Post on 22-Jan-2018
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 -
“Learning Organization” Strategy
Interest
groups
Learning
Health
31
2
Adapted from Korten, 1980
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. jamesduak@yahoo.com. Tel:
+233 244771346
Malnutrition, culture and evil spirits in
Tamale, Ghana
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346
Community building huts for nutritional
rehabilitation in 2008
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+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
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346
Saving the lives of many children
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346
Saving lives of many children
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+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
Health System Development -
“Learning Organization” Strategy
Interest
groups
Learning
Health
31
2
Adapted from Korten, 1980
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
Health System Development -
“Learning Organization” Strategy
Interest
groups
Learning
Health
31
2
Adapted from Korten, 1980
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