Discussants: Laura Tomm Bonde, Angelina Wilson, & Gabriel Oguda
As many may already know, ISECN launched its first “topic” group in September 2011, focusing on “Health promotion in Africa”. We published our first reflection piece in ISECN’s 2012 March HPC. The following reflection article is a result of our second meeting during which we discussed the article “Scaling up health promotion interventions in the era of HIV/AIDS: Challenges for a rights based approach” by Mickey Chopra & Neil Ford . In the paragraphs that follow this introduction, we will briefly summarize the article and the main points of our discussion. Our hope is that these reflections will encourage others to read this article, as well as, inspire others to formulate and share their own perspectives on this article, which we can add to the growing discussion and debate on the issue of HIV/AIDS programming in Africa.
The authors begin by explaining how the rise of HIV/AIDS and other infectious diseases across the globe led to the recognition of the need for rapid and large-scale public health responses. The authors continue by describing how sustained global initiatives, such as the WHO’s Global Fund, operate on the premises that require health systems that are functioning, efficient, and based on a primary health care model. The authors begin to build their case by suggesting that these premises are not enough to generate success, because they do not often hold true, especially in developing nations. The authors support this argument by offering a few examples of suboptimal treatment regimes in the area of tuberculosis (TB) and malaria despite large investments by established organizations. They then centralize their thesis in the case of HIV/AIDS where they argue that the reasons behind disappointing results in curbing the HIV/AIDS epidemic can be directly attributed to the lack of engagement with communities.
The paper begins by describing four different approaches to scaling up efforts that have been used in the past. These include:
• The blueprint approach;
• the explosion approach;
• the additive approach;
• and the biological approach.
The blueprint approach is a model framework that is designed by outsiders. The explosion approach uses selected interventions and incorporates them into national priorities. An example of the explosion approach includes mass polio campaigns. Because this approach often overlooks local priorities, in most cases the result is failure. The additive approach is one that works from the philosophy of bottom up and uses culturally-adaptive initiatives that are initially financed from outside and the leadership is gradually phased over to local communities over time. The problem with this approach is that many communities fall into a dependency trap and the phasing-over process never happens, so sustainability suffers. Finally, the authors describe the fourth approach called the biological approach. This approach is one that first identifies successful local initiatives that demonstrate self-reliant empowerment. Programs are encouraged to expand and flourish geographically.
The authors discuss the limitations of the first three approaches but identify how the biological approach has shown promising results. The authors point to the case of Uganda to support this claim. The authors claim that by infusing a ‘Human-Rights-Approach’ with a version of the ‘Biological’ model described above, practitioners can be both adventitious and congruent with a health promotion approach.
We agree that this paper is useful in some ways, but also has limitations and shortcomings, which we will briefly discuss in the following paragraphs. We also questioned in our discussion how this paper brought new insight for us around HIV/AIDS and health promotion. We all agreed that the humans-rights based approach is not far from what we already know, and it seemed like the authors were simply saying the same thing in a different way. Based on our background and experience, there did not seem to be much that was innovative about this paper.
With that said, however, the paper is useful in outlining the various paradigmatic approaches used in scaling up efforts. This overview assists the reader in becoming familiar with the developments in scaling up efforts over time and how these different approaches have had areas of success and areas of disappointment in the past. Another refreshing aspect of this paper is the authors’ realistic view of participatory and community participation in health promotion programs. Many articles often paint community participation as ‘ideal’ and do not mention the inherent problems in pursuing such an approach. These authors clearly outline some of the benefits and some of the anticipated problems that practitioners may face when pursuing this approach. This realistic description is useful.
One limitation of this paper is the paucity of information that is provided in the Uganda example. The authors assume their readers know about and understand in-depth the Uganda “success story” (see the text box below for more reading on this). It would have been helpful in this regard, if the authors had provided a few examples of where the Uganda policy demonstrated tangible success in relation to HIV/AIDS health promotion programming. Also, it would have been interesting to know whether and how the Uganda situation had its challenges. In this way, readers may have been able to take away some key points to emulate within their contexts or had a more in-depth understanding of what successful policy looks like.
____________________For more information on the Uganda story, see: Shelton, J. D., Halperin, D. T., Nantulya,V., Potts, M., Gayle, H. and Holmes, K.K. (2004) Partner reduction is crucial for balanced ‘ABC’ approach to HIV prevention. British Medical Journal, 328, 891–894. _________________________
Another issue raised in our discussion was how the authors did little to convey the philosophical underpinnings of the various scaling up approaches and that of a human rights approach. It would have been useful if the authors presented a table of the various approaches identified in the paper that clearly delineated the premises for which each approach operates, and areas of congruence and tension between and among these areas. In this way, the reader could anticipate where a human rights approach might be useful and instances when those using it in the area of scaling up health promotion programmes might encounter problems. We maintain that if the authors had provided this information, readers could take away useful information to assist and guide them in their scaling up efforts.
In conclusion, this article provides some useful historical overview, but also leaves the reader slightly disappointed in the depth of analysis provided. The authors assume that a human-rights approach combined with a biological model is the answer to future initiatives and do not provide an accurate assessment of this approach for the reader to take away. Therefore the reader is left ill-equipped to understand the breadth of views in relation to the human rights approach.
1. Chopra M, Ford N: Scaling up health promotion interventions in the era of HIV/AIDS: challenges for a rights based approach. Health promotion international 2005, 20(4):383-390. Available online: http://heapro.oxfordjournals.org/content/20/4/383.abstract
Published: May 2012, Health Promotion Connection