Meet our Distinguished Fellows
Distinguished Fellow, The George Institute for Global Health, focusing on Transforming Health Systems
Olive Kobusingye is an accident & emergency surgeon, injury epidemiologist, and published author. She is Director of the Trauma, Injuries and Disability programme at the Makerere University School of Public Health in Kampala, Board Chair of The Road Traffic Injuries Research Network, and co-founder of The Great Outdoors, Uganda.
Can you tell us how you came to work in trauma and injury as a clinician and researcher?
In some ways I think that trauma found me. That may seem a strange way to put it but I grew up, went to medical school, and completed my surgical training during a time when Uganda was at war - we saw trauma on a mass scale.
What I first realised as a medical student and later confirmed as a doctor was that clinical decision-making that was accessible, effective, and of a high standard could turn a patient’s life around. The team based at the Accident & Emergency Department of Mulago Hospital in those early years of my training didn't have a lot to work with; we had limited technology and shortages of almost everything. While I was working there I saw first-hand that with strong professional judgement and good clinical acumen, lives could be saved and transformed.
I got into the research side of injury work to strengthen my clinical practice. While working at Mulago, I was largely unaware that trauma and injury represented a global health burden, only discovering this to be the case when I read about injury severity measurements used internationally. These measurement tools, however, were rarely useful in the context of our health system and patients.
So I started looking at ways of tracking the burden in our area by comparing the patient’s condition when they first presented with that when they were discharged, and reporting what we did while they were under our care.
This marks you setting up a hospital trauma registry – the first in Sub-Saharan Africa. Why did you consider this to be so necessary?
Our team at Mulago started a very basic registry to answer the following questions: ‘How are our patients doing? How many have these types of injuries? How can we advocate, even at the hospital level, to have more resources coming to our department?’. The trauma registry path then led me into injury surveillance.
We found out that the World Health Organization (WHO) had some injury surveillance resources but, again, they weren’t applicable for many low- and middle-income country settings, including Uganda. To address this, I linked up with Margie Peden and other colleagues to review and develop these surveillance guidelines. This highlighted the importance of such systems; not just because they were helping me and the team in Mulago, but because there was a clear need from others across the world.
Working in this field must have been hugely intensive. What kept you motivated?
A lot of trauma patients are perfectly healthy before they are shot, or are involved in a crash, or experience significant burns – the trauma – so, as a clinician, you have a lot on your side. Seeing the destinies of so many injured patients changed by good trauma care – from being seriously injured and likely to die, to being restored to health, sometimes within hours – was very motivating. Of course, many lives are tragically lost to trauma and injury, but many are saved. I’ve found that even with basic tools and equipment, if you have good clinical skills, it’s possible to make transformative change.
I also had the chance to learn from and work alongside some incredibly inspiring people. In New York, Dr Susan Standfast taught me injury epidemiology during my Master’s in Public Health. She was someone who really put the clinical circumstances I’d experienced in Uganda into a wider context and I further understood the scale of the global injury burden and the opportunities to make a real difference to peoples’ lives.
You advise a range of policymakers on injury-related interventions at local, national and international level. Which level do you feel is most important in terms of impact?
I've had the privilege of observing closely and working at different levels. When I started out in the field of injury prevention, I founded the Injury Control Centre in Uganda. At that time we were especially focused on a multi-sectoral approach to injury prevention, so we established grassroots groups working with village health teams. I’ve also worked at the city level, looking at preventing injuries in Kampala, and I’ve been Regional Advisor to the World Health Organization, looking at what injury and violence prevention looks like across 46 African countries.
Evidently, there are different levels of awareness and response at each level. But my experience suggests that if national-level policymakers are not fully persuaded of a proposed injury-related intervention or initiative, then often what is being talked about internationally has little real impact - it just bounces off. Similarly, if you have very motivated stakeholders at a grassroots level who don’t have the support from a better-resourced group, then their efforts often don't go far.
In Uganda we have a wide variety of people who make, influence, or implement policy which represents a major governance problem – and a failure of leadership. For example, one of the nation’s biggest challenges is road traffic related injuries and deaths. We’ve presented data on this burden in various forums, aimed at getting policymakers to look at and confront the challenge – one that isn’t new to them. But no one has sufficient clout to bring the different sectors together (including those who manage the road networks, the health sector, local government, and the police) and prioritise the resource and financial commitment to such life-saving work.
What injury and trauma research or policy is most urgently needed?
Many Ministries of Health continue to invest in more traditional areas of public health because that's what they know; for instance, they will prioritise infectious disease prevention and immunisation coverage with little thought given to the prevention of road deaths. One way to address this challenge is through influencing university curricula: with strengthened injury epidemiology programmes; more robust research into injury and trauma; and effective mechanisms to translate research findings into preventive measures.
You’re also a published author. Can you tell us a little bit about your writing?
I’ve just published my second book, The Patient. It’s a story of patients, the people that look after them, and the systems in which these two groups exist. But it's also my story. I mean, I went into medicine aged 19 and here I am decades later, still dedicated to patients and answering the questions of: ‘how are we faring?’, ‘how are we helping?’, and ‘what more can we do?’. The Patient is central to what we do, and keeping people from becoming patients is what drives most of public health.
What would you like to achieve in your role as a Distinguished Fellow at TGI?
It's a big privilege because it gives me a platform to share my aspiration of strengthening the field of injury epidemiology in low- and middle-income countries. I hope that in this role I can contribute to introducing injury epidemiology and injury research in more training institutions, and take it from the point where it is considered an interesting elective, to where it is a priority area of academic inquiry and policy action.
