power breakfast: development: what is it and how is it acheived?mosley

What is Development, and

How Is It Achieved?

W. Henry Mosley, MD,MPH

CORE Group Round Table

April 24, 2013

Development As Freedom1. Political freedoms

2. Economic facilities

3. Social opportunities (including health, education)

4. Transparency guarantees

5. Protective security

“Each of these distinct types of rights and

opportunities advance the general capability of

a person.”

»Amartya Sen, Development as Freedom, P. 10

Human Capability As

Development

“The perspective of human capability

focuses…on the ability – the substantive

freedom – of people to lead the lives

they have reason to value and to

enhance the real choices they have.”

»Amartya Sen, Development as Freedom, P. 293

What is development, and how is it

achieved?

Expansion of freedom is viewed…both as the

primary end and principle means of

development.

Development consists of the removal of various

types of unfreedoms that leave people with little

choice and little opportunity for exercising their

reasoned agency.– Amartya Sen, Development as Freedom, p xii

How to Promote Development

- Armatya Sen

With adequate social opportunities, individuals

can effectively shape their own destiny and help

each other. They need not be seen primarily as

the passive recipients of the benefits of cunning

development programs.

– Armatya Sen, Development as Freedom, p. 11

How to Promote Sustainable

Development- Mohammed Yunus

You look at the tiniest village and tiniest person

in that village: a very capable person, a very

intelligent person. You have only to create the

proper environment to support these people so

that they can change their own lives.

– Mohammed Yunus, in: Bornstein, D. The Price of a Dream. The Story of the Grameen Bank. p. 215

How to Promote Development- Mohammed Yunus

Grameen’s approach – focusing on the

individual in need as the agent of change – is

diametrically opposite to that taken by

conventional development organizations, which

typically see themselves as agents of change on

behalf of those in need.

– Bornstein, D. The Price of a Dream. The Story of the Grameen Bank. p. 215

Interest

groups

Policymakers,

planners

Managers,

providers

Communities,

households

MIS

Evaluations

Research,pilot projects

The “Blueprint”Development Strategy

Health

Learning Action

Project

Blueprints

Nigeria – Immunization

Case Study

0

10

20

30

40

50

60

70

80

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2007

2010

DPT3

Co

ve

rage %

1985 UNICEF/WHO Global Goal –

“Immunize 80% of the world’s

children by 1990”

Source:http://apps.who.int/immunization_monitoring/en/globalsummary/timeseries/tswuc

overagepol3.htm

Project

succes

s

Nigeria – Immunization

Case Study

0

10

20

30

40

50

60

70

80

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2007

2010

DPT3

Co

ve

rage %

Who immunizes the

children in 1991 and

thereafter?

Source:http://apps.who.int/immunization_monitoring/en/globalsummary/timeseries/tswuc

overagepol3.htm

Program failure

Buying

indicators

Nigeria - Immunization Coverage by State

0

10

20

30

40

50

60

70

80

90

100

Jiga

wa

Bau

chi

Kas

tin

a

Soko

to

Bo

rno

Keb

bi

Kan

o

Zam

fara

Yob

e

Tara

ba

Nig

er

Bay

elsa

Go

mb

e

Nas

araw

a

Ad

amaw

a

Kad

un

a

Ben

ue

Ogu

n

Enu

gu

Akw

a Ib

om

Riv

ers

On

do

Ko

gi

Kw

ara

Pla

teau

Del

ta

Ab

ia

Ebo

nyi

Oyo

Edo

Cro

ss R

iver

s

Lago

s

Ab

uja

An

amb

ra

Imo

Osu

n

Ekit

i

Co

vera

ge (

%)

State

DPT3 coverage by states, DHS 2008

Source: Nigerian Demographic and Health Survey (DHS), 2008

Why is this happening?

12

Communication/Information

Media messages regarding

vaccinations

Community involvement in EPI

Trust in health service provider

Parental

Attitude/Knowledge

Perceived benefit of vaccines

Perceived disease threat

Group pressure for or

against vaccinations

• Immunization Systems

– Access and vaccine

service availability

– Use of all opportunities

– Cost and service quality

– Health worker knowledge

• Family Characteristics

– Education level (of mom and

dad)

– Family size

– Income, occupation

– Ethnicity/language group

*From New Generation Vaccines, 3rd edition

Reasons for No- or Under-immunization:

Definition of Categories*

13

55%

6%

12%

27%

Family Characteristics

Immunization System

Communication and Information

Parental Attitudes and Knowledge

% based on total reasons abstracted from 12 articles on unvaccinated children according to definitions in New

Generation Vaccines, 3rd ed.

