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Public health delivery problems, at the grassroots, are far more complex than most business problems. Photo: HT
Public health delivery problems, at the grassroots, are far more complex than most business problems. Photo: HT

Wisdom of the crowd

Interventions can be truly sustainable only if ownership vests with the natural ownersthe community

If you want to “empower the community", work with them, find change agents within and serve as enablers. This column tries to raise public health issues, through the perspective of my grassroots experience working with communities at the ground level. This has been my beat, after I left McKinsey 15 years ago. Getting insight into ground level health issues must be the starting point for scaled, sustainable change. Hence the column’s name—“Grass route health".

Last week, I was in Mysuru to meet some friends who practise the world’s oldest profession—commercial sex work. I first met them while leading Avahan, the Gates Foundation’s HIV prevention programme, from 2003-2012. In the process, they became guides, mentors, and partners who taught me lessons in programme management and for life.

I had to unlearn a lot of my training at McKinsey which said a smart problem solver must always know the answer. But public health delivery problems, at the grassroots, are far more complex than most business problems. There are many more variables, so many unknowns. Consumer behaviour is often a mystery—she may not even want the product you are offering her.

The understanding of such complex problems, and therefore the solutions, lie with the communities who live with these challenges on a day-to-day basis. Therefore, at the grassroots, very often the smartest thing to do is confess ignorance by saying—“I don’t really understand the problem—Can you explain it to me?". If I had said this to a client at McKinsey, it would, to put it euphemistically, have been career limiting.

Starting Avahan, we saw the obvious problem: condoms did not reach users who needed it most. We came in thinking the solution lay in managing the logistics of the condom supply chain in a smart way. The second problem, we supposed, was that sex workers didn’t know about condoms. The solution surely lay in coming up with novel communications methods that would get through to a sex worker and make a strong impression. There was a string of such suppositions, too embarrassing to relate now. They all came from outside-in, without ever asking the consumer.

We soon started realizing that sex workers knew these things already. As Doddamma told me—“Sex work is our trade. We know all about HIV." The light bulb in my head flickered and I said—“Then I don’t understand—why don’t you use condoms". There was an immediate answer—and the solution. “Put an end to violence in our lives".

The light bulb began to glow. I realized then that sex transactions often turned violent because the client wanted unprotected sex, and they would enforce that violently if needed. The police who picked up a sex worker could also use force for unprotected sex.

Working in equal partnership with the sex workers community, we enabled the creation of a solution. At the core, it consisted of working with the police from the top down, having discovered that there were many in the force willing to change things. It also lay in creating a crisis response protocol that involved local media. Incidents of violence and response times came down.

Sex workers were attracted to this as it tackled their core problem which was violence, not HIV. The data, as it came in, showed a high correlation between incidents of violence, and STI (sexually transmitted infection) incidence, a key marker for HIV infection. This community-led response was one reason the Avahan programme went viral. At the end, it was credited with having averted over 600,000 infections.

In Rajasthan, we are working with adolescent girls who are acting as change agents. During a routine visit to an anganwadi centre, one girl waited for us outside the centre. She was curious about us, and she had insights about why the community does not seek health services. We started talking, and it led to our still nascent adolescent girls programme. Here the girls work in teams within the ambit of their mohallas, to act as a friend and offer help to the pregnant or lactating mother. They are playing a vital linking role between the community and the health system. These are early days, and many right questions must be asked, and good answers found. We are asking. And, we are listening.

Interventions can be truly sustainable only if ownership vests with the natural owners—the community. This is not the easiest route. It is time consuming, requires patience and does not have one correct answer. Various experiments must be tried and will fail.

In my experience, the effort is worth it. Ask Doddamma and the commercial sex workers of Mysuru. Today, they travel the world, sharing their story with communities and catalysing change.

Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok.

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