Carolyn A. Reynolds
Distinguished Fellow, The George Institute for Global Health, focusing on Transforming Health Systems.
Carolyn Reynolds has been driving change in global health and development and US foreign policy for three decades. As well as being a Distinguished Fellow with The George Institute for Global Health, Carolyn is a Senior Associate with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS), where she is serving as an expert adviser to the CSIS Commission for Health Security. She is also a consultant to the World Bank Group and other international organizations.
Until January 2019 Carolyn served as Vice President for Policy and Advocacy at PATH, an international non-profit organization supporting health innovation in developing countries. At PATH, she led a team of more than 40 staff across seven countries to shape evidence-based policies, strengthen partner advocacy capacity, and mobilize public and private resources to improve the health and well-being of people in low-resource settings across Asia and Africa. In this role, she served as PATH’s principal representative to the US government and multilateral organizations, and she led a successful effort to increase US support for international epidemic preparedness.
Prior to joining PATH, Ms. Reynolds was a senior adviser and manager for external and corporate relations at the World Bank Group. In this role she led the Bank Group’s strategic communications and policy advocacy efforts in global health, education and human development, including to mobilize the international response to the Ebola crisis in West Africa in 2014-2016 and to increase political support and financing for universal health coverage and education for all. In earlier positions, she also shaped and led the expansion of the Bank’s global engagement with civil society organizations (CSOs) around the world.
Previously, Ms. Reynolds also was managing director for the US Global Leadership Campaign, where she led a successful issue advocacy campaign to elevate global health, development and “smart power” as priority issues during the 2008 US presidential election. She also directed advocacy and legislative efforts for InterAction, the association of US-based international humanitarian and development CSOs, and she served as legislative aide and acting Africa subcommittee director for the late US Senator Paul Simon (D-IL). She started her career in international development as a volunteer teacher in rural Kenya with WorldTeach and working on a USAID-funded project to facilitate partnerships between US and African CSOs.
Ms. Reynolds holds a Master’s in International Affairs with a concentration in Economic and Political Development from Columbia University and a Bachelor of Arts with a major in Foreign Affairs from the University of Virginia. She lives in Washington, DC with her husband and two daughters.
Juan Angel Rivera Dommarco
Distinguished Fellow, The George Institute for Global Health, focusing on Promoting Healthy Environments.
Dr Juan A. Rivera is General Director of the National Institute of Public Health (INSP) in Mexico and Professor of Nutrition at the Mexican School of Public Health.
In addition to the above, Dr Juan A. Rivera is Executive Board member of International Association of National Public Health Institutes (IANPHI), member of The EAT-Lancet commission, member of the National Academy of Medicine of Mexico, member of the American Society for Nutrition and, Board Directors´ Member of the Pact for Early Childhood. Also, he has been President of the Latin American Society of Nutrition (SLAN), he was founding director of the Center for Nutrition and Health Research at INSP, member of the World Obesity/Public Prevention Steering Committee and, member of the High Level Panel of Experts on Food Security and Nutrition (HLPE).
Juan Rivera PhD received his master´s degree and PhD in International Nutrition from Cornell University, Ithaca. His lines of research are epidemiology of malnutrition in all its forms, study of risk factors of malnutrition, evidence generation to guide the design and the evaluation of policies and malnutrition and, obesity prevention programs as well non-communicable diseases.
At present, he has more than 490 Scientific Publications (287 scientific articles, 136 book chapters, 67 books), he has made more than 690 presentations and conferences in national and international scientific events and, his work has been quoted in more than 19,100 times in different scientific journals around the world.
Distinguished Fellow, The George Institute for Global Health, focusing on Promoting Healthy Environments.
Dr Saxena is a psychiatrist by training, and past Director of the Department of Mental Health and Substance Abuse at World Health Organisation.
His work has involved evaluating evidence on effective public health measures and providing advice and technical assistance to ministries of health on prevention and management of mental, developmental, neurological and substance use disorders and suicide prevention, establishing partnerships with academic centres and civil society organizations and global advocacy for mental health and substance use issues.
Dr Saxena led WHO’s work to implement the Comprehensive Mental Health Action Plan adopted by the World Health Assembly in May 2013, scaling up care for priority mental, neurological and substance use disorders.
What drew you to psychiatry as a profession at the outset?
I was attracted to psychiatry within the first few months of starting my medical degree in 1973. It fascinated me, because it went beyond the physical attributes of a person and involved higher functioning of brain, including cognition, emotions, and much more importantly, people’s behaviour. I saw psychiatry as a subject with lots of exciting developments in the coming few decades, which has turned out to be right.
What have been the main changes that you have seen in the past 40 years working in the field of mental health?
Mental health has changed enormously in these 40 years - it has come out of the shadows! It was a subject that was not talked about or recognized as an important discipline within the health and medical area. But now it is. Knowledge on mental health was very rudimentary, now it is much better. Understanding of the causation of mental illnesses, as well as the range of effective treatments, has improved a lot.
There is also an increasing convergence of various areas of scientific discipline related to mental health. The neuroscientists are now contributing much more to understanding mental disorders. Social scientists are working very closely with the mental health professionals to understand human behaviour, and how sometimes it can be maladaptive and abnormal. Clinical scientists are working on finding out the most effective treatments for mental disorders. Psychotherapy specialists are finding out newer ways of delivering psychotherapies. Pharmacologists are working towards finding out newer medicines for mental disorders. And finally, there are people who are working in the public mental health area to aggregate all of this information, and make a change in the policy and service delivery to reach people who need help.
