fact, more than anything — Disability-Adjusted Life Years, efficiency or budgets — should be our reason for investing in preventive health care. It’s an old refrain, but still the balance between preventive and curative health care could be improved, even in the most forward-thinking forum.
Focusing on preventive health care, huge improvements are needed in the way we work together, not least because health touches upon so many other sectors, each with their own targets, practices and funding streams. Too easily we assume that working together is all about goodwill and a positive attitude. These might be essential, but ultimately we face an issue of competing priorities, which are very often tied to funding streams and targets. Participatory processes and working together can then risk becoming “others participating in our participatory processes,” all too often with little space to adjust to someone else’s agenda.
Truly integrated development can only start by recognizing that one’s own contribution is only a modest piece of the puzzle. We aim to contribute, but it would be arrogant to think that such integration can be captured in one overarching single design, let alone a single organization. It would be arrogant to pretend to have all the answers and expertise. Working together means recognizing the limitations of our own contribution and having the flexibility to align with others.
These days many organizations are using the campaign method — involving mass rallies, committees, social marketing and related communication — to activate change. At SNV, we also use these methods in WASH — and they work. These methods are effective, but we have to ask what the combined effect is if each of us is trying to push a different message, all claiming to be the most important, through these means? It’s the same people rotating through different local committees, the same health workers, the same schoolchildren we’re reaching. From the behavioral change side we know that one message is more effective than multiple messages, and we know that each change is a small process in itself. However, internationally, all these campaigns have high priority and are all driven by global data.
Compromise is never easy, but in the end working together for health will mean making real choices, painful choices, about what to focus on first. I would be arguing that the priority is water, sanitation and hygiene of course!
Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.