Interview on emerging global health trends

Global Health Council
Environmental Scan
Key Informant Interview Guide


Name of key informant: ___Dr. E. Mohamed Rafique_________________________

Title/position: ___UN Country Team Solution Exchange Moderator for the AIDS Community

Organization/affiliation: ____UNDP_____(UNAIDS)___________________________

Date: ____January 30, 2007

Telephone number: ___+91 11 41354545 Extn 307___________________________

Email: ___emrafi@gmail.com______________________________________

Name of interviewer: Lisa Howard-Grabman

This interview seeks your input for an environmental scan that has been initiated by the Global Health Council in an effort to ensure that the Council’s work strategically addresses emerging global health trends and issues over the next five to ten years. The Council’s mission will continue to be to ensure that all who strive for improvement and equity in global health have the information and resources they need to succeed.

The global context is rapidly evolving as disease control priorities shift, technology evolves and the social and political context present opportunities and challenges in governance, management of and access to information, services and other resources, the global economy, religious and ethnic conflict, violence and migration, and other opportunities and challenges. The Council is interested in gathering input from leading experts in the field like you. The interviews will be entirely confidential. The results of all the interviews will be consolidated, summarized, and then shared and analyzed with members of the GHC team. Portions of the findings may be included in a doctoral dissertation. Your input will be a part of the whole picture.

Please be as honest and open as you can be and feel free to ask me any questions at any point during the interview. The interview should take about 30 to 45 minutes to complete depending on how much you have to say.

Would you like to proceed with the interview? Yes No Comment:

_______________________________________________________

Information about Interviewee

• What is your current position at [your organization]? Contracted by UN Country Team- as a Moderator- network facilitator Research, summarizer on various topics by email- not able to get everyone’s input because they are not all email savvy.

• How would you describe your current role as it relates to global health?

• Policy maker
X Policy advocate
• Health program implementer
• Funder/donor
• Other ________________________

Additional details: solution exchange- facilitate exchange of experience to formulate policy recommendations. Lessons learned, gaps to inform program development.


Trends and emerging issues that will impact on global health

• Over the last decade, what major changes have you observed in global health?
More of lifestyle diseases. Heart disease, stroke, diabetes, HIV also. Aftereffects of development. Hypertension. People are too sedentary.

• What are the top three to five major global trends or emerging issues that you believe will most impact on global health over the next decade? Why?
Marked improvement in economy in many countries. People are taking part in funding in development. Better infrastructure. Population growth. Models of helping better growth and development. Money/economy of health won’t be a big issue. But reaching the unreached people in undeveloped countries. How do we translate better development into better health?

• What epidemiologic and demographic changes are occurring or are likely to occur in the near future that may shift current health priorities?
In developed countries, there is more emphasis on smaller families, in India, people are migrating to cities on a large scale. Urbanization, break up of extended families. Epidemiology- family changes are causing an impact on health. Smaller nuclear families are left with emptiness syndrome. Old parents, empty nest. Alone. We have more old population. Sexually active population is lessening. We also have the younger population growing, both are vulnerable populations (adolescents). Need capacity building for health care workers to cater to these populations.

• What major policy issues are likely to affect global health over the next five to ten years?
Health is now more and more curative, people not emphasizing prevention. Funding organizations are thinking about prevention still, but people are only thinking about health as pills. Need more emphasis on prevention. Drug pricing, marketing of drugs will have big impact on health care, mortality and morbidity. If you look at it through prevention angle, there should be like two horses pulling a cart (preventive and curative). Funding of prevention should still be the main key.

• What new (or existing) technologies will play important roles in improving health?
The way trends are going now, many people see side effects from antibiotics, antifungals and antivirals. New discoveries of medicines. Will create new types of side effects that may be worse. Cancer drugs, and others. People are becoming more choosy- want fewer side effects. Gene therapy, Immunotherapy and preventive methods. Vaccines, other technology, has not progressed as fast as people want. Inputs need to come from diverse areas. Availability of medicines- can shop for them fairly freely. We know the side effects and we choose what we want.

• What funding sources and health care financing schemes are likely to support (or detract from) health programs and policies over the next five to ten years?
Supporting health care programs, one policy that has been working well is taxation on international flights that support buying medications. Plans in the UK to fund the global malaria effort will create more money in a short time. Health money has been diverted for development or for non-development, like elections, not on an international level, but on a more local level. Budget that is for social development, when half the year is gone, they want to divert money that would have been for health and is shifted to other lines. This happened in corporate sector more than public sector, but we will need to work at the grassroots to put a stop to it. People cover up these acts. The doctors sitting in a small clinic don’t have the power to stop it.