When I started clinical work, mental health was still stigmatized. Only people with severe mental disorders would come for clinical care and often after much delay. There was misinformation. Mental disorders were not recognized as valid disorders or the domain of doctors to treat. During my career in mental health, I have seen a major change. People are now more inclined to take help, and much earlier. The stigma still remains, but is less.
In the 20 years that I worked at WHO, I witnessed the public mental health scenario also changing substantially. Earlier, policy makers in many low and middle-income countries would not acknowledge that they had a mental health problem in their country. It was seen as a problem for “the highly developed countries”. They also felt they didn’t need to tackle this issue because they viewed it was the responsibility of families to look after people.
The increasing understanding of public mental health means it is now seen as an important area of public health planning. Ministers of Health not only unanimously agreed with the Mental Health Action Plan of WHO in 2013, but also started asking for more guidance to implement it. Over the years, I have worked alongside my colleagues in many countries to help establish effective evidence-based, community mental health systems.
Mental health is in a much better shape than one could have imagined 40 years back. However, it still remains one of the most challenging areas for public health policy, and the amount of resources that are going into it are a very small fraction of what is needed. Understanding of mental health among policy makers has improved, but their actions are still not commensurate with the large and increasing needs.
What role do different stakeholders play in shaping mental health policy?
Mental health is an area that requires a large number of stakeholders working closely together. At WHO I had an opportunity to work with government ministries of health as the primary partners, alongside academic institutions, to stimulate public health oriented research, distil research findings, and use them for policy planning and service development.
Another important stakeholder in the mental health field is the civil society; NGOs and civil society can use scientific information and evidence-based guidelines like WHO’s mental health Atlas and mhGAP to advocacy and influence the government policy. I have found interacting with civil society, and especially people with lived experience of mental disorders to be a very rewarding and gratifying experience. Their voices sometimes made far more impact than the efforts of research centres.
Is there a treatment gap?
In spite of this major progress, the gap between what is needed and what is available, is a still very large. The vast majority of people in low and middle-income countries who have a mental disorder are not able to access any help. Even in highly developed economies, almost 50% of people who have depression are not able to get professional help. No other health condition has that kind of treatment gap and the disparities exist not only in low and middle-income countries, but also in high income countries. That's why I say that when it comes to mental health, all countries are developing countries. Some are a little ahead of others, but they all have a lot to do to advance mental health for their citizens. Disparities also exist within communities, and within urban and rural areas, particularly between the rich and the poor. Trained mental health care providers are missing almost completely from rural areas in some countries, so people have to travel 200, sometimes 500 kilometres to access mental health care. Many people are unable to do this because of financial, or other reasons.
What tools and resources are available to assist in decreasing the treatment gap?
The mental health care system is starved of human and financial resources. Although it is improving, improvements are taking time. Mechanisms to help strengthen mental health care system are extremely important. One of them is to use primary health professionals such as general doctors, general nurses, as well as community health care workers, to assist in identifying and treating at least some of the basic mental health disorders. They can identify and treat the majority of mental disorders at least at a very basic level.
The mhGAP package developed by WHO provides very useful information about how to train non-specialist providers, in identifying and treating mental, neurological and substance use disorders. It has been successfully used in more than hundred countries and proven to be a very useful tool to increase the capacity of mental health care system to deliver care.
The second innovation is the use of technology, which can help in a variety of ways. It can deliver information, and sometimes even care, directly to people. Using websites or mobile phone apps people can access care when there is no health care worker around. Technology can also help in training primary care providers, wherever they are, in identifying and taking care of mental disorders, as well as in collecting useful information, which can be used by the health care system to improve care.
What else do you see as key drivers of change in the near future?
One of key drivers for change is the rise in number of people with lived experience of mental disorders in leadership roles, reinforcing ‘it should be nothing about us without us’. This is transforming the whole discussion around mental health. Every policy initiative, every change in the way services are organized, and every new treatment needs to have inputs from people and families who have experienced mental health issues in their lives. This is happening increasingly and it has the largest potential to make a positive change, but there is still a lot of ground to cover.
You have dedicated your career to championing the cause of mental health. What drives you?
What drives me is the fact that the needs are very high in mental health; it is one of the areas where people have suffered in silence for a long time. The support and encouragement from colleagues from all over the world, from very diverse backgrounds, motivates me to continue to work in this area. Now that people are willing to work together, there is a chance to make a real difference.
Distinguished Fellow, The George Institute for Global Health, focusing on Transforming Health Systems.
Göran Tomson is a Professor of International Health Systems Research, linked to Medical Management Centre (MMC) at the Department of Learning, Informatics, Management and Ethics (LIME) at Karolinska Institutet. He is a Counselor UN Agenda 2030 at the President’s office at KI. He is a co-founder and a Senior Advisor at the Swedish Institute for Global Health Transformation (SIGHT) at the Royal Swedish Academy of Sciences, and Co-founder ReAct the international network to contain antibiotic resistance, responsible for coordinating the work that led to the Alliance for Health Policy and Systems Research now at WHO.
Göran’s extensive research and policy work focuses on universal health coverage and has been conducted in countries such as China, Kenya, Lao PDR, Sweden, Tanzania, Uganda, Vietnam, and Zambia and his experience in the field of health policy and systems research has led to his appointment to various organizational committees. He has a major interest is in capacity building (institutional and individual), and has supervised 40 PhD students.
Tell us a bit about your background and current roles.
I carried out my professional medical training at the Karolinska Institutet (KI) in Stockholm where I am now senior counselor at the President´s Office on the UN Agenda 2030, and professor in international health systems research. Further, I am currently senior advisor at, and co-founder of SIGHT (Swedish Institute of Global Health Transformation) at the Royal Swedish Academy of Sciences, Stockholm and visiting professor at Shandong University, China.
