1. What is Development, and
How Is It Achieved?
W. Henry Mosley, MD,MPH
CORE Group Round Table
April 24, 2013

2. Development As Freedom
1. Political freedoms
2. Economic facilities
3. Social opportunities (including health, education)
4. Transparency guarantees
5. Protective security
“Each of these distinct types of rights and
opportunities advance the general capability of
a person.”
»Amartya Sen, Development as Freedom, P. 10

3. Human Capability As
Development
“The perspective of human capability
focuses…on the ability – the substantive
freedom – of people to lead the lives
they have reason to value and to
enhance the real choices they have.”
»Amartya Sen, Development as Freedom, P. 293

4. What is development, and how is it
achieved?
Expansion of freedom is viewed…both as the
primary end and principle means of
development.
Development consists of the removal of various
types of unfreedoms that leave people with little
choice and little opportunity for exercising their
reasoned agency.
– Amartya Sen, Development as Freedom, p xii

5. How to Promote Development
- Armatya Sen
 With adequate social opportunities, individuals
can effectively shape their own destiny and help
each other. They need not be seen primarily as
the passive recipients of the benefits of cunning
development programs.
– Armatya Sen, Development as Freedom, p. 11

6. How to Promote Sustainable
Development
- Mohammed Yunus
 You look at the tiniest village and tiniest person
in that village: a very capable person, a very
intelligent person. You have only to create the
proper environment to support these people so
that they can change their own lives.
– Mohammed Yunus, in: Bornstein, D. The Price of a Dream.
The Story of the Grameen Bank. p. 215

7. How to Promote Development
- Mohammed Yunus
 Grameen’s approach – focusing on the
individual in need as the agent of change – is
diametrically opposite to that taken by
conventional development organizations, which
typically see themselves as agents of change on
behalf of those in need.
– Bornstein, D. The Price of a Dream. The Story of the
Grameen Bank. p. 215

8. Interest
groups
Policymakers,
planners
Managers,
providers
Communities,
households
MIS
Evaluations
Research,
pilot projects
The “Blueprint”
Development Strategy
Health
Learning Action
Project
Blueprints

9. Nigeria – Immunization
Case Study
0
10
20
30
40
50
60
70
80
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2007
2010
DPT3
Coverage%
1985 UNICEF/WHO Global Goal –
“Immunize 80% of the world’s
children by 1990”
Source:http://apps.who.int/immunization_monitoring/en/globalsummary/timeseries/tswuc
overagepol3.htm
Project
succes
s

10. Nigeria – Immunization
Case Study
0
10
20
30
40
50
60
70
80
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2007
2010
DPT3
Coverage%
Who immunizes the
children in 1991 and
thereafter?
Source:http://apps.who.int/immunization_monitoring/en/globalsummary/timeseries/tswuc
overagepol3.htm
Program failure
Buying
indicators

11. Nigeria - Immunization Coverage by State
0
10
20
30
40
50
60
70
80
90
100
Jigawa
Bauchi
Kastina
Sokoto
Borno
Kebbi
Kano
Zamfara
Yobe
Taraba
Niger
Bayelsa
Gombe
Nasarawa
Adamawa
Kaduna
Benue
Ogun
Enugu
AkwaIbom
Rivers
Ondo
Kogi
Kwara
Plateau
Delta
Abia
Ebonyi
Oyo
Edo
CrossRivers
Lagos
Abuja
Anambra
Imo
Osun
Ekiti
Coverage(%)
State
DPT3 coverage by states, DHS 2008
Source: Nigerian Demographic and Health Survey (DHS), 2008
Why is this happening?

12. 12
Communication/Information
Media messages regarding
vaccinations
Community involvement in EPI
Trust in health service provider
Parental
Attitude/Knowledge
Perceived benefit of vaccines
Perceived disease threat
Group pressure for or
against vaccinations
• Immunization Systems
– Access and vaccine
service availability
– Use of all opportunities
– Cost and service quality
– Health worker knowledge
• Family Characteristics
– Education level (of mom and
dad)
– Family size
– Income, occupation
– Ethnicity/language group
*From New Generation Vaccines, 3rd edition
Reasons for No- or Under-immunization:
Definition of Categories*

13. 13
55%
6%
12%
27%
Family Characteristics
Immunization System
Communication and Information
Parental Attitudes and Knowledge
% based on total reasons abstracted from 12 articles on unvaccinated children according to definitions in New
Generation Vaccines, 3rd ed.
Reasons for being UNvaccinated

