Development Partners David H. Peters, MD, MPH, DrPH, FACP.docx

Development Partners
David H. Peters, MD, MPH, DrPH, FACPM
Johns Hopkins University
Learning Objectives
health, as well as their
mandates, strengths, and weaknesses
implications of how development
assistance is provided
2
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Development Partner Mandates,
Structures, and Capabilities

Section A
A Complex Global Architecture
OECD G-20
UN agencies
Bretton
Woods
>200 multilateral
development
agencies
127 bilateral
development
agencies
±18,000
international
development
nongovernmental
organizations
Multinational
corporations and
foreign direct
investment

4
Types of International Health Organizations
• World Health Organization
• World Bank
• UN organizations (e.g., United Nations Children's Fund
[UNICEF], United Nations
Population Fund [UNFPA], Joint United Nations Programme on
HIV/AIDS
[UNAIDS], United Nations Development Programme [UNDP])
• Regional Development Banks (e.g., African Development
Bank [AfDB], Asian
Development Bank [ADB], Inter-American Development Bank
[IADB], European
Bank for Reconstruction and Development [ERBD], New
Development Bank [NDB;
Brazil, Russia, India, China, South Africa])
5

-income countries in Development Assistance
Committee (DAC) of the
Organisation for Economic Co-operation and Development
(OECD)
• United States Agency for International Development (USAID)
• President's Emergency Plan for AIDS Relief (PEPFAR; United
States)
• Japan International Cooperation Agency (JICA)
• Department for International Development (DFID; United
Kingdom)
• Dutch Ministry of Foreign Affairs
6
• Global Fund to Fight AIDS, TB, and Malaria
• GAVI Alliance
ganizations:
– Catholic Relief Services – CARE

– World Lutheran Services – Save the Children
– World Vision – Oxfam
– Management Sciences for Health – Family Health
International
– John Snow International – Jhpiego
7
• Merck Company Foundation
• Bristol-Myers Squibb Foundation
• MobileExxon Foundation
8
(Consortium of Universities for
Global Health)

9
-profit organizations
10
International Health Organization Roles
rams

11
What Differentiates Agencies?
Mandate and mission
• e.g., humanitarian assistance, specific diseases or populations,
research
-profit
technology, in-country
experience
12
World Health Organization

dquarters in Geneva, Switzerland
Health)
offices
possible level of health
13
World Health Organization: Mandates
Source: WHO Constitution. Available at:
http://www.who.int/governance/eb/who_constitution_en.pdf.
Accessed June 1, 2015. 14
a. Act as the directing and co-ordinating authority on
international health work;
b. Establish and maintain effective collaboration with the
United Nations, specialized agencies, governmental health
administrations, professional groups and such other
organizations as may be deemed appropriate;
c. Assist Governments, upon request, in strengthening health
services;
d. Furnish appropriate technical assistance and, in emergencies,
necessary aid upon the request or acceptance of

Governments;
e. Provide or assist in providing, upon the request of the United
Nations, health services and facilities to special groups,
such as the peoples of trust territories;
f. Establish and maintain such administrative and technical
services as may be required, including epidemiological and
statistical services;
g. Stimulate and advance work to eradicate epidemic, endemic
and other diseases;
h. Promote, in co-operation with other specialized agencies
where necessary, the prevention of accidental injuries;
i. Promote, in co-operation with other specialized agencies
where necessary, the improvement of nutrition, housing,
sanitation, recreation, economic or working conditions and
other aspects of environmental hygiene;
j. Promote co-operation among scientific and professional
groups which contribute to the advancement of health;
k. Propose conventions, agreements and regulations, and make
recommendations with respect to international health
matters and to perform.
World Health Organization: Special Issues
technical assistance
accountability

15
The World Bank Group
(IBRD; low-interest financing based on sovereign)
-free
loans and grants)
Finance Corporation (IFC; financing to private
sector)
Governors)
cutive Director
16
The World Bank Group: Purpose, Mandates, and Special Issues

, policy advice, research, and
analysis
(economics, public
administration, education, infrastructure)
ntries
controversial investments
17
UNICEF
ndate 1953

fundraising and advocacy)
their basic needs and
to expand their opportunities to reach their full potential
18
UNICEF: Mandates
for
children affected by World War II
international standards of
behaviour toward children
countries, particularly developing
countries, ensure a “first call for children” and to build their
capacity to form appropriate
policies and deliver services for children and their families
children—victims of war, disasters,
extreme poverty, all forms of violence and exploitation and
those with disabilities
—in
coordination with United

Nations partners and humanitarian agencies, UNICEF makes its
unique facilities for rapid
response available to its partners to relieve the suffering of
children and those who provide
their care
their full participation in the
political, social, and economic development of their
communities
Source: UNICEF Mission Statement. Available at:
http://www.unicef.org/about/who/index_mission.html. Accessed
June 1, 2015. 19
UNICEF: Special Issues
onable effectiveness of child health programs
20
Global Fund to Fight AIDS, TB, and Malaria
–private partnership
(Swiss foundation), founded in 2002
ons:

multilateral agencies)
ing requests
a sustainable and
significant contribution in the fight against AIDS, tuberculosis,
and malaria in
countries in need, and contributing to poverty reduction as part
of the MDGs
21
Global Fund to Fight AIDS, TB, and Malaria: Mandates
quality of applications
to fight AIDS, TB, and malaria
fight AIDS, TB, and
malaria on the basis of
performance
22

Global Fund to Fight AIDS, TB, and Malaria: Special Issues
hree health conditions
-house technical and managerial expertise
Initiatives (GHIs)
23
Complexity and Confusion
24
Complementarities between agencies Mission creep and
overlapping mandates
Historical legitimacy of UN and Bretton
Woods
Organizational challenges in evolving to
reflect dynamic and changing world order
Importance of cross-agency coordination High transaction costs,
slow movement
Enhanced emphasis on accountability and
achieving results Tensions with country ownership

Growing corporate social responsibility
investments Unmapped, and how socially responsible?
U.S. Government Global Health Architecture
25
Adapted from: The Kaiser Family Foundation. (2013). U.S.
Global Health Policy: The U.S. Government Engagement in
Global Health: A Primer. Available at:
https://kaiserfamilyfoundation.files.wordpress.com/2013/02/840
8.pdf. Accessed June 1, 2015.
distributed.
Aid Harmonization and Alignment
Section B
Main Sources of
Global Funding
for Health
Source: McCoy, D., Chand, S., & Sridhar, D. (2009).
Global health funding: how much, where it comes

from and where it goes. Health Policy and
Planning, 24(6), 407–417.
http://doi.org/10.1093/heapol/czp026 2
Development Assistance for Health, by Channel of Assistance
Source: Dieleman, J. L., Graves, C. M., Templin, T., et al.
(2014). Global health development assistance remained steady
in 2013 but did not align with recipients’ disease
burden. Health Affairs (Project Hope), 33(5), 878–886.
http://doi.org/10.1377/hlthaff.2013.1432 3
Official
Development
Assistance (ODA)
and Share of GNI
From DAC
Countries Since
1960
4
Source: Development Initiatives. Global aid trends –
ODA: what you need to know. Available at:
http://devinit.org/#!/post/global-aid-trends-need-
know. Accessed June 2, 2015.
DAC Countries’ Contributions to ODA as Percent of GNI
(2012)

Source: OECD DAC data and Development Initiatives, 2012.
Note: UN Target = 0.7% of GNI
5
Matching Top
Countries for DAH
With Top
Countries for
DALYs
Adapted from: Ravishankar, N., Gubbins, P.,
Cooley, R. J., Leach-Kemon, K., Michaud, C. M.,
Jamison, D. T., & Murray, C. J. L. (2009). Financing
of global health: tracking development assistance
for health from 1990 to 2007. Lancet, 373(9681),
2113–2124. http://doi.org/10.1016/S0140-
6736(09)60881-3 6
Does Development Assistance for Health Crowd Out
Government Spending on Health?
Source: Ooms, G., Decoster, K., Miti, K., Rens, S., Van
Leemput, L., Vermeiren, P., & Van Damme, W. (2010).
Crowding out: are relations between international health aid and
government health funding too complex to be captured in
averages only? Lancet, 375(9723), 1403–1405.
http://doi.org/10.1016/S0140-6736(10)60207-3 7
International health aid % of GDP Government health funding
% of GDP Government

funding 2002 2006 Change 2002 2006 Change
Benin 1.1% 1.0% –0.1% 1.1% 1.5% 0.4%
Burkina Faso 0.7% 2.1% 1.4% 1.6% 1.7% 0.1%
Stable/increased
Ethiopia 0.5% 1.7% 1.2% 2.4% 1.0% –1.4% Decreased
Ghana 1.0% 1.2% 0.2% 2.2% 1.3% –0.9%
Kenya 0.7% 0.7% 0.0% 1.7% 2.0% 0.3%
Madagascar 1.2% 1.6% 0.4% 2.0% 1.0% –1.0%
Malawi 4.4% 7.7% 3.3% 4.4% 4.1% –0.3% Decreased
Mali 0.8% 1.0% 0.2% 1.5% 1.9% 0.4%
Mozambique 1.8% 3.0% 1.2% 2.3% 1.4% –0.9% Decreased
Niger 0.8% 1.9% 1.1% 1.4% 1.4% 0.0% Stable/increased
Rwanda 1.4% 5.7% 4.3% 1.8% 2.8% 1.0% Stable/increased
Senegal 0.8% 0.7% –0.1% 1.3% 3.2% 1.9%
Uganda 1.6% 2.2% 0.6% 3.2% 2.2% –1.0% Decreased
United Republic of Tanzania 0.4% 2.8% 2.4% 1.5% 2.1% 0.6%
Stable/increased
Zambia 1.7% 2.4% 0.7% 3.0% 2.2% –0.8% Decreased
Recipient Countries’ View of Aid Channels
8
Source: International Development Association. (2007). Aid
Architecture: An Overview of the Main Trends in Official
Development Assistance Flows. Available at:
http://www.worldbank.org/ida/papers/IDA15_Replenishment/Ai
darchitecture.pdf. Accessed June 2, 2015.
The Volatility of Health Aid
9