What led you to become interested in health systems?
When I started working as a paediatrician at a university hospital in Stockholm I was unaware of the importance of socioeconomic factors for children´s health and well-being. Practicing as a paediatrician was part of a gradual awakening for me. At the time I was doing research on trans-placental passage of meperidine (passage of the medication meperidine, used for pain relief, from the mother to the foetus through the placenta). Increasingly, my interest turned to individuals, the health system and public health. In part, this was as a result of being influenced by my mother´s solidarity with those less fortunate; but I was also becoming increasingly aware of appalling inequities globally.
So my PhD studies instead combined anthropology, epidemiology and pharmacology to better understand the use of the most popular element of health systems – medicines. My field work was carried out in Sri Lanka. From there onwards my area of expertise was what was then called international health (now global health). Health systems research, and in the beginning particularly the rational use of drugs (medicines), became a specialty of mine. Gradually, my interest widened to include the complexity of health systems with its subsystems (Fig.1 in my blog ) - especially interventions to ensure universal health care of good quality with a focus on Low and Middle Income Countries (LMICs).
You’ve been working in health systems research for over thirty years. When you look back, what are some of the highlights?
There are many. I have been fortunate to work with great individuals. Between 1995 and 2015 I led the Health Systems and Policy research group at KI, assessed as outstanding in an external evaluation in 2010. A special interest has been individual and institutional capacity building, and it has been my privilege to supervise and learn from 40 PhD students from all over the world. Many of them are now full professors, directors of research and deans of institutions. A former postdoc is now head of health at UNICEF in New York.
Between 1992 and 2002 I led a large national drug policy programme in Lao PDR (then one of the poorest countries in the world) financed by Sida - the Swedish development assistance agency. When the Lao government sought help they had identified self-medication and proliferation of substandard or fake drugs as their main issues. With the help of small scale health systems research projects it was possible to identify other problems in need of a more comprehensive approach. In a remarkably short period of just one year a completely new drug policy was formulated and adopted (published in the Lancet). The policy formulation was a domestic affair with ten ministries. A drug law, a quality control centre and treatment guidelines were some of the deliverables. After a while it became evident that the implementation of the policy did not proceed as expected. To enhance the process in a context sensitive way, health systems research training was introduced as an element in the policy. My KI team led a process to train researchers, policy makers and practitioners in priority-setting, identification of issues and methods of implementation, as well as data collection and report writing. Themes included the rational use of drugs, the effects of regulation on private sector performance, and quality of drugs. The minister of health at the time acknowledged that the strengthening of human resources and the development of institutions and health systems research facilitated more evidence for informed policy and decision making. The Lao experience is among the more gratifying professional processes I have been involved in.
Networking has been another special interest of mine. This can unite people, harness their ideas, and energise and mobilise them for activities in need of attention. Representing Sweden has its advantages given its history of engagement globally. Together with visionary change agents globally I have tried over the years to ‘challenge lazy orthodoxies and aspire to be a disruptive innovator’, as Richard Horton wrote about myself and the other co-founder of SIGHT in a Lancet commentary in 2017.
Networks and alliances I have co-founded (in one case coordinated preparatory work - AHPSR) in areas then receiving little attention are set out in the table below.
|INRUD - International Network for Rational Use of Drugs||1991||INRUD focuses on LMICs|
|AHPSR - Alliance for Health Policy and Systems Research||1999||I coordinated the preparatory work in 1997 and have since 2002 served in various roles on the Scientific Technical Advisory Committee. Hosted by WHO Geneva.|
|ReAct - The International Network to Contain Antibiotic Resistance hosted by Uppsala University, with regional hubs||2005||See www.reactgroup.org|
|EVIPNet - Evidence Informed Policy Network at WHO HQ, with regional hubs||2005|
|SIGHT - Swedish Institute for Global Health Transformation at the Royal Swedish Academy of Sciences||2017||See www.sight.kva.se and GI SIGHT video.|
Tell us about your work with the WHO Alliance for Health Policy and Systems Research (AHPSR).
In 1996 The Ad Hoc Committee on Health Research Relating to Future Intervention Options identified health systems research as one of four priority areas. The Norwegian and Swedish governments were commissioned to explore this and I was asked to coordinate a small working group paving the way for what became the Alliance for Health Systems Research, which became operational in 1999. In its 20 years of existence, the Alliance has risen to the burgeoning demand for evidence on health systems strengthening, by shepherding the growth of the health policy and systems research (HPSR) field through the production of definitive methodological texts and materials and the creation of a vibrant community of partners and grantees, particularly research institutions and ministries of health in LMICs. The small secretariat has for many years been hosted by the WHO at its headquarters in Geneva.
The Alliance has heralded a shift away from passive knowledge production in the arena of health systems to catalysing demand and use of knowledge by health systems decision makers, by engaging them in setting research priorities, co-producing research, and institutionalising knowledge use for health system improvements. The multi-disciplinary nature of the work is emphasised. Key deliverables over the years include the Flagship report Systems thinking for health systems strengthening, The Reader in Health Policy and Systems Research and since 2010 co-organising the Global Symposium on Health Systems Research every second year. One of the most significant factors driving the HPSR field has been the recognition of the importance of strong and resilient health systems - the Ebola crisis being just one of many examples. An issue has been the presence or absence of the ‘P’ in HPSR. From the start, even in the planning phase of AHPSR, it was considered important to include the ‘P’, underlining the close link between research and policy as well as the importance of doing research not only for but also on policy. The focus of the work is on LMICs but increasingly some products are also being used in HIC institutions.
