By Marlee Tichenor
This past October, I had the pleasure of attending the Senegalese National Coalition for Health and Social Action’s (COSAS) panel on Impact Evaluation in the Health System at the West African Research Center in Dakar, Senegal. Created in early 2017, COSAS is a network of public and private health workers, epidemiologists, policy makers, social scientists, and advocates working toward health equity in Senegal. COSAS aims to contribute to the development and evaluation of health policies, promote health equity and a holistic vision of health, play a role in health surveillance, and promote the discussion of and produce studies on these issues for a larger audience. The coalition convenes members of its multidisciplinary network to discuss pressing issues and to provide possible solutions to the problems facing the Senegalese health system. In September, the coalition also convened a panel to promote a more collaborative relationship between traditional healers and biomedical practitioners, as the Senegalese Ministerial Council is in the midst of passing legislation for the responsible practice of traditional medicine after decades of advocative work to encourage the government to engage with the traditional sector.
At October’s event, COSAS president Dr. Abdoul Kane chaired four panelists with different perspectives on the practice and logics of health intervention evaluation: the Ministry of Health’s Dr. Cheikhou Sakho, the influential public health scholar Professor Issakha Diallo, the human geography scholar Professor Adama Faye, and the National AIDS Control Program’s Dr. Niang Diallo. Together, the four speakers provided a view into the complex politics, practices, and difficulties, as well as the ultimate importance, of evaluating the impacts of health interventions in Senegal. The nature of health development has changed dramatically since the late 1990s, as the number of public, private, national, and international organizations intervening and the number of simultaneous and targeted interventions have increased. In this context, longstanding epistemological differences between measuring the success of health care policies on the part of epidemiologists, economists, public health advocates, and others come into stark relief in the monitoring and evaluation process, where different approaches to health are made to be comparable and arguments about causality are asserted.
In his introduction to the panel, Dr. Sakho framed the day’s discussion by the two questions at the heart of evaluative work: first, evaluators must determine whether there has been a positive change at the population level, and then, they must identify the root causes for such a positive change. Professor Diallo, a scholar who had trained a large number of the panelists and audience members in public health, then carefully presented the issues and challenges of evaluating health impact. The most fundamental question in the act of evaluation is: how do we define health? Diallo provided three models for defining health, those of the World Health Organization, of epidemiologists, and of economists, roughly delineated. The WHO defines health in the ideal, as the complete physical, mental, and social well-being and not merely as the absence of sickness. Epidemiologists, on the other hand, define health as the absence of suffering, which can be measured by morbidity, mortality, and the rate of invalidity on the population level. Finally, economists define health as a form of human capital or economic good, as a sound investment for countries and private industry for optimum economic output. This has been most recently encapsulated in the World Bank’s new initiative to carefully measure countries’ “human capital” through monitoring indicators on universal health coverage and education quality and coverage on the national level.
The way that health interventions are evaluated and monitored is then part and parcel of how health is defined within a national public-private health system, and there is considerable negotiation with the different indicators that are taken as proxies for health care coverage. For example, Diallo explained how a recent global health project launched in Senegal had as its ultimate goal to improve adolescent health care in Senegal, but the indicator used to measure the rate of improving quality adolescent health care was the available choice in health care options. Choice cannot stand in for quality or accessibility, Diallo asserted, and thus much more careful discussion of indicators and measurement is necessary and should be a part of all health project planning.
Professor Adama Faye, a geography professor at Cheikh Anta Diop University in Dakar, then explained and complicated the concepts of causality and counterfactuality, concepts upon which the work of evaluation depends. I will speak further on counterfactuality at a later time, but Faye explained how asserting causation is active work and that the evidence can point to several different root causes for changes in population health. Because there are often many different health interventions being combined or implemented in parallel in Senegal, Faye argued, we have to have a kind of evaluative practice that similarly combines methods for evaluating. We have to have both better health indicators and better socio-economic indicators, and we need both qualitative and quantitative approaches to evaluating the impact of health interventions. The National Malarial Control Program is taken almost universally to be Senegal’s most impactful health program, but Faye cautioned us to think about the difficulties of attributing causality to one program in Senegal’s crowded health sphere. Finally, Dr. Niang Diallo spoke about his experience with the National AIDS Control Program, and the different ways that the program’s impacts have been measured. A crucial, if not both obvious and difficult, component of the evaluative process is incorporating evaluative findings into a program’s future strategies, as the NACP did when it incorporated the findings of two studies, with the same parameters, about the impact of its programs in Kédougou in 2010 and 2015.
How do we measure the impact of health interventions and how does the measurement of health or of health’s absence impact global health discourse and funding? How is the measuring of health co-constructive of ideas about what health is and what kinds of negotiations are underway in health development in Senegal as the country works towards universal health coverage? These are the questions at the heart of my current fieldwork in Senegal, and my next blog entries will expand on these questions and provide preliminary views into the power of health metrics in global health development.