Source: Godal, T. (2005). Opinion: Do we have the architecture
for health aid right? Increasing global aid effectiveness. Nature
Reviews Microbiology, 3(11), 899–903.
http://doi.org/10.1038/nrmicro1269
Hosting Missions and Report Writing Are Major Burdens at the
District Level:
Tanzania District Examples
10 Source: In-country interviews; DMO visitor log; team
analysis. Karen Caines High Level Forum presentation (2009).
*Assumes around
50 working days
per quarter and
100 per half year,
although reported
to work in excess
of that
What Are the Alternatives for Development Assistance?
Sector-Wide Approaches
(SWAps)
Joint Assessment of National
Strategies (JANS)
Global Health Initiatives
11

Disparate
projects
Projects
supporting
sectoral
policy
Common
planning and
management
processes
Jointly
agreed
sectoral
program
with pooled
funding
Un-
earmarked
budget
support
Paris Principles of Aid Effectiveness (2005)
over their development

policies and strategies and coordinate development actions
strategies, institutions, and
procedures in developing countries
collectively effective
focuses on the desired
results and uses information to improve decision making
accountability and
transparency in the use of development resources
Source: Paris Declaration on Aid Effectiveness. Available at:
http://www.oecd.org/dac/effectiveness/34428351.pdf. Accessed
June 2, 2015. 12
Oslo Declaration (2007)
match domestic commitment
and reflect the requirements of those in need and not one that is
characterized by
charity and donors’ national interests”

Source: Oslo Ministerial Declaration—global health: a pressing
foreign policy issue of our time. (2007). Lancet, 369(9570),
1373–1378.
http://doi.org/10.1016/S0140-6736(07)60498-X 13
Concluding Thoughts
partners involved in
global health, with overlapping mandates and capabilities
opportunity but also
unintended consequences
and providing it in
constructive ways
14
Lecture Evaluation
Your feedback is very important
and will be used for future
revisions.
The Evaluation link is available

on the lecture page.
15
AB
Informed Engagement in International Health Work:
Cultural Competence
Caitlin Kennedy, PhD
Outline
2
purposes under
rules of fair use for registered students in this course only. No
distributed.

Section A
What Is Cultural Competence?
Do You Have Any Pets at Home?
4
What Is Culture?
include the language,
thoughts, communications, actions, customs, beliefs, values,
and institutions of racial,
ethnic, religious, or social groups
5
What Is Culture?
avior are …
within a cultural group

6
Outline
l competence in public health?
7
What Is Competence?
effectively as an individual and
an organization within the context of the cultural beliefs,
behaviors, and needs
presented by households, patients, and communities
8
What Training Have You Had in Cultural Competence?

9
Outline
10
When and Where Is Cultural Competence Needed?
Source: Sachdev, N. (September 5, 2012). Ebola disease terror
in Congo | French Tribune. Available at:
http://frenchtribune.com/teneur/1213233-ebola-disease-terror-
congo.
Accessed December 11, 2014. 11
Case Example: Ebola
"We have been unable to control the spread due to continued

denials,
cultural burying practices, disregard for the advice of health
workers and
disrespect for the warnings by the government.”
—Liberian President Ellen Johnson Sirleaf,
national address, August 19, 2014
Source: Zavis, A. (August 20, 2014). Clashes erupt as Liberia
seals off slum to prevent spread of Ebola. Los Angeles Times.
Available at:
http://www.latimes.com/world/africa/la-fg-africa-liberia-ebola-
quarantine-curfew-20140820-story.html. Accessed December
15, 2014. 12
Case Example: Ebola
Source: Sun, L. H., Dennis, B., Bernstein, L., Achenbach, J.
(October 4, 2014). How Ebola sped out of control. Washington
Post. Available at:
http://www.washingtonpost.com/sf/national/2014/10/04/how-
ebola-sped-out-of-control/. Accessed December 11, 2014. 13

14
Communicating With Other Public Health Professionals
structural, economic, and
social factors
15
purposes under
distributed.
Section B
How Do You Do Cultural Competence
in Public Health?

Question 1
healthcare providers in the
United States do best (are most competent)?
a. Providing services in the language of the patients
b. Taking into account different local understandings of health
and illness
c. Recognizing how their own cultural perspectives shape the
clinical encounter
2
Question 2
imensions of cultural competence do you feel the
projects funded by global
health organizations and development agencies do best (are
most competent)?
a. Providing programs and services in the language of the
clients
and illness
c. Recognizing how their own cultural perspectives shape
programmatic encounters
3
Anthropology in the Clinic (Kleinman and Benson, 2006)

4 Source: Kleinman, A., & Benson, P. (2006). Anthropology in
the clinic: the problem of cultural competency and how to fix it.
PLoS Med, 3(10), e294.
Explanatory Models Approach
social world affects and
is affected by illness”
medicine
Source: Kleinman, A., & Benson, P. (2006). Anthropology in
PLoS Med, 3(10), e294. 5
Steps in Cultural Formulation
1. Ethnic identity
2. What is at stake?
3. The illness narrative
4. Psychosocial stresses
5. Influence of culture on clinical relationships

6. The problems of a cultural competency approach
PLoS Med, 3(10), e294. 6
Case Example: Ebola
experienced seven Ebola epidemics
break occurred in 1976
were a total of 1,034 infections and 794
deaths (76.7% mortality)
1995) have been in rural, isolated
communities
Source: Wild, F., & Pettypiece, S. (August 25, 2014). Ebola
Kills 13 in Congo Outbreak Separate From W. Africa.
Bloomberg. Available at:
http://www.bloomberg.com/news/2014-08-24/ebola-kills-13-in-
congo-outbreak-separate-from-w-africa.html. Accessed
December 11, 2014. 7
Case Example:
Ebola

Source: Wild, F., & Pettypiece, S. (August 25,
2014). Ebola Kills 13 in Congo Outbreak Separate
From W. Africa. Bloomberg. Available at:
http://www.bloomberg.com/news/2014-08-
24/ebola-kills-13-in-congo-outbreak-separate-from-
w-africa.html. Accessed December 11, 2014. 8
Case Example: Ebola
clinical and
community-based interventions to prevent and respond to Ebola
outbreaks
lese experience and expertise into a
framework and practical
approach to effectively respond to the West African epidemic
9
Steps in Cultural Formulation /
Explanatory Models Approach for Public Health
1. Ethnic identity

10
In Summary
care
lture is dynamic and relevant in different ways to different
problems
work:
cultures
petence is the start of a conversation best
approached through an
ethnographic approach, not as a technical skill to be mastered
11
Lecture Evaluation
Your feedback is very important and

will be used for future revisions.
The Evaluation link is available on the
lecture page.
12
AB
Global Health Diplomacy
Sara Bennett, PhD
Learning Objective
relevance for negotiating
improvements in health
2
distributed.
Components of Health Diplomacy

Section A
Globalization and Health
4
Health Diplomacy: A Working Definition
5
—
ations
their foreign policy”
Source: Feldbaum, H., Lee, K., & Michaud, J. (2010). Global
health and foreign policy. Epidemiologic Reviews, 32, 82–92.
http://doi.org/10.1093/epirev/mxq006 6
—

—
t resolution, and
communication on international
agreements on health
—
—
communication on international
agreements on health
1. Efforts to promote the role of global health in foreign policy
2. Use of health interventions to promote foreign policy
objectives

Global Health Diplomacy and Foreign Policy
governance
equity and justice
• All people have an equal opportunity to realize their health
potential
-
interest” of nation-states
9
Links and Tensions Between Health and Foreign Policy
Dimension
Role for diplomacy in
international health
Risks
10

Dimension
Risks
Security
Need to prevent destabilizing health
events (e.g., epidemics)
Priorities of wealthy nations over low-
and middle-income countries; can be
polarizing through military’s role
11
Dimension
Risks
Security

Trade
Trade regimes designed to lead to
innovation and growth
Can benefit rich rather than poor and
inhibit access to life-saving technologies
12
Dimension
Risks
Security
Trade

Global public
goods
Promote goods that benefit all and do
not diminish in use (e.g., pandemic
prevention)
Often difficult to support/enforce rules
associated with global public goods
13
Dimension
Risks
Security
Trade