14. Interest
groups
Policymakers,
planners
Managers,
providers
Communities,
households
MIS
Evaluations
Research,
pilot projects
The “Blueprint” Strategy
A fundamental flaw
Health
Learning Action
Project
Blueprints
Disconnects
learning from
action

15. Learning for Development
 A key lesson is that development is not
easy. It is at its core, a social and
cultural process that requires a slow
process of learning from the ground up
in order to be effective and sustainable.
»Rao, V, Walton, M. Culture and Public Action. P. 363

16. Policymakers,
planners
Managers,
providers
Communities,
households
TasksCompetencies
Health System Development
“Learning Organization” Strategy
Interest
groups
Learning
Health
3
1
2
Linking
Action to
Learning
Adapted from Korten, 1980

17. Policymakers,
planners
Managers,
providers
Communities,
households
TasksCompetencies
Health System Development -
“Learning Organization” Strategy
Interest
groups
Learning
Health
3
1
2
Adapted from Korten, 1980

18. 1. Learning to fit
 The task – learning how to understand
the household’s needs and
constraints, and how to introduce new
values, practices, knowledge, skills, and
technologies to help
households/mothers become more
resourceful in the production of health
OutputsNeeds

19. Starting in 2006, the King’s Medical Centre
has grown to become a centre of excellence!
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346

20. Malnutrition, culture and evil spirits in
Tamale, Ghana
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346

21. Community building huts for nutritional
rehabilitation in 2008
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346
Mothers will not take their children
to live in the hospital.

22. Mothers and children live in the huts for 6
weeks for rehabilitation
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346

23. Saving the lives of many children
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346

24. Saving lives of many children
Dr James Duah. The King's Medical
Centre. jamesduak@yahoo.com. Tel:
+233 244771346

25. The response of the mothers
of Tamale -
 “How many of our children would be
alive if we had know this was diet and
not evil spirits.”
 “We just didn’t know, nobody told us.”

26. Policymakers,
planners
Managers,
providers
Communities,
households
TasksCompetencies
Health System Development -
“Learning Organization” Strategy
Interest
groups
Learning
Health
3
1
2
Adapted from Korten, 1980

27. 2. Learning to fit
 The task – learning how to change
the organizational culture so it can
develop the competencies to do the
tasks required to design, implement
and be accountable for programs that
promote the household production of
health
Distinctive
competencies
Task
requirements

28. *Nkwanta District is in rural east-central Ghana.
*
CHPS = Community-based Health Planning and Services

31. Results of engaging the households and
communities

33. Policymakers,
planners
Managers,
providers
Communities,
households
TasksCompetencies
Health System Development -
“Learning Organization” Strategy
Interest
groups
Learning
Health
3
1
2
Adapted from Korten, 1980

34. 3. Learning to fit
 The task – learning how to engage all
stakeholders in a creative partnership with
shared values that will generate a shared
vision leading to policies, strategies and
cooperative programs that will promote
and support the household production of
health
Decision
process
Demand
expression

35. Engaging stakeholders in a shared vision
for a health future that everyone desires
 Are
families, the
primary
producers of
health, engag
ed by
government in
shaping the
national
health vision?

36. Millennium Development Goals
5. Reduce maternal mortality by 75 % between
1990 and 2015
Decline required to
reach the MDG
Reference: Lancet, 2010

37. Reducing Maternal Mortality -
Vision shared by whom?
 Government - Reduce MMR* by 3% a
year (75% in 25 years)
*MMR = Maternal Mortality Ratio, generally expressed
as maternal deaths per 100,000 live births

38. Let’s ask a
pregnant
woman’s
husband:
“How much
maternal
mortality would
you like? ”

39. Vision shared by whom?
 Government - Reduce MMR by 3% a
year
 Household - Zero MMR

40. Let’s ask the community:
How much maternal mortality would you
like?

41. Vision shared by whom?
Government - Reduce MMR by 3% a
year
Household - Zero MMR
Community - Zero MMR

42. Maternal Mortality - Blueprint Project Can
the community participate here?
 Strategic
objective:
 Reduce MMR by
15% in 5 years from
500/100,000 to
425/100,000

43. Maternal Mortality – Action Learning
Can the community participate here?
 Vision - No mother dies from child
birth in our community.
 Should we do it alone?
 Or with communities
 and households?

44. Health
Production
Public
Resources
A Leader is a Catalyst for
Change
The Learning Organization is the
Instrument of Change

45. Sustainable Development Requires
Action Learning
 “Development can be neither given nor
received; it must be generated from within.”
 “What the less developed have been most
deprived of is not the fruits of
development, but the opportunity to develop
themselves.”

Ref: “Systems Thinking” Jamshid Gharajedaghi