Monitoring Public Health
I spent the past week in Istanbul with public health advocates from around the globe. They're a sharp and dedicated group of people who speak their own language: those of us from outside their world quickly learned to translate the alphabet soup of government agencies they regularly deal with, as well as the acronyms for the life-extending treatments and facilities that are at the center of their work: ARV's, the main treatment for PLWA's that are often acquired through CBO'swith support from by UNAIDS (translation: Anti-RetroVirals, People Living With AIDs, Community-Based Organizations, and UNAIDS: the Joint United Nations Program on HIV/AIDS). The group was not only focused on HIV/AIDS; representatives from public health groups focusing on Roma health, harm reduction, paliative care, marginalized populations, multi-drug resistant tuberculosis were all in evidence.
The topic for discussion during the three-day event was monitoring, something that donors and governments have increasingly thrown their weight behind. What became apparent to me, a newcomer to this field, is that monitoring is not a single activity, nor is there an agreed-upon definition of what monitoring groups actually do. The range of activities that are included under the heading "monitoring" include both quantitative and qualitative work. Human Rights Watch, for instance, for the most part produces work which is akin to top-quality investigative journalism; their reports are based on extensive interviews and are carefully fact-checked against a legal framework springing from the Universal Declaration on Human Rights, as well as the follow-up Covenant on Civil and Political Rights. Human Rights Watch runs an HIV/AIDS and human rights program, which documents human rights abuses related to the epidemic, and is very much in keeping with their interview-based methodology.
Other public health groups present were working on more quantitative monitoring projects, involving government finances, distribution of drugs, and use of treatment programs. The multitude of approaches and topics was dizzying, for someone coming from outside the public health world; more dizzying still was obvious importance of these efforts. The range was also broad: some groups were setting their own monitoring goals and creating their own methodologies to meet them, like Global Health Watch, while others, like IDASA in South Africa are monitoring by using internationally recognized methodologies, like UNAIDS' NASA (National AIDS Spending Assessment) framework.
Most interesting, though, were the questions that monitoring groups across the board wrestled with: when government is a partner in a monitoring project, do you trust their data? And how does a project managed by civil society maintain independence when the only way to crucial data sets is through a friendly government official? How to ensure quality data from partners working in disparate countries with, often, little in the way of communications technologies? Should monitoring projects only be undertaken by research universities, or can community-based monitoring be reliable? And a question that seemed to underride all the discussions I had: why monitor?
Without monitoring by external organizations, there's simply no way to hold governments to their promises made at either the international level (i.e., being a signatory to the Covenant on Civil and Political Rights) or at the national level (i.e., that a certain percentage of a national budget will be spent on the acquisition and distribution of anti-retroviral drugs). Further, monitoring needs to take place in order to prove the efficacy of experimental health programs; the harm reduction movement, which advocates for, among other things, the provision of clean needles and methadone treatment for drug addict, inevitably runs up against resistance from governments who might act as implementors. Without the proof of a harm reduction program's successes in holding down the rate of HIV transmission in a population, there is little argument to be made against skeptics.
However, the above arguments assume that monitoring is a *tactic* in a larger advocacy campaign; i.e., that the monitoring is simply a way to advance a broader goal. This is not always the case, it seems; some organizations monitor as a end in and of itself. In these cases, the monitoring projects tend to be more community-based, and are being undertaken as a way to both empower civil society, and to remind government that, in fact, they are accountable to their populations. This isn't to say that these kinds of projects don't also engage in advocacy, but rather that they see the monitoring itself as a crucial type of engagement.
As for me, I was interested in how these different projects were using online tools and forum to advocate, post-monitoring, both within their home countries, and on the international level. Several people told me that they considered monitoring "the easy part" (a serious assertion, given the complexity of the projects represented); the real challenge was taking the information and making a compelling argument gauged to the right people. As one participant said, "There's a huge difference between dissemination and campaigning." Indeed. Given the growing number of online projects aimed at supporting advocacy campaigns, the time seems ripe to bring the two populations together.