Presented by MEASURE Evaluation Deputy Director Jim Thomas, MPH, PhD.

1. Structural Interventions:
A proposed agenda
James Thomas, MPH, PhD
Department of Epidemiology
Deputy Director, MEASURE Evaluation
University of North Carolina

2. What I’ll cover
 What a structural intervention is
 The measurement challenges
 The lure of the magic bullet
 Why pursue structural interventions?
 The example of women’s land rights
 A proposed agenda

3. Examples of structural interventions
• Removing the pump handle
• Sewers
• Protected & purified water
• Iodized salt
• Vehicle air bags
• Building regulations
• Tobacco control
• Closing bath houses

4. Structural interventions
(behavioral) (structural)
High Personal Volition Low
HIV “Have fewer partners” Alleviate poverty
Drugs “Just say no” Fight drug cartels
Obesity “Exercise more” Walkable neighborhoods

5. Proximal and Distal
D
C B A

6. Proximal and Distal
L J
C
O U
Z A M
E
R X B
Y
F

7. The lure of the magic bullet
• Proximal
• Few other variables
• Mechanistic
• Quantifiable
• Clear counterfactual

8. The lure of the magic bullet

9. Why pursue structural interventions?
The high road
• True to public health
• Human rights

10. Why pursue structural interventions?
The pragmatic road
• Always cycling against
traffic if context not
addressed
• Magic bullets require
systems to develop
and distribute them
• Hitting many birds with
one stone

11. Land rights as a structural factor
Less able to
Loss of home Loss of control
remain in
over one’s life
treatment
Lack of Loss of income-
Try income Less condom
land rights generating
alternatives use
property
Inability to grow More sex
Loss of land partners
food

12. Exploring data on land rights and HIV
 Reviewed literature
 Reviewed datasets
 Interviewed land rights
organizations

13. Literature
 Land rights and HIV: qualitative and anecdotal
 More proximal, more evidence
(e.g., conditional cash transfer)

14. Datasets

15. Datasets
 Aligned with land rights or HIV
 Modest potential for supplementing existing
data

16. Land rights organizations

17. Land rights organizations
Preliminary draft

18. International Justice Mission (IJM)
 Data collected systematically from all clients
 Quantitative and qualitative
 Computerized
 Study of property grabbing
 Baseline (2005- 2007)
 Follow-up (2012)
 2nd follow-up (2015)

19. Land rights . . . . . . . . . . . . . . . and HIV
Silos
• Professions
• Thinking
• Funding

20. The silo gap results in…
• Fewer shared insights
• Fewer shared resources
• Lack of scientific evidence
• Lack of interventions
• No M&E
• Unresolved forces of
transmission

21. A proposed agenda
1. Bring people together
 Break down silos
 Leverage existing opportunities

22. A proposed agenda
2. Document what we know
 Inventory the evidence on structural interventions
 Identify structural components of magic bullets
 Establish an on-line clearinghouse
 Write guidance on implementation
 Propose agendas

23. A proposed agenda
3. Build on what we have (example)
 Help IJM analyze their data
 Advise IJM on additional data to collect
 Collect data to complement IJM’s

24. A proposed agenda
4. Use non-linear approaches
 Crowdsourced science

26. A proposed agenda
4. Use non-linear approaches
 Crowdsourced science
 Agent-based modeling
 Identify data to collect
 Model costs and benefits

27. Thanks
 USAID & PEPFAR
 Katherine Tumlinson
 Megan Clarke
 Evette Cordoba
 Carolina Mejia
 ICRW
Photo credit: McKay Savage

28. MEASURE Evaluation is a MEASURE project funded by the
U.S. Agency for International Development and implemented by
the Carolina Population Center at the University of North Carolina
at Chapel Hill in partnership with Futures Group International,
ICF Macro, John Snow, Inc., Management Sciences for Health,
and Tulane University. Views expressed in this presentation do not
necessarily reflect the views of USAID or the U.S. government.
MEASURE Evaluation is the USAID Global Health Bureau's
primary vehicle for supporting improvements in monitoring and
evaluation in population, health and nutrition worldwide.