Implications of global trends and emerging issues for those working in global health

• What are the major challenges that people working to improve global health will face over the next five to ten years?
We have seen over the last five years that there are new diseases repeating and chronic diseases increasing, new diseases emerging like avian flu, ebola. Malaria and TB, HIV. Polio and leprosy in pockets have stagnant statistics. These types of things could be controlled, but in developing countries, it is not being controlled as well. Green pastures for health workers. Mostly lifestyle diseases in places like India, but also infectious diseases in the less developed countries. We see mostly lifestyle diseases in the hospitals, but vaccines and preventable diseases in PHC services. The challenges in the developed country today are the challenges in the developing countries ten years from now.

• What types of support will organizations working to improve global health need to help them address these emerging challenges, issues and trends?
They would require to know exact data, needs, whatever lifestyle diseases people are suffering from to target interventions, what are emerging diseases in developing countries, what are the latest technologies/approaches to deal with these diseases? Trends in funding agencies to work on business of health, health policy. Cost-effectiveness analysis. In health to an extent we can see it, but from the intervention perspective, comparing how to spend money to get biggest return on health. Need to consider prevention. There are a big chunk of people who are already infected. What do we do about that? Need to consider both prevention and treatment. Policies affect effectiveness of the programs.

• What are potential new opportunities, resources and support that may be emerging that organizations working in global health could tap into?
Funding organizations are going to fund programs in a major way, but need to find out who will be having the most money. Every organization needs IT support, hardware (Gates, Dell, HP will all have their foundations and could be tapped). These are being used daily by people, from toothpaste to other consumer goods. Their profits could be tapped- multinationals. A lot of money is being spent on media, news, children’s shows—who is sponsoring these shows? Companies that show profits could be giving back to the communities where they make their money. Corporate social responsibility to pay for the health of the manpower that is creating their profits.

Global Health Council goals & priorities

• What are the top three emerging opportunities that GHC should take advantage of in order to most effectively advance improvement and equity of global health?
Don’t have global mortality and morbidity data, but GHC should identify what diseases affect mortality and morbidity most, most impact on health. At the end of the day, what is the population we need to cater to? Keep looking at the data and tailor programs to the reality. Developing nations having access- how to reach them, what are most effective approaches, getting to the pockets in some countries in transition and to the lesser developed countries. Improving infrastructure, access. Need to look at why people cannot or do not access information/services. May need to tailor programs to address reality (safer delivery in the home or ways to transport women to the hospital, other solutions that work locally and can be shared with other similar areas). Can’t use same solutions that work in developed countries in less developed countries. Global Health Council can take a lot of lessons from MSF. Should interview them to get their lessons. Don’t need to reinvent the wheel.

• Currently, the Council’s priorities focus on addressing the core global health programs that the US government funds such as AIDS, malaria, TB, diarrheal disease, etc. However, there are a number of alternative ways to frame the Council’s strategic priorities (for example, by focusing on cross-cutting issues such as strengthening health systems, increasing equity of access to information and services, including chronic diseases and conditions, etc.). On what three to five priorities do you think the Council should focus its agenda over the next five to ten years, to best achieve its mission and remain a relevant voice in the changing environment?
With HIV, we found that we needed to strengthen the health system and increase access for everyone. Though the problem was raised by HIV, you can’t just treat the disease, you need to have the cart and the horse. Need to have the priorities, but you also need the infrastructure and access. Setting up the system is one of the biggest challenges, but once it is set up, everything moves more easily. It needs a lot of funding. It works for all diseases. If you have a defunct hospital, to reestablish it, it takes time and money and capacity, and then monitoring. Need to focus on both. Whichever diseases you prioritize can be determined by the data on mortality and morbidity, as well as looking through lens of strengthening the overall health system. Fund whatever the system needs first and then integrate the services. In India, we have one female Anganwadi worker in every smallest unit of health care. She has to look after the needs of infants through school age children. She maintains more than 16 records every month. Nutrition, vaccination, etc. We are trying to integrate everything into one register. Try to avoid duplication and be more complete.