Global public
goods
Promote goods that benefit all and do
not diminish in use (e.g., pandemic
prevention)
Often difficult to support/enforce rules
associated with global public goods
Human rights Health as a fundamental human right Soft law—
difficult to enforce
Ethics Underpins arguments for health equity Moral arguments
often neglected
14
distributed.
Tools of Global Governance
Section B
An Example:

Sharing Samples
of H5N1
Source: Walsh, B. (May 10, 2007). Indonesia’s bird
flu showdown. Time. Available at:
http://content.time.com/time/health/article/0,85
99,1619229,00.html. Accessed June 23, 2015. 2
The H5N1 Story and Indonesia
3
spread from 17 to 60 countries
4
Between 2005 and 2007, the “Bird Flu” H5N1 outbreak
-to-human
transmission took place in Indonesia

5
1 outbreak
-to-human
samples of H5N1 with WHO
bility of vaccine
manufacturers to produce
effective vaccines
6
-to-human

effective vaccines
ses produced
annually, the large majority go to
high-income countries, and capacity to scale up production is
limited
7
uman cases and clusters of human-to-human
effective vaccines
annually, the large majority go to
high-income countries, and capacity to scale up production is
limited

minister of health said,
“We feel let down by the WHO. We only demand fairness.”
8
Which Aspects of Global Diplomacy Does This Case Illustrate?
Principle Applied to H5N1
9
Security High-income countries saw H5N1 as a security risk
that affected them directly,
though it was concentrated in southeast Asia. This put it high on
their agendas.
10

their agendas.
Trade The Indonesian Minister’s primary concern was that there
was nothing in trade
laws that would ensure that his country’s population benefitted
from H5N1
vaccines. Without global intervention, private for-profit
pharmaceutical firms will
sell vaccines to whoever can pay most.
11
their agendas.
from H5N1
Global public
goods

Knowledge of H5N1 was a global public good, but the vaccine
based on it was not;
it was a private good going only to those who could afford it.
12
their agendas.
from H5N1
Global public
goods
Human rights Health as a fundamental human right could be
interpreted as requiring
distribution of the vaccine to those in need.

13
their agendas.
from H5N1
Global public
goods
Human rights Health as a fundamental human right could be
interpreted as requiring
distribution of the vaccine to those in need.
Ethics Ethical perspectives, particularly principles of
beneficence or equity, suggest that
those most in need should have access.

14
15
Category Definition Examples
Hard laws
Soft rules
Codes of
conduct
Private
actions
16

Hard laws
International treaties, formal agreements
under international law, entered into by
international actors (e.g., states and
international organizations)
Framework Convention
on tobacco control,
International Health Regulations
Soft rules
Codes of
conduct
Private
actions
17
Hard laws

on tobacco control,
Soft rules
Formal agreements by international
actors, not legally binding, constitute
obligations
Millennium Development Goals,
Abuja Declaration
Codes of
conduct
Private
actions
18
Hard laws

on tobacco control,
Soft rules
obligations
Abuja Declaration
Codes of
conduct
Self-regulation entered into by states and
nonstate actors
Commonwealth code of practice on
international recruitment of health
professionals
Private
actions
19

Hard laws
on tobacco control,
Soft rules
obligations
Abuja Declaration
Codes of
conduct
Self-regulation entered into by states and
nonstate actors
Commonwealth code of practice on
international recruitment of health
professionals
Private
actions
Actions by private actors that have

international influence due to market
power/position
Research funder rules on open-access
data and publishing,
UK Stem cell bank
20
Concluding Thoughts: Global Health Diplomacy and Foreign
Policy
and economic (trade)
self-interest (“high politics / hard power”)
• This gives advantage to existing political, military, and
economic powers
• National security tends to trump individual security
goods, investment in
development, protection of human rights, and moral reasoning
(“low politics / soft-smart power”)
21
Strengthening Global Health Diplomacy

foreign policy
program design and
assessment
development and health outcomes in
health programs, particularly
to promote equity
making
arguments
onsistencies between foreign
policy and global health
goals
-power” politics in favor of health outcomes
22
Lecture Evaluation
Your feedback is very important
and will be used for future
revisions.
The Evaluation link is available
on the lecture page.
23

AB
David H. Peters, MD, MPH, DrPH, FACPM
Understanding Health Systems
Today’s Class
in a health system?
2
purposes under
distributed.
An Introduction to Understanding Health Systems
Section A

Ceci N’est Pas Une Pipe
4
Ceci N’est Pas Une Pipe
5
Not an Epidemic
6
Common View of Health Systems in International Health
-cutting issues:
7
Building Blocks to Meet Health Systems Goals

Source: WHO (2007). Everybody’s business: Strengthening
health systems to improve health outcomes.
System building blocks Overall goals/outcomes
Service delivery
Information
Medical products, technologies
Health workforce
Financing
Leadership/governance
Improved health
(level and equity)
Responsiveness
Financial risk
protection
Improved efficiency
Access
coverage
Quality
safety
8

What Is a Health System?
management that culminate in the delivery of health services to
the population”
Roemer (1991)
restore, or maintain health”
9
What Is a Health System? (continued)
management that culminate in the delivery of health services to
the population”
restore, or maintain health”
dated)
10

What Is a System?
together for a purpose
11
Health System Actors, Functions, and Outcomes
People
Financing
Revenue generation
Risk pooling
Allocation and purchasing
Input management
Human resources Knowledge
Pharmaceuticals Technology
Consumables Capital
Providers
public/private
informal
Health status
Protection from health
impoverishment
Oversight

Policy setting Information, disclosure, and advocacy
Regulation Strategic partnerships and incentives
The State
politicians
policy-makers
Trust/satisfaction in system
Service delivery
Public health services
Ambulatory care
Inpatient care
12
Health Systems Purposes
1. Reducing mortality, morbidity, disability, malnutrition,
unwanted
fertility; improving quality of life
2. Reducing poverty due to illness or health care payments
3. Improving trust and satisfaction with health system
13
Measures of Purpose in a Health System

bution of …
14
Source: World Development Indicators. (2009).
Child Mortality Across the World
0
50
100
150
200
250
300
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
U
n
d
e
r

fi
ve
m
o
rt
al
it
y
ra
te
(p
e
r
1
,0
0
0
l
iv
e
b
ir
th
s)

World
East Asia and Pacific
East Europe and Central Asia
Middle East and
North Africa
Sub-Saharan Africa
South Asia
Western Europe
15
Common Pathway
childhood
mortality according to millennium development goals?
Source: Subramanian, Naimoli, Matsubayashi, and Peters
(2011). Do we have the right models for scaling up health
services to achieve the Millennium Development Goals? BMC
Health Services Research. 16
Poor Financial Protection: Out-of-Pocket Payments for Health
0

10
20
30
40
50
60
70
80
90
100
0 10000 20000 30000 40000 50000 60000 70000
GDP Per Capita ($Int PPP) 2005
O
ut
-O
f-
P
oc
ke
t A

s
P
er
ce
nt
o
f T
ot
al
H
ea
lth
E
xp
en
di
tu
re
17
Trust in a Health System

ion
with services
18
MEASURING EQUALITY: THE CONCENTRATION
INDEX
Measuring Equality: The Concentration Index
19
Measuring Health Inequalities
Source: Data from Victora et al.’s study of MCH program in
Ceara, Brazil.
CI = 2 x area
between 45° line and
concentration curve
CI < 0 when variable
is higher amongst poor
20

Who Captures the Benefits of Different Health Services in
India?
Source: Mahal et al. (2001). The poor and health service use in
India. 21
Public Financing of Health “Benefit Incidence”
Pro-rich distribution
Pro-poor distribution
22
Health System Actors
People
Providers
public/private
informal
The State
politicians
policy-makers
Oversight
and
compacts

Client
power
Political
voice
23
Who Produces Health?
24
After Households, Health Services Are Provided By …
—formal sector
Public sector providers
25
Other Health Systems Actors?

and medical information systems organizations
-based and philanthropic organisations
regulatory)
26
Key Functions
27

Health Services Can Be Organized According to …
iority program/disease
-centered
28
Health Financing: Key Functions
29
Oversight

