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There Is No "I" in "Global Health"

“There is no ‘I’ in team.” This aphorism decorates the walls of many gyms and locker rooms and describes the mentality of some of the great championship teams from the sports world in recent years (think basketball’s San Antonio Spurs or baseball’s San Francisco Giants).  It’s also the perspective that’s needed if we are going to take collective approaches to social problems. Within global health, there are sophisticated challenges that require funders, governments, and NGOs to come together and work toward collective impact. We’ve been working with one client to explore what it takes to strengthen diabetes care in emerging market countries and we found that the involvement of multiple stakeholders, including research institutions, private and public health providers, and other supporting organizations, is important for providing comprehensive solutions.

If this kind of approach was easy – or this kind of team was easy to build – we’d all be doing it. Evaluation holds particular challenges. First, many funders and service providers are focused on measuring their specific impacts on social issues, since they need to justify their activities to stakeholders (such as funders). Second, it can be difficult to understand the relative impact of pieces of a collective or integrated approach to service delivery, particularly in the area of global health. The latter challenge is what this blog aims to address. Is it enough to be able to say that the combination of certain interventions achieves outcomes, or is more specific attribution of program components necessary? Would not greater understanding of the relative benefit and worth of specific interventions be more valuable? And if this is important, how can it be accomplished? Team-first teams do win championships, but this initial success can raise the price of the players to unaffordable heights due to salary caps or other financial limitations (a challenge not unknown in the global health sphere). It takes a skillful General Manager to correctly identify and invest in the most important and cost-efficient elements in order to replicate success.

The question of intervention-specific evaluation’s value has come to light through our recent work with a foundation addressing children affected by AIDS (for more on this subject, see this UNICEF publication). This is a target population for which integrated delivery of health, nutritional, educational, and economic support holds great promise, and for which knowledge of relative impact is important due to huge shortages in funding and the vast array of potential interventions. There is a strong need for development of best practices for integrated service delivery for children affected by AIDS.  I would argue that it is essential to develop best practices so that stakeholders can understand not just the best types of interventions to include in an integrated program, but the best mixes as well. Counterarguments to this idea are that it can be very difficult and expensive to measure the specific impacts of different inputs, which is true; educational outcomes and health outcomes are heavily affected by nutrition, for instance. However, using pilots that had different levels of funding and focus on various interventions such as nutrition, education, or health support could enable better understanding among funders and organizations on how to best target their resources.

The team-first mentality is essential for collectively tackling complex global health issues, but there are situations where understanding of the relative importance of interventions would be valuable. While a true sports G.M.-mentality of measuring individual impact may not be possible, there may be other ways to guide funders toward the types of interventions that should receive the greatest funding within a comprehensive model. How do you see this tension—between wanting coordinated approaches but also needing to evaluate the relative value of individual interventions—playing out?