AMA Journal of Ethics. July 2016, Volume 18, Number 7: 676-680.
A Framework for Assessing Responsibility in Intergovernmental Partnerships
Advancing the health of the global poor requires a “compass-based” framework that guides both morally sound and pragmatically effective action.
Commentary by Ranu S. Dhillon, MD, and Pranay Nadella
You are a physician working at a public hospital in Mozambique through an intergovernmental partnership. Recently, many of your Mozambican colleagues have been complaining that their pay is insufficient and that their working conditions are poor. They suspect this situation is directly due to government policies that are also exacerbating the poor health of the country’s residents. In response, these colleagues have decided to strike; they will not see patients until the government increases their wages and invests more resources in the nation’s health care sector. One of your colleagues invites you to join the strike. You know that if you do, you will jeopardize your relationship with local government officials, possibly putting at risk the entire program you’ve been maintaining in partnership with your colleagues. On the other hand, you know that if you do not stand with your local colleagues, they are likely to feel that you have not supported their struggle; thus you might well be jeopardizing your relationship with them.
How should you respond? What are the best strategies for balancing the need to establish and nurture personal and professional relationships with local colleagues and the need to maintain allegiance to political forces that enable effective partnerships among governments, health care organizations, health care workers, and members of the public?
Advancing the health of the poor and fighting for equity is not as simple as investing resources and implementing programs. As this case highlights, achieving health improvements, especially across entire countries and through government systems, requires aligning a wide array of actors with a diverse set of interests, all of which influence how health care is delivered. Because so many of these factors are location specific, there is no comprehensive handbook for global health practitioners to use in situations like the one sketched out above.
A Compass-Based Framework for Global Health Interventions
Those involved in global health must develop a framework, or a set of navigational tools, for assessing the forces at play in any given situation and for making decisions that are morally sound yet pragmatically effective in promoting the health of the poor.
Moral compass. In quandaries like the one presented above, global health practitioners should be guided by a “moral compass” that aligns with whatever is best and right for the people whom they seek to serve. Global health professionals find themselves in a wide range of roles, from advising or running a program in partnership with the national or local government to collaborating intimately with a single physician or implementing programs with colleagues. They should seek to have productive relationships with all these agents, but their ultimate obligation is to the intended beneficiaries of their efforts. The well-being of these beneficiaries must come first. For example, when one of the authors (RSD) was advising the president of Guinea during the Ebola epidemic, he emphasized that he was there to advocate for the communities suffering through the horrors of the epidemic. To the extent possible, he attempted to align the interests of the president, the president’s administration, and his colleagues—from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and other agencies who were partners in the Ebola response—with those of the communities. No matter how important other relationships and partnerships are in delivering health care effectively, the global health practitioner must always put first the interests of those for whom he or she is ultimately working.
Effectiveness compass. At the same time, a global health practitioner needs an “effectiveness compass” to navigate the messy political and social realities that can undermine health care delivery. While working in India, one of the authors (RSD) found that collaborating with the government health system was complicated by competing interests, corruption, and chronically absentee officials. Remaining above the fray, so to speak, would have meant carrying out only the few trivial projects that were free of controversy and neglecting deeper, more important issues because they were morally and tactically difficult to manage. When RSD visited an Indian village and spoke to a poor woman living there, he could not tell her that while his group could intervene to improve her health and the health of her children, the bureaucracy at play was too difficult to work around, and so they would not be intervening at all. Instead, his group jumped fully into the labyrinth of political complexities in order to push for the reforms needed to see gains in health, despite the mess and complexity of doing so. If we are to advocate for the poor, it is our responsibility—while never compromising our moral integrity—to be savvy and find ways to get real, palpable results for the people we aim to serve. Therein lies one of the greatest challenges of global health work: coordinating the multiplicity of interests involved in health care delivery so that programs and interventions adhere to the highest moral standards and are still effective in advancing the health of the poor.
Applying the Compass-Based Framework to the Case
This case provides a concrete example of a situation in which the twin compasses of morality and effectiveness must serve as a guide. The conundrum is clear: on the one hand, supporting the health worker strike would damage relationships with the government that in turn could jeopardize not only the program but also, if the strike were unsuccessful, the global health practitioner’s positioning to potentially broker changes that could resolve the health workers’ demands and advance the people’s health. Moreover, were the public hospital health workers to strike, the most vulnerable patients would be penalized the most since they are without reasonable access to health care. On the other hand, not to stand in solidarity with your colleagues, who have legitimate and ultimately important demands, would undermine your relationships with them and thus your ability to advance health care in the hospital. Finally, not to join the strike might be to miss a prime opportunity to push for the policy changes and investments needed to more meaningfully improve the health of the poor.