30
HOW DOES A GOVERNMENT
PROVIDE OVERSIGHT IN THE
HEALTH SECTOR?
How Does a Government Provide Oversight in the Health
Sector?
31
Traditional Regulation
enterprises, citizens, and government itself, including laws,
orders, and
other rules issued by all levels of government and by bodies to
which
governments have delegated regulatory powers
market
decisions such as pricing, competition, market entry, or exit
environment, and social cohesion
and

paperwork, so-called “red tape”
ims at improving regulatory quality, be it
the
revision of a single regulation; of regulatory institutions; or
improved processes for making regulations and managing
reform
complete or partial elimination of regulation in a sector
Source: OECD. (1997). 32
Oversight Approaches in the Health Sector
-making
-regulation
dependent media
33
Effective Regulation in the Health Sector

greatly
influence performance
consumer’s
groups, professional organizations, media
-production-regulation may be more effective than
government
enforcement of rules
Source: Peters & Muraleedharan. (2008). Regulating India’s
health sector: To what end? What future?
Social Sciences & Medicine. 34
purposes under
distributed.
Systems Thinking
Section B
Systems and Non-Systems

connection affects other
elements of the system
purpose
-systems
ent
not necessarily affect
other elements
2
Systematic Thinking
or
action
3
Systems Thinking

in a
system
4
Changes in Country Characteristics and Coverage of Health
Services
5
DPT3 SBA TB Dx TB Tx
Governance 0.51* 0.47* 0.27* 0.04
U5MR -0.71* -0.74* -0.24* -0.30*
Fertility -0.64* -0.72* -0.18* -0.27*
Literacy rate 0.61* 0.79* 0.22* 0.24*
GNI per capita 0.41* 0.56* 0.11* 0.11*
Health expenditure 0.36* 0.50* 0.18* 0.06
ODA 0.05* 0.13* 0.17* 0.16*
Population (1990) -0.02 -0.06 -0.15* 0.12*
Pair-wise correlation coefficients (* p < 0.05)
Source: Matsubayashi, Peters, & Rahman. (2009). Analysis of
cross-country changes in health services. In Improving

Health Service Delivery.
Systems Thinking: Key Concepts
tions have multiple-order consequences
6
Systems Thinking Means Less Focus on …
ing the “right” financing or organization
7
Many Cost-Effective Interventions Address MDGs Four and
Five …
8

Lancet child survival
series (2003)
Lancet newborn
series (2005)
Lancet maternal
survival series (2006)
Lancet nutrition
series (2008)
Evidence
base
Comprehensive
reviews
Community-based
interventions
review
Literature and
program review
Few RCTs
Literature and
program review
RCTs and
observational
studies
Focus

Under-five child
survival
Newborn deaths
Maternal deaths and
morbidity
Child and adult
outcomes
Included
23 interventions
reviewed
16 newborn
interventions
120
interventions
considered
45 interventions
Implementation challenge is a
systems problem
Systems Thinking Means More Focus on …
—changing behavior is beyond
health

services
es to guide change
9
Systems Thinking Focuses on Results
and manage
according to
results
10
purposes under
distributed.
Effecting Change in a Health System
Section C

Values: Do They Matter?
expertise
s drive behavior in any human system
2
Influential Ethical Perspectives
—maximize greatest good for the greatest
number
minority?
—individuals have rights to choose for themselves
—societies raise members with good
character to
create the good society
3

The “Control Knobs” of Public Intervention in Health Systems
1. Oversight—how you regulate and use information to change
behavior of key actors
2. Organization—who delivers services and manages health
systems
inputs and how they are delivered
3. Financing—how to raise money, pool funds, allocate and pay
for
health care
4
Strategies to Improve Implementation in a Health System
5
Strategy type Examples
Public oversight
Policy reviews; regulations;
contracting; empowering community
oversight, supporting consumer
organizations
Organizational
change: provider
based

Quality improvement programs;
training; human resource
management; logistics systems;
decentralization of public services
Organizational
change: community
based
Community development programs;
demand creation
Health financing
Provider payment system change;
subsidies; health insurance
What Works in Improving Health Service Delivery in
Developing Countries
6
Number of studies
screened
Number of studies with
adequate designs
1. Health services
strengthening strategies
208 150
2. Community empowerment in
health strategies

27,000 156
3. Improving health worker
performance
40,000 127
4. Improving performance in
health services organizations
127,000 88
Health Service Implementation: Common Findings
replicable in much detail
y unintended consequences, not
predictable
in detail
influence on
how they are implemented
7
How Strategies Are Implemented Matters

8
Randomized
controlled trials
All “adequate”
studies
Odds ratio Odds ratio
Community coordination and organization .. 4.6**
Local adaptation of the intervention 9.3 4.3 *
Broad-based support of various stakeholders .. 3.9 *
Consultation and engagement of powerful interest
groups
2.8 3.8**
Flexibility and modification through stakeholder
feedback
.. 3.4 *
Representation from powerful interest groups 2.4 3.0 *
Constraints reduction plans 6.7 2.7 *
* P-value < 0.05; ** P-value < 0.01

Successful Implementation Factors
local
context is associated with more complete strategy
implementation,
and adaptation is easier in small-scale interventions
-specific programs that are
effective
in one area can be successfully scaled up nationally
fective than single
strategies, but risk of failure is greater
9
What Are the Uses of Health Systems Models?

scaling up
10
Summary
knowledge base, including the ability to …
—actors, connections, principles,
purpose
11
Lecture Evaluation
12
Please take a moment to evaluate
this lecture. Your feedback is very
important and will be used for future
revisions. The Evaluation link is
available on the lecture page.
introIH-sec13a-petersintroIH-sec13b-petersintroIH-sec13c-
peters

Informed Engagement in International Health Work:
Cultural Competence
Caitlin Kennedy, PhD
Outline
2
purposes under
distributed.
Section A
What Is Cultural Competence?
Do You Have Any Pets at Home?

4
What Is Culture?
5
What Is Culture?
within a cultural group
6
Outline

etence needed?
7
What Is Competence?
effectively as an individual and
an organization within the context of the cultural beliefs,
behaviors, and needs
presented by households, patients, and communities
8
What Training Have You Had in Cultural Competence?
ing?
9

Outline
10
Source: Sachdev, N. (September 5, 2012). Ebola disease terror
in Congo | French Tribune. Available at:
http://frenchtribune.com/teneur/1213233-ebola-disease-terror-
congo.
Accessed December 11, 2014. 11
Case Example: Ebola
"We have been unable to control the spread due to continued
denials,
cultural burying practices, disregard for the advice of health
workers and
disrespect for the warnings by the government.”
—Liberian President Ellen Johnson Sirleaf,

national address, August 19, 2014
Source: Zavis, A. (August 20, 2014). Clashes erupt as Liberia
seals off slum to prevent spread of Ebola. Los Angeles Times.
Available at:
http://www.latimes.com/world/africa/la-fg-africa-liberia-ebola-
quarantine-curfew-20140820-story.html. Accessed December
15, 2014. 12
Case Example: Ebola
Source: Sun, L. H., Dennis, B., Bernstein, L., Achenbach, J.
(October 4, 2014). How Ebola sped out of control. Washington
Post. Available at:
http://www.washingtonpost.com/sf/national/2014/10/04/how-
ebola-sped-out-of-control/. Accessed December 11, 2014. 13
ciplines
14

Communicating With Other Public Health Professionals
is shaped by myriad
structural, economic, and
social factors
15
purposes under
distributed.
Section B
How Do You Do Cultural Competence
in Public Health?
Question 1
healthcare providers in the
United States do best (are most competent)?
a. Providing services in the language of the patients

and illness
c. Recognizing how their own cultural perspectives shape the
clinical encounter
2
Question 2
projects funded by global
health organizations and development agencies do best (are
most competent)?
a. Providing programs and services in the language of the
clients
and illness
c. Recognizing how their own cultural perspectives shape
programmatic encounters
3
Anthropology in the Clinic (Kleinman and Benson, 2006)
4 Source: Kleinman, A., & Benson, P. (2006). Anthropology in
PLoS Med, 3(10), e294.

Explanatory Models Approach
w the
social world affects and
is affected by illness”
medicine
PLoS Med, 3(10), e294. 5
Steps in Cultural Formulation
1. Ethnic identity
PLoS Med, 3(10), e294. 6

Case Example: Ebola
experienced seven Ebola epidemics
were a total of 1,034 infections and 794
deaths (76.7% mortality)
1995) have been in rural, isolated
communities
Source: Wild, F., & Pettypiece, S. (August 25, 2014). Ebola
Kills 13 in Congo Outbreak Separate From W. Africa.
Bloomberg. Available at:
http://www.bloomberg.com/news/2014-08-24/ebola-kills-13-in-
congo-outbreak-separate-from-w-africa.html. Accessed
December 11, 2014. 7
Case Example:
Ebola
Source: Wild, F., & Pettypiece, S. (August 25,
2014). Ebola Kills 13 in Congo Outbreak Separate
From W. Africa. Bloomberg. Available at:
http://www.bloomberg.com/news/2014-08-
24/ebola-kills-13-in-congo-outbreak-separate-from-
w-africa.html. Accessed December 11, 2014. 8

Case Example: Ebola
clinical and
community-based interventions to prevent and respond to Ebola
outbreaks
framework and practical
approach to effectively respond to the West African epidemic
9
Steps in Cultural Formulation /
Explanatory Models Approach for Public Health
1. Ethnic identity

10
In Summary
derstanding health and health
care
problems
work:
from different
cultures
approached through an
ethnographic approach, not as a technical skill to be mastered
11
Lecture Evaluation
Your feedback is very important and
will be used for future revisions.
The Evaluation link is available on the
lecture page.
12
AB