To summarise, the Alliance objectives are to:
1. provide a unique forum for the HPSR community;
2. support institutional capacity for conduct and uptake of HPSR
3. stimulate generation of knowledge and innovation to nurture health system learning and resilience; and
4. increase demand and use of knowledge for strengthening health systems.
What does it mean to be a Distinguished Fellow at The George Institute?
Firstly, reconnecting - I was invited to Australia three times during the early 90s, twice to Sydney in conjunction with the launch and implementation of the Australian pharmaceutical policy, at that time arguably one of the most dynamic in the world. I much appreciated the ambiance, openness, pioneering spirit and creativity. I hope to experience the same in the interactions with The George Institute now dealing with global health, including health systems. Secondly, the Fellowship gave me an incentive to look back and try to summarise my professional trajectory - something I would not have done otherwise. I am humbled by what I have been part of, and understand that as much as I am an academic I am also an entrepreneur and “builder” who has been fortunate to see windows of opportunity in partnering with outstanding professionals. The UN Agenda 2030 with its SDGs and targets aims to transform the world for sustainability. The Academy must contribute, as must SIGHT. To have something meaningful to aspire to is a blessing. I hope to learn and contribute further here in partnering with The George Institute, including leveraging my networks.
By the way, Göran is Swedish for George.
Distinguished Fellow, The George Institute for Global Health, focusing on Promoting Healthy Environments.
Corinna Hawkes is Professor of Food Policy and Director of the Centre for Food Policy at City University of London, Vice Chair of the London Child Obesity Taskforce established by the Mayor of London, and serves on a variety of international initiatives. Between 2015-18 she was Co-Chair of the Independent Expert Group of the Global Nutrition Report, which tracks progress on addressing malnutrition in all its forms.
You wanted to be a politician when you were younger and your PhD in geography focused on environmental change, so how did you end up working in food policy research?
After my PhD, I wanted to do something more people-focused. I went to Los Angeles for a few months after I got married, and I discovered the wonderful local farmers’ markets. Not only that, but I found there was a movement of people actively engaged in trying to improve the food on their plates. I’d grown up with a progressive mother passionate about good food, a love of cooking myself and a long-standing interest in the science of food (I idolised my great-grandfather, who had won a Nobel Prize for his contribution to the discovery of vitamins). All of this came together in my mind, and I realised I had found my passion and resolved to do something about it.
What keeps you motivated?
For me, food is something to be relished and enjoyed; it’s part of our social fabric. However, millions of children around the world live in poverty and consume dull, monotonous diets. Others enjoy eating (too many) sugary, fatty and salty foods – but then they get sick. I believe the world would be a better place if everyone gained health and happiness from eating well. It’s a tough nut to crack, though, and I often contemplate how little we have moved in that direction. I am driven by wanting to find out how to design actions that will really make a difference to people’s lives and change how they eat for the better. If we fail, we learn, and then we try again.
On a personal note another intrinsic motivation was my mother, who died when I was 18. When I was discovering food, I realised how deeply I was affected by the fact her beliefs about the importance of good food were never listened to. She cut an isolated figure, for example, when she complained about the food in my schools. As a result, I am constantly motivated by wanting to give her the voice she never had. That’s pretty motivating.
What does the latest Global Nutrition Report tell us?
The Global Nutrition Report 2018 focuses a lot on diets. It’s a pretty dismal picture. Globally, the proportion of babies who are exclusively breastfed up to 6 months of age is 41%, and sales of infant formula are growing rapidly. Regardless of wealth, school-aged children, adolescents and adults are eating too many refined grains and sugary foods and drinks, and not enough foods that promote health, such as fruits, vegetables, legumes and whole grains. For example, 30.3% of school-aged children do not eat any fruit daily, yet 43.7% consume soda every day. Meanwhile, analysis of over 23,000 packaged food products shows that 69% are of relatively poor nutrient quality, with the proportion higher in lower income than high-income countries.
These are diabolical findings and show that food policies need to do so much more. They must be effectively designed to ensure the system that produces our food is incentivised in the right way and that people have support to eat well.
That said, there is some good news; more and more countries are requiring front-of-pack nutrition labelling, legislating on sugary drink taxes, and taking actions to reduce trans fats and salt. And, crucially, these actions are proving effective.
You advise a range of policymakers on diet-related ill health, at city, national and international levels. Which level do you feel is most important in terms of impact?
To be honest, all of them; they’re all interconnected. At the city level, I’m really enjoying my work as Vice Chair of the Mayor of London’s Child Obesity Taskforce, which brings me closer to the people affected by the problem, as well as to those decision-makers who can make a difference. The work I do with policymakers at the national level feels more top down, but is fundamentally important because it’s where the national direction is set, as well as decisions about population-wide policy applicable to all citizens.
Then the international – and global – level is important for two main reasons. First, we need frameworks, political statements and technical guidance at a global level where there are issues relevant to the whole world. This was one of my objectives in establishing the NOURISHING Framework for policies for healthy diets, when I was working at World Cancer Research Fund International. Second, engaging at the international level is a means of inspiring and sharing lessons. For example, I am excited by the various city networks that have been established around food and health.
What do you think are the biggest challenges policymakers face in addressing rising levels of obesity?
The biggest challenge is that the policies designed to address obesity come up against two pretty major conflicts: our current economic model, and the reality of people’s lives.
Our prevailing economic model creates incentives that contribute to obesity. All food companies, no matter their size, compete with each other to attract custom. These competitive dynamics are at the heart of the problem and create a lock-in, preventing crucial change.