• What role has advocacy played in the growth in U.S. and global investments in global health? What role has the Global Health Council played in this growth?
US investments may be the biggest player globally. US spending on arms and US spending on health—there is a big disparity. This needs to be addressed. Push for more for health. Money will not solve all the problems, but it helps. When people say that we don’t have the money, there is but it is being spent on military. I don’t really know how we are going to get the US President to listen.

• To what extent do you perceive the Global Health Council as a 'global' player/stakeholder in key global health conversations and policy decisions? How could the Council expand its global presence? What would be an appropriate role?
It depends on how much of the strategies we can provide to transplant success stories from one place to another. How to increase access to information on success stories. Need to be able to provide information to people who may be working in similar types of situations/settings.

• What other organizations do you know of that have similar roles, goals and scopes of work to those of GHC? What particular “lessons learned” or models do these other organizations offer from which the Council could learn/use to inform its work? What is GHC’s current “value added” to the field?
Not in health, but it would be good to look at World Economic Forum to see how they became global. They document things well, the right information at the right time. Technology to facilitate dissemination of information in a timely manner. GHC will have to look into how it will get relevant health information and get it to people who need it. India’s problem, for example, like polio, and in Java someone may have eradicated it in a similar setting, how do we learn from that? Generate lists of who is interested in what information and link them. Networking. These are things that don’t require a lot of funding, but it requires good information, good contacts, good networking. If you were looking into implementation, it would be more like MSF.

• In what area do you think the Council could demonstrate its leadership over the next five to ten years? Why?
Policy formulation. Need to be advisors to the leaders. Work on advocacy, help members advocate and communicate with leaders, policy makers. If you want health to be everyone’s priority, you need to get leaders on board. Get people who are committed to the cause and are very well known. People who push the cause forward. Increases visibility.

• What should the Council not do? Why?
It should not antagonize leaders, critics (South Africa is a good example). Turn those people around to our advantage. This is a challenge and the first reaction is that it is scientifically wrong, but we will make enemies that way. Figure out how to get people over to our side.

• What do you think the Council should be doing differently over the next 5 to 10 years to increase its contribution to improving global health?
It should go into areas where none have gone. There are so many people working in HIV, there are gaps, but are there more gaps in other health areas? Look for areas of high need where others are not focusing. One thing that HIV brought us is back to basics. We are forced to go back to basics. If you want to give ARV, you have to learn about side effects, nursing, medicines, infrastructures, prevention, everything. We have terribly slipped up in health priorities- strayed from the basics. Including the 100% preventable. Looking for the tree and missing the whole forest.

How the Council can work most effectively

• What do you think the Council does exceptionally well now? What are its current strengths?
Don’t know that well. No clear idea about what GHC is doing now.

• What do you think the Council could do more effectively?
Promote the idea of construction rather than destruction. Prioritizing health over war. People can be helped by things that can be easily solved. Developing humanity rather than destroying humanity. You can’t have war and destruction and health together.

• How can the Council further strengthen its role as an advocate ('a voice') for global health?
The Council should see where its strengths are and use them to advocate at the top levels, with UN, other international bodies, US government. Identify key players. Work with multilaterals and bilaterals.

• Who do you think the Council should actively recruit as new members for the Council to be most effective? Why?
The Council should develop a system of being voluntary members of a “think tank”. Recruit people to implement policy, tap brains from membership to get information and experience from various parts of the globe. Experience that has not necessarily been documented, but is in the brains of people. Similar processes like this one could be used. Videoconferencing and email, web can provide input. You don’t need to have conferences, but you could have them if you want more interaction. Find out who is interested in different issues and tap them on those issues.

• What types of services should the Council provide to its members, partners and other constituencies? Why?
The services as far as HIV, candlelight memorial, was innovative, new. The date is now saved in the country for this. News items have graduated to third or earlier page news around that day. Help build local capacity to advocate for various health priorities in our own countries. Each country will have different priorities, but they can learn how to promote them and advocate for them. What are the priorities for particular areas and what events can we do to establish awareness and commitment?



• What types of technology should the Council consider using to better serve its members, partners and other constituencies?
Email, infrastructure, some organizations work at grassroots with no access to internet. There are more telephones/cell phones. Should look at how to use email and cell phones to get those people who are less connected to be more informed, involved. E-Translation and have someone there to correct mistakes of the machine. Development workers who can share information and knowledge to inform policies. How to marry old and new technologies. One good thing that happened in this country is that we can send email to the post office and the post office can deliver it. We are not going to stop using computers. Printed post delivered the same day. How do we reconvert printed mail into email again.