PLoS Medicine | www.plosmedicine.org 1673
Essay
October 2006 | Volume 3 | Issue 10 | e294
Cultural competency has become a fashionable term for
clinicians and researchers. Yet no one can
defi ne this term precisely enough to
operationalize it in clinical training and
best practices.
It is clear that culture does matter in
the clinic. Cultural factors are crucial
to diagnosis, treatment, and care.
They shape health-related beliefs,
behaviors, and values [1,2]. But the
large claims about the value of cultural
competence for the art of professional
care-giving around the world are simply
not supported by robust evaluation
research showing that systematic
attention to culture really improves
clinical services. This lack of evidence
is a failure of outcome research to take
culture seriously enough to routinely
assess the cost-effectiveness of culturally
informed therapeutic practices, not a
lack of effort to introduce culturally
informed strategies into clinical settings
[3].
Problems with the Idea of Cultural

Competency
One major problem with the idea of
cultural competency is that it suggests
culture can be reduced to a technical
skill for which clinicians can be trained
to develop expertise [4]. This problem
stems from how culture is defi ned in
medicine, which contrasts strikingly
with its current use in anthropology—
the fi eld in which the concept of
culture originated [5–9]. Culture is
often made synonymous with ethnicity,
nationality, and language. For example,
patients of a certain ethnicity—such as,
the “Mexican patient”—are assumed
to have a core set of beliefs about
illness owing to fi xed ethnic traits.
Cultural competency becomes a series
of “do’s and don’ts” that defi ne how
to treat a patient of a given ethnic
background [10]. The idea of isolated
societies with shared cultural meanings
would be rejected by anthropologists,
today, since it leads to dangerous
stereotyping—such as, “Chinese believe
this,” “Japanese believe that,” and so
on—as if entire societies or ethnic
groups could be described by these
simple slogans [11 –13].
Another problem is that cultural
factors are not always central to a case,
and might actually hinder a more

practical understanding of an episode
(see Box 1).
Historically in the health-care
domain, culture referred almost solely
to the domain of the patient and
family. As seen in the case scenario
in Box 1, we can also talk about the
culture of the professional caregiver—
including both the cultural background
of the doctor, nurse, or social worker,
and the culture of biomedicine
itself—especially as it is expressed in
institutions such as hospitals, clinics,
and medical schools [14]. Indeed, the
culture of biomedicine is now seen
as key to the transmission of stigma,
the incorporation and maintenance
of racial bias in institutions, and the
development of health disparities
across minority groups [15–18].
Culture Is Not Static
In anthropology today, culture is
not seen as homogenous or static.
Anthropologists emphasize that culture
Anthropology in the Clinic: The Problem
of Cultural Competency and How to Fix It
Arthur Kleinman*, Peter Benson
Funding: Our work on cultural aspects of clinical care
has been supported by the Michael Crichton Fund,
Harvard Medical School, and by a National Institute of
Mental Health Training Grant on “Culture and Mental

Health Services” (5T32MH018006-21).
Competing Interests: The authors declare that they
have no competing interests.
Citation: Kleinman A, Benson P (2006) Anthropology
in the clinic: The problem of cultural competency and
how to fi x it. PLoS Med 3(10): e294. DOI: 10.1371/
journal.pmed.0030294
DOI: 10.1371/journal.pmed.0030294
Copyright: © 2006 Kleinman and Benson. This is
an open-access article distributed under the terms
of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Arthur Kleinman is Chair and Esther and Sidney
Rabb Professor in the Department of Anthropology
at Harvard University, and Professor of Psychiatry
and Medical Anthropology at Harvard Medical
School, Boston, Massachusetts, United States of
America. Peter Benson is a PhD candidate in medical
anthropology in the Department of Anthropology
at Harvard University, Cambridge, Massachusetts,
United States of America.
* To whom correspondence should be addressed.
E-mail: [email protected]
The Essay section contains opinion pieces on topics
of broad interest to a general medical audience.
Box 1. Case Scenario: Cultural
Assumptions May Hinder

Practical Understanding
A medical anthropologist is asked by
a pediatrician in California to consult in
the care of a Mexican man who is HIV
positive. The man’s wife had died of AIDS
one year ago. He has a four-year-old son
who is HIV positive, but he has not been
bringing the child in regularly for care.
The explanation given by the clinicians
assumed that the problem turned on a
radically different cultural understanding.
What the anthropologist found, though,
was to the contrary. This man had a near
complete understanding of HIV/AIDS
and its treatment—largely through the
support of a local nonprofi t organization
aimed at supporting Mexican-American
patients with HIV. However, he was a
very-low-paid bus driver, often working
late-night shifts, and he had no time
to take his son to the clinic to receive
care for him as regularly as his doctors
requested. His failure to attend was not
because of cultural differences, but rather
his practical, socioeconomic situation.
Talking with him and taking into account
his “local world” were more useful than
positing radically different Mexican
health beliefs.
is not a single variable but rather

comprises multiple variables, affecting
all aspects of experience. Culture is
inseparable from economic, political,
religious, psychological, and biological
conditions. Culture is a process
through which ordinary activities and
conditions take on an emotional tone
and a moral meaning for participants.
Cultural processes include
the embodiment of meaning in
psychophysiological reactions [19],
the development of interpersonal
attachments [20], the serious
performance of religious practices
[21], common-sense interpretations
[22], and the cultivation of collective
and individual identity [23]. Cultural
processes frequently differ within the
same ethnic or social group because
of differences in age cohort, gender,
political association, class, religion,
ethnicity, and even personality.
The Importance of Ethnography
It is of course legitimate and highly
desirable for clinicians to be sensitive
to cultural difference, and to attempt
to provide care that deals with cultural
issues from an anthropological
perspective. We believe that the optimal
way to do this is to train clinicians in
ethnography. “Ethnography” is the
technical term used in anthropology
for its core methodology. It refers to

an anthropologist’s description of
what life is like in a “local world,” a
specifi c setting in a society—usually
one different from that of the
anthropologist’s world. Traditionally,
the ethnographer visits a foreign
country, learns the language, and,
systematically, describes social patterns
in a particular village, neighborhood,
or network [24]. What sets this
apart from other methods of social
research is the importance placed on
understanding the native’s point of
view [25]. The ethnographer practices
an intensive and imaginative empathy
for the experience of the natives—
appreciating and humanly engaging
with their foreignness [26], and
understanding their religion, moral
values, and everyday practices [27,28].
Ethnography is different than
cultural competency. It eschews the
“trait list approach” that understands
culture as a set of already-known
factors, such as “Chinese eat pork,
Jews don’t.” (Millions of Chinese are
vegetarians or are Muslims who do
not eat pork; some Jews, including the
corresponding author of this paper,
love pork.) Ethnography emphasizes
engagement with others and with the
practices that people undertake in their
local worlds. It also emphasizes the
ambivalence that many people feel as

a result of being between worlds (for
example, persons who identify as both
African-American and Irish, Jewish and
Christian, American and French) in a
way that cultural competency does not.
And ethnography eschews the technical
mastery that the term “competency”
suggests. Anthropologists and clinicians
share a common belief—i.e., the
primacy of experience [29–33]. The
clinician, as an anthropologist of
sorts, can empathize with the lived
experience of the patient’s illness, and
try to understand the illness as the
patient understands, feels, perceives,
and responds to it.
The Explanatory Models Approach
One of us [AK] introduced the
“explanatory models approach,”
which is widely used in American
medical schools today, as an interview
technique (described below) that
tries to understand how the social
world affects and is affected by illness.
Despite its infl uence, we’ve often
witnessed misadventure when clinicians
and clinical students use explanatory
models. They materialize the models
as a kind of substance or measurement
(like hemoglobin, blood pressure, or X
rays), and use it to end a conversation
rather to start a conversation. The
moment when the human experience

of illness is recast into technical disease
categories something crucial to the
experience is lost because it was not
validated as an appropriate clinical
concern [34].
Rather, explanatory models
ought to open clinicians to human
communication and set their expert
knowledge alongside (not over and
above) the patient’s own explanation
and viewpoint. Using this approach,
clinicians can perform a “mini-
ethnography,” organized into a series
of six steps. This is a revision of the
Cultural Formulation included in the
fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders
(DSM-IV) (see Appendix I in [35])
[36,37].
A Revised Cultural Formulation
Step 1: Ethnic identity. The fi rst step
is to ask about ethnic identity and
determine whether it matters for the
patient—whether it is an important
part of the patient’s sense of self. As
part of this inquiry, it is crucial to
acknowledge and affi rm a person’s
experience of ethnicity and illness. This
is basic to any therapeutic interaction,
and enables a respectful inquiry into
the person’s identity. The clinician
can communicate a recognition that
people live their ethnicity differently,

that the experience of ethnicity is
complicated but important, and that
it bears signifi cance in the health-care
setting. Treating ethnicity as a matter
of empirical evidence means that its
salience depends on the situation.
Ethnicity is not an abstract identity,
as the DSM-IV cultural formulation
implies, but a vital aspect of how life is
lived. Its importance varies from case
to case and depends on the person. It
defi nes how people see themselves and
their place within family, work, and
social networks. Rather than assuming
knowledge of the patient, which can
lead to stereotyping, simply asking the
patient about ethnicity and its salience
is the best way to start.
Step 2: What is at stake? The second
step is to evaluate what is at stake as
patients and their loved ones face an
episode of illness. This evaluation may
include close relationships, material
resources, religious commitments, and
even life itself. The question, “What is
at stake?” can be asked by clinicians;
the responses to this question will vary
within and between ethnic groups, and
Box 2. The Explanatory Models
Approach
• What do you call this problem?
• What do you believe is the cause of
this problem?