These dynamics would not be so powerful if it weren’t for the reality of so many people’s lives. What’s the use of supplying delicious, nutritious foods if people cannot afford them? Or if they lack the spaces to cook, or the skills to do so? People then develop unhealthy habits and preferences that keep them locked in.
What food policy research or data is most urgently needed?
If we are going to shift the needle on diets, there are four areas we really need more work on. First, we need to identify policies that can help create healthier food economies and healthier business models. Second, we need to understand people’s lived experience of food in a way that can help us design people-centred solutions that work. Third, we need to test these solutions in cities, to see if they are effective and equitable. And finally, we need to ensure policies are consistent and coherent throughout the food system in supporting these changes.
For me, all this comes together in urban food environments. When I started working very proactively in food systems, I realised that changing how people encounter the food system – which is where we shop and acquire food in stores, restaurants, schools, urban gardens etc. - is potentially a very powerful lever for change.
Taking a people-centred approach to urban food provisioning (where people acquire food in an urban setting) means understanding how people live their lives and their feelings around food, identifying the viable business models that cater to this and then figuring out if we have policy frameworks that incentivise change in a consistent way. I am interested in exploring this much more proactively, from the local to the global.
What would you be doing if you hadn’t moved into food policy?
If I were to be doing something other than food policy, I’d have set up a bookshop with my husband, with a little café attached where I’d take on the role of cook and business partner. I know what a tough job that would have been, though!
Rajani Ved is a medical doctor with public health training and is also the Executive Director, National Health Systems Resource Centre in New Delhi, India.
Your career spans more than three decades. Can you give us a snapshot?
The early part of my career was spent providing community-level clinical care both to Self Help Groups of women and providing services to the general community. I worked with NGOs, international agencies, including donor agencies, and government. For nearly a decade now, I have been working with the National Health Systems Resource Centre (NHSRC), established by the Ministry of Health and Family Welfare, where my role has been to work with state- and district-level health systems and strengthen implementation through program reviews, capacity building, and mentoring and enabling responsive policy adaptation and formulation.
I’ve been fortunate that for quite a lot of my career, I have worked extensively with NGOs and therefore directly with communities. This, I believe, has stood me in good stead in what I do now, because I try to bring a people-centred approach to what I do. The last few years have been much more at a policy level, but there are enough opportunities here that enable me to link ground reality with policy change.
You have worked in many areas of primary healthcare. Are there any projects that stand out to you?
Around 15 years ago, through a MacArthur Fellowship, I received a grant to test delivering a package of reproductive health-related knowledge and skills to women organised in groups as part of micro-credit programs. The women were more interested in micro-credit and employment generation than hearing about messages/content around reproductive health. So I had to design an intervention that was acceptable to the women and the very limited time that they had for themselves. In the span of a year, from spending an hour a week with them, I managed to get about 15 women’s Self Help Group leaders to spend two days every month with my team and I in a residential camp, talking about their day to day lives and how health impacted themselves, their families, and livelihoods. I understood that unless we were able to deliver health messages to them in ways that enabled action in their lived reality, most of this knowledge was superfluous.
It was also here that I understood how information was enabling – particularly how information on health entitlements, based on a good understanding of services and rights, could be effectively converted into demanding accountability from the health system. This was the case for the women who were already empowered as a result of being part of the Self Help Groups. I think my best moment was when one of the women who I had worked with demanded that a gynecologist in a district hospital actually examine her more thoroughly in a way that used some of the technical language we’d covered.
You know, when we talk so much about health promotion and putting health in people's hands, we don't really look at their everyday lives. I think these women gave me the grounding to understand how health systems should approach women’s health and this laid the foundation for my work with community health workers, which is the other thing I’m really passionate about. My time in NHSRC has taught me much about how to grow such programs through capacity building, onsite mentoring and just, and rightful payment mechanisms. I like to think these two experiences would rank as my most valuable learning and perhaps my most significant contributions.
How transferable are community health worker programs, known as ASHAs, to other low- and middle-income countries?
I certainly think they are transferable because almost all the situations in India would be applicable to other low- and middle-income countries. In India, we have implemented ASHA training at scale, systematically developed guidelines and standards, devised certification programs, created incentive systems, supportive and supervisory mechanisms, and enabled integration into health systems, creating the institutional mechanisms to run community health worker program at scale, and I think those are very relevant to other countries.
What are some of the challenges in scaling up community programs?
I will give you an example of an NGO pilot in Western India for a home-based newborn care intervention involving community health workers who were trained in home-based newborns, including asphyxia management, sepsis management, provision of injectable antibiotics, and of course a host of other home care behaviours. This was approved by the Government for inclusion into ASHA training, given our high newborn mortality rate in 2011.
It was a fairly intensive program and we realised it required a lot of hand-holding support of the workers and supervision. Some of our ASHAs were low-literate or non-literate so we needed to make sure that their training was of very high quality and focused more on skill than on didactic knowledge. We also had to provide a regular medicine kit, as well as ensuring their credibility, both in terms of knowledge and skills and also in terms of connection with the larger system and structures. I think that was essential for the community to be accepting of them in taking care of their newborn babies.
I can by no means say that we achieved the results of the small-scale project because in large-scale implementation, particularly of models that are process-intensive and complex, quality and supervision tend to be compromised. To overcome some of these challenges we made several adaptations - splitting training into modules so that trainers met more often with ASHAs, providing them with some handholding, reducing the components of the intervention, building a supervisory cadre, linking newborn care to a monetary incentive, etc. I would say that just under half the ASHAs are now contributing to newborn care, but this needs to be viewed from the perspective of scale.