Reasons for being UNvaccinated

Interest

groups

Policymakers,

planners

Managers,

providers

Communities,

households

MIS

Evaluations

Research,pilot projects

The “Blueprint” Strategy

A fundamental flaw

Health

Learning Action

Project

Blueprints

Disconnects learning from

action

Learning for Development

A key lesson is that development is not

easy. It is at its core, a social and

cultural process that requires a slow

process of learning from the ground up

in order to be effective and sustainable.

»Rao, V, Walton, M. Culture and Public Action. P. 363

Policymakers,

plannersManagers,

providers

Communities,

households

TasksCompetencies

Health System Development

“Learning Organization” Strategy

Interest

groups

Learning

Health

31

2

Linking

Action to

Learning

Adapted from Korten, 1980

Policymakers,

plannersManagers,

providers

Communities,

households

TasksCompetencies

Health System Development -


Interest

groups

Learning

Health

31

2


1. Learning to fit

The task – learning how to understand

the household’s needs and

constraints, and how to introduce new

values, practices, knowledge, skills, and

technologies to help

households/mothers become more

resourceful in the production of health

OutputsNeeds

Starting in 2006, the King’s Medical Centre

has grown to become a centre of excellence!

Dr James Duah. The King's Medical

Centre. [email protected]. Tel:

+233 244771346

Malnutrition, culture and evil spirits in

Tamale, Ghana



+233 244771346

Community building huts for nutritional

rehabilitation in 2008



+233 244771346

Mothers will not take their children

to live in the hospital.

Mothers and children live in the huts for 6

weeks for rehabilitation



+233 244771346

Saving the lives of many children



+233 244771346

Saving lives of many children



+233 244771346

The response of the mothers

of Tamale -

“How many of our children would be

alive if we had know this was diet and

not evil spirits.”

“We just didn’t know, nobody told us.”

Policymakers,

plannersManagers,

providers

Communities,

households

TasksCompetencies



Interest

groups

Learning

Health

31

2


2. Learning to fit

The task – learning how to change

the organizational culture so it can

develop the competencies to do the

tasks required to design, implement

and be accountable for programs that

promote the household production of

health

Distinctive

competencies

Task

requirements

*Nkwanta District is in rural east-central Ghana.

*

CHPS = Community-based Health Planning and Services

Results of engaging the households and

communities

Policymakers,

plannersManagers,

providers

Communities,

households

TasksCompetencies



Interest

groups

Learning

Health

31

2


3. Learning to fit

The task – learning how to engage all

stakeholders in a creative partnership with

shared values that will generate a shared

vision leading to policies, strategies and

cooperative programs that will promote

and support the household production of

health

Decision

process

Demand

expression

Engaging stakeholders in a shared vision

for a health future that everyone desires

Are

families, the

primary

producers of

health, engag

ed by

government in

shaping the

national

health vision?

Millennium Development Goals

5. Reduce maternal mortality by 75 % between

1990 and 2015

Decline required to

reach the MDG

Reference: Lancet, 2010

Reducing Maternal Mortality -

Vision shared by whom? Government - Reduce MMR* by 3% a

year (75% in 25 years)

*MMR = Maternal Mortality Ratio, generally expressed

as maternal deaths per 100,000 live births

Let’s ask a

pregnant

woman’s

husband:

“How much

maternal

mortality would

you like? ”

Vision shared by whom?

Government - Reduce MMR by 3% a

year

Household - Zero MMR

Let’s ask the community:

How much maternal mortality would you

like?

Vision shared by whom?

Government - Reduce MMR by 3% a

year

Household - Zero MMR

Community - Zero MMR

Maternal Mortality - Blueprint Project Can

the community participate here?

Strategic

objective:

Reduce MMR by

15% in 5 years from

500/100,000 to

425/100,000

Maternal Mortality – Action Learning

Can the community participate here?

Vision - No mother dies from child

birth in our community.

Should we do it alone?

Or with communities

and households?

Health

ProductionPublic

Resources

A Leader is a Catalyst for

Change

The Learning Organization is the

Instrument of Change

Sustainable Development Requires

Action Learning

“Development can be neither given nor

received; it must be generated from within.”

“What the less developed have been most

deprived of is not the fruits of

development, but the opportunity to develop

themselves.”

Ref: “Systems Thinking” Jamshid Gharajedaghi

power breakfast: development: what is it and how is it acheived?mosley

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