• What course do you expect it to take?
How serious is it?
• What do you think this problem does
inside your body?
• How does it affect your body and your
mind?
• What do you most fear about this
condition?
• What do you most fear about the
treatment?
(Source: Chapter 15 in [38])
will shed light on the moral lives of
patients and their families.
Step 3: The illness narrative. Step
3 is to reconstruct the patient’s
“illness narrative” [38]. This involves
a series of questions (about one’s
explanatory model) aimed at acquiring
an understanding of the meaning of
illness (Box 2).
The patient and family’s explanatory

models can then be used to open up
a conversation on cultural meanings
that may hold serious implications for
care. In this conversation, the clinician
should be open to cultural differences
in local worlds, and the patient should
recognize that doctors do not fi t a
certain stereotype any more than they
themselves do.
Step 4: Psychosocial stresses. Step
4 is to consider the ongoing stresses
and social supports that characterize
people’s lives. The clinician records the
chief psychosocial problems associated
with the illness and its treatment (such
as family tensions, work problems,
fi nancial diffi culties, and personal
anxiety). For example, if the clinicians
described in the case scenario in Box 1
had carried out step 4, they could have
avoided the misunderstanding with
their Mexican-American patient. The
clinician can also list interventions to
improve any of the patient’s diffi culties,
such as professional therapy, self-
treatment, family assistance, and
alternative or complementary medicine.
Step 5: Infl uence of culture on
clinical relationships. Step 5 is to
examine culture in terms of its
infl uence on clinical relationships.
Clinicians are grounded in the world
of the patient, in their own personal
network, and in the professional

world of biomedicine and institutions.
One crucial tool in ethnography is
the critical self-refl ection that comes
from the unsettling but enlightening
experience of being between social
worlds (for example, the world of the
researcher/doctor and the world of the
patient/participant of ethnographic
research). So, too, it is important to
train clinicians to unpack the formative
effect that the culture of biomedicine
and institutions has on the most
routine clinical practices—including
bias, inappropriate and excessive use
of advanced technology interventions,
and, of course, stereotyping. Teaching
practitioners to consider the effects
of the culture of biomedicine is
contrary to the view of the expert as
authority and to the media’s view that
technical expertise is always the best
answer. The statement “First do no
harm by stereotyping” should appear
on the walls of all clinics that cater
to immigrant, refugee, and ethnic-
minority populations. And yet since
culture does not only apply to these
groups, it ought to appear on the walls
of all clinics.
Step 6: The problems of a cultural
competency approach. Finally, step 6
is to take into account the question
of effi cacy—namely, “Does this
intervention actually work in particular

cases?” There are also potential
side-effects. Every intervention has
potential unwanted effects, and this
is also true of a culturalist approach.
Perhaps the most serious side-effect of
cultural competency is that attention to
cultural difference can be interpreted
by patients and families as intrusive,
and might even contribute to a sense
of being singled out and stigmatized
[3,11,12]. Another danger is that
overemphasis on cultural difference
can lead to the mistaken idea that if
we can only identify the cultural root
of the problem, it can be resolved.
The situation is usually much more
complicated. For example, in her
infl uential book, The Spirit Catches You
and You Fall Down , Ann Fadiman shows
that while inattention to culturally
important factors creates havoc in
the care of a young Hmong patient
with epilepsy, once the cultural issues
are addressed, there is still no easy
resolution [33]. Instead, a whole new
series of questions is raised.
Determining What Is at Stake for
the Patient
The case history in Box 3 gives
an example of how simply using
culturally appropriate terms to explain
people’s life stories helps the health
professionals to restore a “broken”
relationship and allows treatment to

continue. This case is not settled, nor is
it an example of any kind of technical
competency. But there are two
illuminating aspects of this case. First, it
is important that health-care providers
do not stigmatize or stereotype
patients. This is a case study of an
individual. Not all Chinese people fi t
this life story, and many contemporary
Chinese now accept the diagnosis of
depression. Second, culture is not
just what patients have; clinicians
also participate in cultural worlds. A
physician too rigidly oriented around
the classifi cation system of biomedicine
might fi nd it unacceptable to use lay
classifi cations for the treatment.
For the late French moral
philosopher Emmanuel Levinas, in
the face of a person’s suffering, the
fi rst ethical task is acknowledgement
[39]. Face-to-face moral issues
precede and take precedence over
epistemological and cultural ones
[40]. There is something more
basic and more crucial than cultural
competency in understanding the life
of the patient, and this is the moral
meaning of suffering—what is at stake
for the patient; what the patient, at a
deep level, stands to gain or lose. The
explanatory models approach does not
ask, for example, “What do Mexicans

Box 3. Case Scenario: The
Importance of Using Culturally
Appropriate Terms to Explain
People’s Life Stories
Miss Lin is a 24-year-old exchange
student from China in graduate school in
the United States, where she developed
symptoms of palpitations, shortness
of breath, dizziness, fatigue, and
headaches. A thorough medical work-
up leaves the symptoms unexplained. A
psychiatric consultant diagnoses a mixed
depressive-anxiety disorder. Miss Lin
is placed on antidepressants and does
cognitive-behavioral psychotherapy,
with symptoms getting better over a six-
week period; but they do not disappear
completely.
Subsequently, the patient drops out
of treatment and refuses further contact
with the medical system. Anthropological
consultation discovers that Miss Lin
comes from a Chinese family in Beijing—
one of her cousins is hospitalized with
chronic mental illness. So powerful is
the stigma of that illness for this family
that Miss Lin cannot conceive of the
idea that she is suffering from a mental
disorder, and refuses to deal with her
American health-care providers because
they use the terms “anxiety disorder” and
“depressive disorder.” In this instance,
she herself points out that in China
the term that is used is neurasthenia

or a stress-related condition. On the
anthropologist’s urging, clinicians
reconnect with Miss Lin under this label.
Acknowledgments
The two case scenarios included in this
article are fi ctional, but they are inspired by
the real clinical experience of the authors.
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critical demonstration with American Indian
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Fabrega H Jr, Parron DL, et al. (1999) The
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187: 457–464.
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Suffering, healing, and the human condition.
New York: Basic Books. 304 p.
39. Levinas E (2000) Useless suffering. In: Smith
MB, Harshav B, translators. Entre nous:
Thinking-of-the-other. New York: Columbia
University Press. pp. 91–101.
40. Levinas E, (1998) Otherwise than being:
Or beyond essence. Pittsburgh: Duquesne
41. Goethe (1978) Elective affi nities. New York:
Penguin. 304 p.
42. Lensing LA (2003 February 28) Franz would be
with us here. Times Literary Supplement. pp.
13–15.
43. Kleinman A (2006) What really matters: Living
a moral life amidst uncertainty and danger.
Oxford: Oxford University Press. 272 p.
call this problem?” It asks, “What do
you call this problem?” and thus a
direct and immediate appeal is made

to the patient as an individual, not as a
representative of a group.
Conclusion
What clinicians want to understand
through the mini-ethnography is what
really matters—what is really at stake
for patients, their families, and, at
times, their communities, and also what
is at stake for themselves. If we were
to reduce the six steps of culturally
informed care to one activity that even
the busiest clinician should be able to
fi nd time to do, it would be to routinely
ask patients (and where appropriate
family members) what matters most to
them in the experience of illness and
treatment. The clinicians can then use
that crucial information in thinking
through treatment decisions and
negotiating with patients.
This is much different than cultural
competency. Finding out what matters
most to another person is not a
technical skill. It is an elective affi nity to
the patient. This orientation becomes
part of the practitioner’s sense of self,
and interpersonal skills become an
important part of the practitioner’s
clinical resources [41]. It is what Franz
Kafka said “a born doctor” has: “a
hunger for people” [42]. And its main
thrust is to focus on the patient as an
individual, not a stereotype; as a human

being facing danger and uncertainty,
not merely a case; as an opportunity
for the doctor to engage in an essential
moral task, not an issue in cost-
accounting [43]. �
Moral and Ethical Considerations
Maria Merritt, PhD
! Terminology: “Moral” and “Ethical”
! Moral reasons for engaging in international health programs
and research
! Ethical conduct of work in international health
Overview
2
! No uniform correct way to use these terms
! A helpful way to use them in this class
! Moral reasoning involves critical reflection on the right way
for human beings to

treat each other
! Ethical conduct involves doing right by people in specific
contexts of action
• Especially in professional contexts
Terminology: “Moral” and “Ethical”
3
purposes under
distributed.
Moral Reasons for Engaging in
International Health
Section A
! Why should it be thought that “the peoples of wealthy
nations, or their governments on
their behalf, should take measures to improve health in the
developing world”? (Wolff,
p. 78)
What Is the Basis of the Global Health Duty?
5