What role does digital technology play in improving primary healthcare in India?
There is a lot of emphasis on the use of digital technology from policy makers as in India we are moving from selective healthcare to comprehensive care. There are several potential uses. The first and most basic is population numeration, and empanelment – or understanding where people live in proximity to Health and Wellness Centers, which provide the first level of care. Other uses of digital applications include recording patient data, use in population analytics, reporting on prevalence and control, especially for chronic diseases, use in decision support systems, telemedicine/teleconsultation, etc.
Of course, part of this is providing ASHAs with smartphones so that they have the population data in their phones linked to the facility level, and then to primary health centre records. We are moving in that direction but internet connectivity is a problem in about 20 to 25 percent of the country. Also, ASHA workers are dealing with complex chronic diseases now and they need to be much more highly skilled, have much more hands-on training and have higher literacy levels. In areas where they have been trained to use smartphones, they have adapted remarkably but here one is talking about ASHAs who already have higher literacy levels.
In this fellowship you want to focus on women’s health, can you tell us more about the focus of your work?
For my fellowship I’d like to focus on non-communicable diseases among women, particularly related to their understanding of and access to care, and increasing provider sensitivity to women’s health issues.
Most of my work has been in an environment where we have implemented selective primary healthcare, especially for women, limited to pregnancy and delivery. Access to care for NCDs amongst poor women is a challenge, because women from lower-ranked socioeconomic classes in India have much less access to healthcare than their counterparts who are richer, belong to the upper class and who live in urban areas. Poverty and lack of access affects every part of their life, not just maternal health. My concern is that we don’t have much experience dealing with women with chronic diseases, much less among poor women in rural and urban areas. We hardly know anything about their risk of stroke, cardiovascular disease, kidney disease etc. There is a real lack of information and research in this area.
We need to use some of those lessons that we have already learned about accessing marginalised and vulnerable women and transfer the learning to implementing a chronic disease program. Finally, I have a new found interest in the challenge of mulitsectorality. Care for chronic diseases will have to involve all sectors, it's not just the health system alone. It’s about improving sanitation, nutrition, livelihoods, and other areas that pose challenges to the health of women. It’s far more complex than anything that we have dealt with in the past and we don't have either the institutional structure or the program experience. These are the areas I am interested in working on during the fellowship.
Professor Trish Greenhalgh is our inaugural Distinguished Fellow and has a focus on Transforming Health Systems.
Trish Greenhalgh is also Professor of Primary Care Health Sciences at Nuffield Department of Primary Care Health Sciences at the University of Oxford.
What inspired you to work in health research, and what keeps you motivated?
I think I’ve always had a ‘research brain’. Even at my university interview back at age 17, I was asking the interviewers more questions about their research than they asked me! Research is the systematic search for new knowledge. Whether qualitative or quantitative, research is characterised by careful selection of the appropriate methods to answer the question posed, rigorous application of those methods to the highest standard achievable, reflexive awareness of the possibility of error, and measures taken to minimise and take account of error. I guess what keeps me motivated is the excitement of discovery. And by that, I don’t mean dramatic Eureka moments but the more incremental enlightenment we get as we deepen our understanding of complex phenomena.
If you hadn’t gone into health, what would you have done instead?
If I hadn’t been accepted for medicine, I would have kept applying until I got in. I wanted to be a doctor from age three. I never had a Plan B.
What do you see as the most pressing goals for public health?
The 17 Sustainable Development Goals announced last year by the United Nations are pretty good. One, “good health and well-being”, is explicitly about health; the other 16 e.g. “end poverty”, “reduce inequalities”, “reduce climate change” are all health-related in some way. I think those of us who are interested in the strategic direction of public health are shifting from single-issue approaches to a more ‘health in all policies’ mindset. I once heard Sir Andy Haines give a brilliant lecture on planetary health; he talked about how he’s working increasingly with zoologists, soil scientists and other experts outside health to try to address global challenges.
When do you think health initiatives work best and can you give an example?
Health initiatives tend to flop when they’re too narrowly conceived, e.g. not sufficiently interdisciplinary, and when they fail to take account of context and practicalities. Indeed, I worry about the medical mind-set whose basic script is the ‘drug for a disease’ model. Physician researchers over-use randomised controlled trials – which focus the analysis on demonstrating internal validity (‘can it work’) at the expense of external validity (‘is it going to work here?’). Yes you’re right that research, advocacy and policy need to come together, but I would also say that these streams of activity need to co-evolve from the outset so that – for example – the researcher is writing the grant application with a clear and respectful idea of where the policymakers and advocates are coming from, and that research as it unfolds takes continual account of its intended end-users, ideally through ongoing, cross-sector dialogue.
Here’s an example. My team have been doing a series of studies, mostly secondary research and modelling, on how best to prevent type-2 diabetes through both individual and population measures. We worked from the outset with local policymakers, and also from an early stage, national policymakers to shape the questions we were asking. They told us that they found existing systematic reviews unhelpful because the questions posed were of academic interest but did not tell them for example which options were likely to be affordable, given local contingencies. Our recent publications, and more in the pipeline, have been tightly focused on providing the kind of answers that policymakers will find useful. See for example:
- Efficacy and effectiveness of screen and treat policies in prevention of type-2 diabetes: systematic review and meta-analysis of screening tests and interventions.
- Preventing type-2 diabetes: systematic review of studies of cost-effectiveness of lifestyle programs and metformin, with and without screening, for pre-diabetes.
