1. For the last 25 years, I have been in the global health in development business; mostly addressing it from the perspectives of health and nutrition and, short term, in over 50 countries. I have seen more than enough to look back with hindsight. The trick for me has been to do so without betraying my deep ideological convictions.

2. First of all, has it all been worthwhile? An overall balance would prompt me to say yes. But it is a guarded yes. In this business, we really operate on the ‘two steps forwards – one and ¾ steps backwards’ mode. The measuring stick for ‘worthwhileness’ has to be what is left behind after all the efforts we have witnessed in ODA. And of that that is left behind that really counts, it is the intangibles that count the most; not the half-achieved objectives of projects. Key among these intangibles is changed attitudes of some of the people who worked with me.

3. Over the years, I have mostly worked inside and through government (and international) bureaucracies. I have thus realized that rigidities in the minds and behavior of senior national cadres is inherent to bureaucracies –transcending the North/South and the ideological barriers. My experience took me from working as a long-term adviser of the MOH in Kenya to that in Vietnam, where I had hoped things would be different. But there is something intriguingly common to bureaucracies in that they abhor change with rewards rather coming from staying the course.

4. You are under pressure to move the project along, it takes you six months to assert yourself in your new position (while your coworkers are measuring you up), you experience your first frustrations of things not moving, of deadlines passing with no glory, of you increasingly taking the role of the doer rather than of the promoter and coordinator, of the project not spending funds according to plans to keep up a credible absorptive capacity, of the project bringing in short term consultants that have never been in the country and are expected in three weeks to speak words of wisdom that have never been spoken before, and so on…

5. Working on global health issues, when things do not work out the way you think they should, you try to keep your mental sanity and not to hate yourself every morning when you look at yourself in the mirror. The truth is that you get so caught up in the whirl of things that you do not take time out to look at things overall, in perspective: Is all this you do really helping? Helping who? Further, I cannot emphasize enough the advice I have for you to take every opportunity to escape the claws of the central bureaucracy to do some work in the field. It has always proven to be rewarding, a source of some satisfaction for a sense of accomplishment on small undertakings. It is the string of such small victories that keeps you in reasonable mental health, because this work does not have big victories in the realm of ODA.

6. In essence, what you have really become is another (more efficient and well paid) bureaucrat. You have learned not to take a first ‘no’ as a definite answer and know your way around to revert such a decision –you have nothing to lose, you are not putting your neck on the line. [Besides that, you have developed some relationships with one or two more progressive senior officers in the organization whom you consult and carefully use as needed. Again –in the search of some long term achievements on the fringes of the project you work in– I have found it very rewarding to establish professional contacts and long term working relationships with young faculty (in my case) in schools of public health and/or departments of nutrition or community medicine in the local university. This is always an important source of new inspiration.]

7. In your immediate working environment, things are tougher. You find that your coworkers have their own parallel agendas –as opposed to you who devote better than 90% of your time to project objectives. The project does not cater to their parallel agendas and, therefore, (no wonder) you ‘lose’ your colleagues to different degrees and get only very partial cooperation. The sad truth is that often these parallel agendas are related to their sheer everyday economic survival given their meager salaries.

8. It has been my own personal rewarding experience that you can always find at least one (young) cadre in your unit with whom you can work more closely and who is eager to learn and do with you; someone who has not yet been caught by the negative influences of the prevailing ‘system’. Seize such opportunities and develop them as intensely as you can. You will gain a strategic ally for life.

9. All projects have training components, and working in the bureaucracy, you see an array of workshops being organized for staff by many donors or by the government itself. An unwarranted faith has been placed on this entity: the workshop. Workshops are our prescription to inform and upgrade people’s skills. But although it may achieve the former, it certainly does not achieve the latter: Staff returns from workshops and goes on with their routines as if nothing had been learned. Moreover, training is atomized into different components by different single-track donors with each one doing his thing in an uncoordinated way. The result is multiple workshops for the same staff every year, with the hope that the (poorly qualified) staff will do the integration and coordination in their own heads… Failing to recognize this is costing billions of dollars around the world. People have called this epidemic “workshopitis”. As it stands, workshops are more a source of sporadic extra income for staff than of changed behaviors. No funding is thrown in to follow up on workshops’ medium or long-term impact. Donors like workshops, because money is spent and quickly written off against the budget.

10. On the other hand, institutionalized support supervision of field activities of programs and projects is virtually non-existent.
The time has come to make a bold move.

11. Continuing education and support supervision activities have to be merged. The budget available for workshops should be used instead to fund multi-disciplinarily trained support supervision teams (one by province?) to go around at least two times a year to visit peripheral units. They will stay 4-5 days in each place before moving on to the next unit; they will work with the staff in their every day chores and routines, correct mistakes, introduce new procedures, educate on the job on technical and managerial matters, on reliable information systems, etc. Workshops are to be kept to a bare minimum.

12. I have by now seen too many well intentioned, well planned, well executed, culturally sensitive, balanced top-down/bottom-up interventions in the realm of global health and development that have still failed to bring about and sustain desired changes. There are deeply ingrained flaws in the public sector staff’s system of motivation and dedication that no amount of outside intervention can affect. The truth is that, given this fait accompli, one might as well stop the farce and stop these uncertain efforts which, in a way, are costing the country double: by keeping up the bottom heavy public sector payroll and by the claim holders not being involved in any decision making. I think it will be cheaper to scrap some of the highly inefficient operations on food and nutrition in an environment of ever falling public resources.

13. With all this (…and so much more), is work on global health issues still exciting to me? I think yes. But again, a qualified yes.

14. I think the Northern model of development has, so far, miserably failed to endorse a realistic conceptual framework of the causes of preventable ill-health, preventable under- and over- nutrition and preventable deaths, because it has not had the courage to put the political and economic causes of worldwide poverty, and these preventable outcomes in the proper perspective so as to give those causes the needed priority for more determined actions. In that sense, I continue to feel guilty of being part of this system. I feel I am being instrumental in changing things just to leave them the same way. But I want to think that, over the years, I have contributed my small grain of salt to expose, demystify and correct some of the flaws of a technocratic approach to global health issues oversold (not always in good faith) for their potential impact. Much work is still needed.

15. I now settle for working on the right to health, to food, to water and to development with less grandiose expectations, not missing any opportunity to raise awareness about its contradictions, always trying to stay faithful to my ideological convictions. In this way –despite alternating between depression and (small) euphoria- every day continues to be a challenge to me.

Claudio Schuftan, Ho Chi Minh City

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