! Justice: moral obligations across borders
! Libertarianism
! Nationalism
! Cosmopolitanism
! Justice: human rights perspective
! Humanitarian duty
Outline
6
National Boundaries and Duties of Justice
7
Duties to assist the
disadvantaged in your
own country
disadvantaged in other
countries
Moral rationale: Who owes what
to whom?
Libertarianism X All people primarily owe each other only non-

interference
Nationalism Moderate X
Compatriots bound by same
government have distinct positive
moral claims on each other
Cosmopolitanism Extensive
People universally have positive
Justice: Cosmopolitan Perspective
8
! “Southern states are now epicenter of HIV/AIDS in the US”
(Teresa Wiltz,
Washington Post, September 22, 2014)
! “None of the nine Deep South states with the highest rates of
new HIV/AIDS diagnoses—
Alabama, Georgia, Florida, Louisiana, Mississippi, North
Carolina, South Carolina,
Tennessee, and Texas—have opted to expand Medicaid under
the Affordable Care Act.
Those states also have the highest fatality rates from HIV in the
country …”
! A physician recently treated “… a young man in Montgomery,
Ala., who was blinded by

cryptococcal meningitis, a disease typically found among HIV-
positive people living in
sub-Saharan Africa.” Said the treating physician ...
! “That’s a tragedy that shouldn’t happen in our country.”
How Are We Doing in the US?
9
Cosmopolitanism as Possible Basis for Global Health Duty
10
disadvantaged in your
own country
disadvantaged in other
countries
Moral rationale: Who owes what
to whom?
Libertarianism X All people primarily owe each other only non-
interference
Nationalism Moderate X
Compatriots bound by same
government have distinct positive

Cosmopolitanism Extensive
People universally have positive
Justice:
Human Rights
Perspective
11
! Human rights can be seen as moral claims that are “embodied
in the practices of
international law” (Wolff, p. 86)
! Conventions, declarations, international courts
! “… it is possible to accept the doctrine of human rights from
a variety of moral or
political standpoints, of which the cosmopolitan perspective is
merely one” (Wolff, p.
98, note 26)
Human Rights
12
! “Different people will find their own [moral] justifications”
! No moral perspective has a “privileged place as providing the

core foundation” for the
political doctrine of recognizing human rights
! Human rights have “moral foundations, but no particular
moral foundation”
Broad Appeal of Human Rights
13
! Duties based on human rights typically require the
international community to remain
silent and not criticize government actors
True or False?
14
Human Rights in Action
15
Right holders All human beings
Primary duty bearers Government of each country
Role of compatriots within
each country
“... criticize ... regime for failing to meet the human rights of its
citizens” (Wolff, p. 88)

Role of international
community
“... criticize ... regime for failing to
meet the human rights of its
citizens” (Wolff, p. 88)
“... take steps to encourage and assist
national governments in carrying out
their duties ...” (Wolff, p. 86)
“... perhaps pick up the duty in extreme cases of failure ...”
(Wolff, p. 86)
Humanitarian Duty
16
Humanitarian Assistance (Wolff, pp. 93–96)
17
Who ought to act?
Whoever “is best placed” to act in fulfillment of unmet health
needs (Wolff, p.
93)
What kinds of action are
required?
Provision of money, health care, supplies, facilities, etc.

To whom is humanitarian
assistance owed?
" No one in particular
" You might act wrongly if you never offered humanitarian
assistance
" But no one can say “it is owed to me!”
How is humanitarian
assistance related to the
“international social
structure?
Tends to leave in place existing asymmetries of wealth, power,
and status
! Each line of reasoning requires defense through moral
argumentation
! Maybe “different types of programs, in different countries,
have different [moral]
justifications” (Wolff, p. 79)
! Moral foundations make a difference to determining “when
enough has been
done” (Wolff, p. 79)
Recap: Moral Considerations
18

purposes under
distributed.
Ethical Conduct of Work in
Section B
Health and Human Rights, Vol. 11, No. 1. (2009): pp. 87–92
2
Setting the Stage
3
! Eradication: the permanent reduction to zero of the worldwide
incidence of infection
caused by a specific agent as a result of deliberate efforts so
that intervention
measures are no longer needed
International Health Context
4 Source: Dowdle, W. R. (1998). The principles of disease
elimination and eradication. Bull World Health Organ, 76, 22–
25.

! By definition, eradication as a goal—“the permanent
reduction to zero of the
worldwide incidence of infection”—is global in scope and
affects future
! Yet the achievement of the goal entails comprehensive
participation by every affected
local constituency in the present
International Health Context
5
! This is “a public-private partnership led by national
governments and spearheaded by”
WHO, Rotary International, US CDC, and UNICEF
! Launched: 1988
! Goal: “to eradicate polio worldwide”
! International investment to date: >$8 billion
! Number of children immunized to date: >2.5 billion
Global Polio Eradication Initiative (GPEI)
6

! “Polio remains endemic in three countries—Afghanistan,
Nigeria and Pakistan.”
! “Until poliovirus transmission is interrupted in these
countries, all countries remain at
risk of importation of polio, especially in the ‘poliovirus
importation belt’ of countries
from west Africa to the Horn of Africa.”
Countries of Greatest Interest
7
! Focus on pages 89–91 of Rubincam & Naysmith
! Using concepts from Wolff, consider the following:
1. What moral basis could there be for GPEI?
2. What moral basis could there be for the 2003 community
boycott and the 2008
community interference with GPEI activities?
3. Is there a conflict of moral reasoning between GPEI and
community actors?
4. How would you act as a GPEI leader? As a community
leader? For what moral
reasons?
Questions for Reflection
8

! The case illustrates ethical questions—how to do right by
people in specific
situations—that often arise in work related to international
health
! You can use moral concepts to ...
! Identify important reasons why actors might be doing what
they do; and
! Analyze complex situations where moral reasons vary among
different actors; and
! Listen, learn, and think about how to resolve tensions or
conflicts that may involve
differing moral viewpoints
Concluding Comments
9
Your feedback is very
important and will be used
for future revisions.
The Evaluation link is
available on the lecture
page.
Lecture Evaluation
10

Working With Different Stakeholders
Peter J. Winch, MD, MPH
distributed.
Stakeholders
Section A
Stakeholders
international health and
their respective roles changed since World War II?
–1970
–2000
3

Who Are the Stakeholders?
interest (stake)”
organization, project or
policy direction”
Sources:
Mason, R. O., & Mitroff, I. I. (1981). Challenging Strategic
Planning Assumptions: Theory, Cases, and Techniques. John
Wiley & Sons Incorporated.
Crosby, B. (1992). Stakeholder Analysis: A Vital Tool for
Strategic Managers. USAID’s Implementing Policy Change
Project.
Walt, G. (1994). Health Policy: An Introduction to Process and
Power. Johannesburg : London ; Atlantic Highlands, N.J:
Witwatersrand University Press; Zed Books.
[Cited in: Varvasovszky, Z., & Brugha, R. (2000). A
stakeholder analysis. Health Policy and Planning, 15(3), 338–
345.] 4
“Clarkson (1995) defines stakeholders as ‘persons or group that
have, or
claim, ownership, rights or interests in a corporation and its
activities, past,
present, or future.’”

—Varvasovszky and Brugha (2000)
Who Are the Stakeholders?
Source: Varvasovszky, Z., & Brugha, R. (2000). A stakeholder
analysis. Health Policy and Planning, 15(3), 338–345.
[Referencing: Clarkson, M. E. (1995). A Stakeholder
framework for analyzing and evaluating corporate social
performance. Academy of Management Review, 20(1), 92–117.]
5
Other Related Terms
• Walt, Buse, and Harmer, p. 853
to multilateral and
bilateral organizations
Source: Walt, G., Buse, K., & Harmer, A. Chapter 17:
Cooperation in Global Health. In: Merson, M., Black, R. E., &
Mills, A., eds. Global Health: Diseases, Programs, Systems,
and Policies. (2012) (3rd edition). Burlington, MA: Jones &
Bartlett Learning. 6

Engagement With Stakeholders During Three Periods
Bartlett Learning.
1945–
1970–2000
artnerships
2000–
7
Bartlett Learning.
1945–
1970–2000
nce of horizontal partnerships

2000–
8
“Vertical representation describes the relationship between the
state and
international organizations that make up the United Nations
system, which
was established in the mid-1940s to represent the interests of all
states and
promote cooperation between them.”
—Walt, Buse, and Harmer, p. 853
Vertical Representation
Bartlett Learning. 9
Yalta Conference:
February 1945
Source: US Government photographer. (1945). "'Big
Three' met at Yalta." Via Wikimedia Commons:
https://commons.wikimedia.org/wiki/File:Yalta_
Conference_(Churchill,_Roosevelt,_Stalin)_(B%26
W).jpg. Public domain. Accessed July 21, 2015. 10

Question One
1. Winston Churchill, Theodore Roosevelt, Vladimir Lenin
2. Winston Churchill, Theodore Roosevelt, Joseph Stalin
3. Winston Churchill, Franklin Roosevelt, Joseph Stalin
4. Tony Blair, Eleanor Roosevelt, Vladimir Putin
11
Question One
1. Winston Churchill, Theodore Roosevelt, Vladimir Lenin
2. Winston Churchill, Theodore Roosevelt, Joseph Stalin
4. Tony Blair, Eleanor Roosevelt, Vladimir Putin
12
Post-War Period
1944 Dumbarton Oaks Conference—preliminary UN plans
1945 Yalta Conference—Russia agrees to enter UN