- Economic evaluation of type-2 diabetes prevention programs: Markov model of low- and high-intensity lifestyle programs and metformin in participants with different categories of intermediate hyperglycaemia.
What recent research excites you and why?
I love Richard Osborne’s work on health literacy. He’s extended the term ‘health literacy’ from the narrow meaning of 'can the person understand medical terms', to a much broader meaning that embraces capacity to access care - including such things as ability to navigate the system, social support, digital access/literacy and what I’d call self-advocacy - and various additional dimensions of being unmotivated, downhearted and downtrodden. These of course relate to the traditional social determinants of health such as poverty and social exclusion. In the OPHELIA project, Osborne’s team have developed high-quality survey instruments to assess these wider aspects of health literacy in a particular community and use those to target different aspects of service development and community support. See for example:
- Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia)
- Optimising health literacy and access of service provision to community dwelling older people with diabetes receiving home nursing support
- Measuring health literacy in community agencies: a Bayesian study of the factor structure and measurement invariance of the health literacy questionnaire (HLQ)
- Distribution of health literacy strengths and weaknesses across socio-demographic groups: a cross-sectional survey using the Health Literacy Questionnaire (HLQ)
What would you like to see come out of your work with the think tank?
I’m keen to develop some ideas on system-level change and what we might do to complement and/or replace the dominant randomised trial approach. Don’t get me wrong – I owe my life to randomised trial research and I believe these designs have a crucial place in healthcare. But I think The George Institute for Global Health is now at the stage where it’s asking what other methodologies might be helpful in addressing global grand challenges, and how can we apply these appropriately. One of my specific interests is large-scale IT projects and why they so often fail or, if they don’t fail completely, why they so often don’t achieve the benefits anticipated. Whilst I’d be happier studying successful IT projects, I think we’ll have plenty of material to chew on as we consider why some of the tech initiatives funded by The George Institute in recent years have been partial rather than unqualified successes.
Michael Moore AM
Michael Moore is Adjunct Professor at the University of Canberra , Visiting Professor at the University of Technology Sydney, is the former CEO of the Public Health Association of Australia and the Immediate-Past President of the World Federation of Public Health Associations.
You started out as teacher, what prompted your move to politics, and then onto public health?
I fell into politics really, trying to attempt to keep the major parties under control with regard to planning issues, like many of us do. Not realising even at the time that planning issues were really also public health issues. And when I got elected, I thought what am I going to do? I'm only here for one term. Who is it that the major parties are not looking after? And I decided to focus on the most vulnerable in society.
What achievements are you most proud of during your career in politics in the ACT with the Public Health Association of Australia, and the World Federation Public Health Associations?
During my early days in the ACT Legislative Assembly we achieved the decriminalisation of cannabis and the legalisation of prostitution. On the prostitution issue, the thing that was different about our approach was that we decided that we were going to empower the sex workers – and this was unusual thinking in the early nineties. Others working on the issue were trying to put controls in place. At the same time I was suggesting that we needed to provide heroin to dependent users and worked with the National Centre for Epidemiology and Population Health to get that proposal up in a sound academic way as a medical and scientific research project. It was very important in terms of changing discourse.
The other thing that I'm particularly proud of nationally is turning the Public Health Association of Australia (PHAA) around to an organisation that really has impact. I had previously left the Public Health Association because I thought it had lost its ability to work across governments, and therefore was not having much influence at all. Of course, it was a huge advantage to understanding how politics works. As President of the World Federation of Public Health Associations (WFPHA) and of the PHAA, I was able to facilitate the building of support groups for young professionals. I've also been a catalyst for the implementation and establishment of the Indigenous Working Group of the WFPHA.
What do you think can be done to improve the Australian healthcare system?
Globally, we're doing quite well and the best indicator, or the easiest indicator of it, is longevity. We're amongst the highest in the world. But when you look at the socioeconomics and the distribution of wealth as a determinant of health it is clear that the distribution is anything but even. The most obvious weakness is in the health outcomes of Aboriginal and Torres Straight Islander people, who have around a 10-year gap in life expectancy. However, Australia’s lack of expenditure on prevention, health promotion and protection has been reduced while there is a focus on hospital and treatment. The most important element, or the first thing we should be doing here is taking prevention, protection and health promotion away from the tight control within the political system. This could be achieved with an Australian Centre for Disease Control, which would help set out what are the highest priorities for prevention.
As a Distinguished Fellow, you will be focusing on the food policy aspect of Promoting Healthy Environments. What do you see as the most important measure that can be implemented to help tackle the obesity crisis?
Sometimes it is really obvious what people should be doing and they're not doing it. I'll use a specific example, the sugar tax. It's really obvious that we should be implementing this policy like many other countries in the world. We know what the evidence is - it's really clear. But on the other hand, we also know that we've got a government that's has just lost its one-seat majority. So you have to understand that getting a sugar tax might take some more time as some sugar seats are marginal seats. But, you never let anything go. Rob Moody, professor of Public Health at Melbourne University, says there are three P's in advocacy - persistence, persistence, and persistence. I think that's the issue. I don't think it's a question of whether or not we have a sugar tax - it's just a question of when.
What do you think you can bring to The George Institute that will benefit people not only here but globally?
I am doing a PhD on advocacy right now which I'm hoping to finish in the next three or four months. I think that's something that I can add to the area of knowledge. It's not just the experience that I've had inside government and outside government, but also because I'm interested in understanding how advocacy works. I've made considerable effort to keep up with the reading to understand what other people are doing and how to carry out advocacy most effectively locally, nationally, and internationally. We need organisations like The George Institute, and the people that work within it, to take leadership and persist until we are able to make things happen.