Additional comments/questions

• What additional comments and/or questions do you have, if any?
I will look onto website and will email if I have anything else.

Thank you so much for taking the time to provide valuable input into GHC’s strategic planning process. We will provide you with a report that summarizes the results of the key informant interviews and focus groups when all the interviews have been completed and the results have been consolidated. If you have any questions or would like to add, clarify or omit anything to this interview, please feel free to contact me at (703) 241-1533 or by email at lisahg@transformationcoaching.org.


Please describe your process in coordinating a past candlelight memorial. For example, how did you find resources? How did you mobilize your community?

At the India Satellite session of the Barcelona 2002 International AIDS Conference, while working as the Scientific Editor of the Solidarity Against the HIV infection in India (SAATHI) e-forum, and as a Candlelight Memorial Coordinator, I arranged the Candlelight Memorial for India that year. As it was part of the India Satellite session, there was no need to arrange it at a separate Venue or event. To every participant leaving India for Barcelona we advertised the presence of the Minister and other important stakeholders at the India session, to ensure good attendance. This technique worked for participants had filled the hall and the corridor of Hall 2B where the event was held!

Dr. Subhashree Raghavan, Founder and Moderator of SAATHI e-forum began the proceedings, after a long wait for the Health Minister's arrival. David Miller, the erstwhile UNAIDS Country Coordinator for India made a presentation on the HIV/AIDS situation in India, which mentioned the challenges and the solutions that may probably work out well in changing the present trends. The challenges and methods to overcome these for UN support were detailed. His last word like his first was motivating Urgency in all sectors. In the next few presentations speakers like the Director of NACO, and the various Ministers of the State and Parliament were mostly emphasizing the points already covered by David, or those that have been heard at previous conferences or meetings. Prohibitive cost was the reason given out for no ARV program for the PHAs. However the Government would promote the units producing ARV and also reduce prices of ARVs. This evoked protests from the Positive groups who were of the opinion that care was one arm of prevention and one could not implement prevention programs as stand-alone ones. Abraham Kurien, the President of the Indian Network of Positive People (INP+) wearing the clothes of departed Ashok Pillai who had died with a CD4 count of 50, made a tribute to his friend. Never afraid to tell the truth Ashok Pillai had even been angry at the system for its inaction. An emotional plea for the treatment cause was falling on deaf ears. Jayasudha's eulogy was presented by her friend Kausalya, the President of the Positive Women's Network (PWN+) while Vivek Anand of Hamsafar presented that of Vasanthy's. These had the same refrain of access to care as the main hurdle.

Back home I pen a few lines that is published in [SAATHII] e-forum as:

Memorial to Ashok, Jayasudha and Vasanthi:

At Hall 2B on a warm July afternoon
The room was small, but it was warm
People gathered for a Memorial

Every heart rapped the drum beat of support
To honor the memory of those Indians lost:
Ashok Pillai, Jayasudha, Vasanthi Shetty,

Their fixed smiles were warmer
Though it was from the walls decorated by their friends;

Ever-departed they smiled silently from the table on the corridor
Where the lamp lighting ceremonies had to be held
Were they smiling at our grand words and grander service?
Of which they had long been fed up?

Or were they smiling at the system that we were part of
That did not help solve their problems?
Or was it that they had at last attained in death
Their freedom from the struggle against HIV and AIDS?
For answers little will we know
For the departed little have we done.

For the Ashoks and Jayasudhas still withering
We pledge to act and so guard what we say
Our talk as transient as the incense rising hesitantly in the air
Hesitant we are and say not boldly that I tried and failed...

Many more are the Ashoks unsung
Still many more the Vasanthis unheard

The pandemic's ravages continues unchecked
And many more are the millions unprotected, untreated, uncared and yet to come.
How many more would have to succumb
From among those whom we see
And therefore we know...

But from among those unseen for whom we feel
The pain is more
For our mind is not distracted by any smiling images
And only the imaginings of the sufferings remain
Etched in most poignant details
Long after the brave end had come.

Imagine how if we know them all
Hall 2B nor all the walls of the Fira de Barcelona
Would not be enough to hold their snaps!
At least then should we hear
What their silent voices have to say.

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