1945
United Nations Conference on International Organization in San
Francisco—UN Charter written
1946 Constitution of WHO signed at UN
1947 Partition and independence of India, Pakistan
1948 WHO formed
1948–1949 Berlin Blockade
1949 Independence of Indonesia, Chinese Revolution
1950–1953 Korean War
1956 Hungarian Revolution, Suez Crisis
1957 Independence of Ghana
1960 Independence of Nigeria
13
Challenges in Newly Independent Countries
place
14

Key Activities of WHO From 1945 to 1970
independent countries
locations of health facilities
and the level of facility at each location
15
Question Two
1970?
Multiple responses possible:
1. Yaws
2. Polio
3. Measles
4. Malaria
5. Smallpox
6. Dengue
16

Question Two
1970?
–1964:
• Yaws, Bejel, Pinta
• Global Control of Treponematoses (GCT)
55–1969:
• Malaria
–1980:
• Smallpox
17
Question Three
1. Ministries of health
2. Roll Back Malaria
3. UNAIDS
4. USAID
5. Nongovernmental organizations (NGOs)
6. Community-based organizations (CBOs)
7. Human rights organizations

8. UNICEF
18
Question Three
2. Roll Back Malaria
3. UNAIDS
5. Nongovernmental organizations (NGOs)
6. Community-based organizations (CBOs)
7. Human rights organizations
19
Prof. Timothy D. Baker (1925–2013)
ring the 1945–1970 period
Image: Professor Timothy Baker. Retrieved July 21, 2015, from
http://www.jhsph.edu/departments/international-health/the-
globe/summer-2014/timothy-baker.html. 20

Prof. Timothy D. Baker (1925–2013)
ation programs in India and Ceylon
during 1950s as assistant chief of the Health Division for US
Technical Cooperation Mission (later USAID)
professor of public health administration
onducted the first health workforce studies across
South America, as well as in Korea, Taiwan, Thailand, and
Vietnam (e.g., “Health manpower in a developing economy:
Taiwan, a case study in planning,” 1967)
ernational Health
and served as acting director
December 17, 2013
Image: Professor Timothy Baker. Retrieved July 21, 2015, from
http://www.jhsph.edu/departments/international-health/the-
globe/summer-2014/timothy-baker.html. 21
Bartlett Learning.
1945–

1970–2000
2000– izontal partnerships and “global health”
22
1970–2000: Key Trends in Stakeholder Engagement
d in
some countries, prone to
human rights abuses
23
1970s: Attention to Community-Based Provision of Care
NY: Cornell University

Press.
Geneva: World Health
Organization.
http://apps.who.int/iris/bitstream/10665/40514/1/9241560428_e
ng.pdf
24
Table of
Contents:
Health by the
People (Newell,
1975)
25
Source: Newell, K. W. (Ed.). (1975). Health by the
People. Geneva: World Health Organization.
Available at:
http://apps.who.int/iris/bitstream/10665/40514/1
/9241560428_eng.pdf. Accessed July 21, 2015.
Elements of the Emerging Approach to Health Services

l, not vertical
(CHWs/VHWs)
26
International Conference on Primary Health Care,
Almaty (Formerly Alma-Ata), Kazakhstan, September 6–12,
1978
al well-being
and not merely the
absence of disease or infirmity”
27
Carl E. Taylor (1916–2010)

Department of
Declaration
Lifetime proponent of
Comprehensive Primary
Health Care
lack of humility to be key
barriers to implementation
Image: Carl E. Taylor 1916-2010. Retrieved July 21, 2015,
from http://www.jhsph.edu/news/stories/2010/carl-taylor.html.
28
Emergence of Stakeholder Analysis as Key Tool
-based organizations
many grant applications
29

distributed.
Changing Roles
Section B
Changing Roles
ers in
international health and
their respective roles changed since World War II?
–present
2

Bartlett Learning.
1945– representation and “international health”
1970–2000
2000–
3
2000–Present: Key Developments in Stakeholder Analysis
—founding of Global Fund
process
international NGOs
d accountability
—Paris Declaration on Aid Effectiveness
4
CSOs and Founding of the Global Fund for AIDS, Tuberculosis,
and Malaria

Malaria” in Wikipedia
affected
Initial idea was a broad antipoverty development fund, but
focus was narrowed to
diseases
Source: “The Global Fund to Fight AIDS, Tuberculosis and
Malaria.” (Updated July 8, 2015). In Wikipedia, the free
encyclopedia. Available at:
http://en.wikipedia.org/wiki/The_Global_Fund_to_Fight_AIDS,
_Tuberculosis_and_Malaria#Creation. Accessed July 21, 2015.
5
Global Fund: Country Coordinating Mechanisms (CCMs)
multisectoral
a CCM
-
based organizations
(CBOs), CSOs, and development partners around the table

Health, but also Ministry of
Finance, UN Development Program (UNDP), international
NGO, etc.
6
Growing roles for NGOs:
Good thing or bad thing?
7
Impacts of NGOs
on Health
Systems (Pfeiffer,
et al., 2008)
Negative impact Positive impact
Manage-
ment
Burden
versee
reporting requirements
needs
Support

building
and harmonized program reporting
integrated planning
Oper-
ations
Fragmentation of services,
vertical technical assistance
sustainability
programmatic resource allocation
service integration
resources within NGO-related
projects
Technical assistance,
innovation, pilot projects
Ministry of Health (MOH) priorities
technical assistance priorities

vertical funds into integrated services
MOH for innovative projects
Human
resources
Shortages
ty for new
programs
of skilled staff
Capacity building
-the-job training for MOH staff
for new program needs
e work
conditions, capacity, and workloads
funding for new management tools
Source: Pfeiffer, J., Johnson, W., Fort, M.,
Shakow, A., Hagopian, A., Gloyd, S., & Gimbel-
Sherr, K. (2008). Strengthening health systems in
poor countries: a code of conduct for

nongovernmental organizations. American Journal
of Public Health, 98(12), 2134–2140.
http://doi.org/10.2105/AJPH.2007.125989
Elements of an
NGO Code of
Conduct for
Health System
Strengthening
(Pfeiffer, et al.,
2008)
1. Hiring practices that ensure long-term health system
sustainability
any hiring from public
systems
2. Compensation practices that strengthen the public sector
and compensate
community health workers
3. Human resources support for local health systems
professionals
MOHs

4. NGO management support for MOHs
ollow MOH geographic, administrative, and personnel
norms
vertical funding
5. Health system community support
promoting government
accountability
6. Advocacy to eliminate wage bill caps and limitations on
health
system investment promoted by international financial
institutions
9
Source: Pfeiffer, J., Johnson, W., Fort, M.,
Shakow, A., Hagopian, A., Gloyd, S., & Gimbel-
Sherr, K. (2008). Strengthening health systems in
poor countries: a code of conduct for
nongovernmental organizations. American Journal
of Public Health, 98(12), 2134–2140.
http://doi.org/10.2105/AJPH.2007.125989
Question Four
implement?

One response only
1. Limit hiring out of public systems
2. Limit pay inequity between public and private sectors
3. Grant similar privileges for expatriate and national
employees
4. Follow Ministry of Health geographic, administrative, and
personnel norms
10
“One agreed HIV/AIDS Action Framework that provides the
basis for
coordinating the work of all partners;
One National HIV/AIDS Coordinating Authority, with a broad-
based multi-
sectoral mandate;
One agreed HIV/AIDS country-level Monitoring and Evaluation
(M&E)
System.”
Three Ones: UNAIDS 2004
Source: UNAIDS. “Three Ones Principles.” Available at:
www.unaids.org.ua/un_support/strategies/ThreeOnes. Accessed
July 21, 2015. 11
Aid Effectiveness

decisions
12
Paris Declaration on Aid Effectiveness, 2005
for NGOs and the Three
Ones of UNAIDS
Source: “Aid effectiveness.” (Updated April 11, 2015). In
Wikipedia, the free encyclopedia. Available at:
https://en.wikipedia.org/wiki/Aid_effectiveness#Paris_Declarati
on_on_Aid_Effectiveness.2C_February_2005. Accessed July 21,
2015. 13
Paris Declaration on Aid Effectiveness, 2005

1. Ownership:
development work
ry plans and priorities
2. Alignment:
and priorities
3. Harmonization:
to lessen administrative
burden on countries
4. Managing for results:
of achievement of
objectives
5. Mutual accountability:
other for use of aid funds,
and to citizens and parliaments for impact of aid
Source: “Aid effectiveness.” (Updated April 11, 2015). In
Wikipedia, the free encyclopedia. Available at:
https://en.wikipedia.org/wiki/Aid_effectiveness#Paris_Declarati
on_on_Aid_Effectiveness.2C_February_2005. Accessed July 21,
2015. 14

distributed.
Stakeholder Analysis, Example 1:
Response to the Anti-Homosexuality
Act in Uganda
Section C
What we mean by stakeholder analysis
2
Stakeholder Analysis
• Why do it, given that only stakeholder is Ministry of Health?
• Essential to appreciate the complex role of different partners
• Requirement as part of grant application process for many
donors
3

Development Partners David H. Peters, MD, MPH, DrPH, FACP.docx

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