Managing this situation in a way that is morally sound and practically effective requires taking a step back from an oversimplified “either-or” dichotomy and considering afresh what would most benefit the people being served. It seems that without a change in health worker pay and working conditions, the current system remains untenable and results in overworked, demoralized health workers with inadequate resources. Policy reforms seem both morally sound and practically necessary for improving the health of the people long term.
If both of the health worker issues cited in the case are legitimate—if, that is, their demands for more pay and better working conditions are appropriate—the next consideration is whether the visiting physician’s joining the strike is the most ethical and effective strategy for improving pay and working conditions for Mozambican health workers. From a moral standpoint, a strike seems problematic in the short term, since it will leave some of the most vulnerable patients without access to care. By joining, the visiting physician is tolerating this risk while potentially forfeiting an opportunity to mediate a solution. Is striking—something of a nuclear option in this scenario—really the best way for the visiting physician to help compel policy changes and greater investment? The answer is difficult to discern from the case alone, but in many similar instances such a drastic move, even if it forces short-term reform, can engender long-lasting hostility between health workers and government officials. Even if immediate changes are adopted, seeing them through to a stronger health system requires an ongoing, collaborative relationship between these two actors, which might not exist in the aftermath of a strike.
Whether or not the visiting physician’s joining the strike is indeed the most moral and effective strategy is also contingent on a better understanding of the government’s current reservations about making the health workers’ requested changes. Is the government well-intentioned but simply without the required resources, or is it misallocating funds due to corruption or poor management? Are government officials so unwilling to discuss and find ways to implement these measures that only drastic moves will get them to act?
This analysis of the players, their relationships, and possible motives provides a more thorough and nuanced understanding of how to benefit the people being served in the case scenario. Furthermore, it elucidates the wider set of options that exist beyond a needlessly simplistic “either-or,” “with us-or-against us” dichotomy. Increased wages and investments would advance the ultimate goal of improving health for Mozambicans living in destitution, but given the moral and tactical limitations of striking to achieve this end, what other strategies might be more sound morally and just as effective, if not more so? If your colleagues are on the verge of striking, you can assume that some of the other options have already been exhausted, but, depending on the specific reasons the government has been reluctant to concede to any of the health workers’ demands, more constructive possibilities should be considered. If the government has the resources and ability to push through reforms for the betterment of the people’s health but is resisting for self-serving reasons, then there might be bigger challenges ahead for advancing health equity, and you might need to consider whether, pending changes in government, building programs with nongovernmental partners and with communities directly might, in fact, be the more morally sound and pragmatically effective route.
Based on this assessment, you might determine that the best course of action is not necessarily to side with your colleagues or with the government but to see whether you can fight for the greater good of the general public in such a way that your colleagues’ demands are realized without a strike. You could use your unique position as a global health practitioner who is an “insider,” but who also has the perceived neutrality that neither your colleagues nor government officials have, to exert leadership in this situation and help broker a more constructive resolution. To favor one side or not act at all in an effort to remain neutral could alienate you from one or both sides, so even though diving in to mediate a standoff is messy, complicated, and potentially ugly, doing so might ultimately best serve the health of the people.
There are no straightforward “rules” or formulas for navigating the broad array of forces that often make or break health care delivery to the poor, but aligning the twin compasses of morality and effectiveness provides a useful framework. Remaining clear-sighted about the ultimate objective—serving the interests of the poor—and assessing how different actors’ interests relate to this goal—to generate the greatest good—can guide the global health practitioner in resolving dilemmas like the one presented in this case in an ethical and effective manner.
Ranu S. Dhillon, MD, is an instructor in medicine in the Division of Global Health Equity at Brigham and Women’s Hospital and Harvard Medical School in Boston. For over a decade, he has worked on building primary and community health systems in several countries including Rwanda, Liberia, Nigeria, and India. As an advisor to the president of Guinea and the National Ebola Coordination Cell, he helped lead the country’s response to the Ebola epidemic.
Pranay Nadella studies statistics and global health at Harvard College in Boston. Because his primary passion is maternal and child health, he conducts research on child nutrition at the Harvard T.H. Chan School of Public Health and serves on the National Youth Council of the March of Dimes, a US-based nonprofit focused on preventing premature births, birth defects, and infant mortality.
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The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
© 2016 American Medical Association. All Rights Reserved. ISSN 2376-6980