He Said This, and She Said That; but … How About We Ask Them?

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With the Millennium Development Goals in place many people have focused on what William Easterly calls a Planner approach on top-down method. This has been challenged recently due to shortcomings in achieving the MDGs. Still many of our policies on a national and international level still do not focus on a grassroots approach. This however is not solely an issue of the implementation method but also with the reform itself. Most often, measurements are based of WHO data or other mathematical models. I agree that quantitative analysis is best, but contest that often the monitoring methods remain stagnant as reform ideas change.  An example of this is a spatial decay formula[1], which would accurately reflect an individual’s proximity to medically trained personnel[2]. This would better reflect physician use because people do not place an arbitrary borders on distance, but operate more on the law of cost/benefit or distance/treatment.

Additionally, when setting up these facilities the systems can take into larger account the views of the local populations. Monitoring and standards are still held at a federal or international level, but daily activities can be better managed from a community-based system. This is seen in developing countries and even in ‘modernized’ countries such as the United Kingdom. When this reform is implemented in a top-down structure instead of a bottom-up system, often it is aligned to failure and protest as seen in Colombia with its current reform. Therefore, the question arises of how to mitigate government monitoring to prevent corruption and malpractice v. identifying local needs and demands.

A perfect example of this debate is in the Mental Health Act law in Ghana in March of 2012. Local demands on the system for better mental health reform issued the change from a previous law (created in the 1960’s) to the new MHA law. This desire showed great promise for use on the local level; however, national structural problems are creating issues in its implementation[3]. This shows that even with a strong local demand for a service, there needs to be an adequate national supply of infrastructure. At some level, just as the MDGs have failed to be completed due to low, local demand. Other systems are fledgling due to low, national supply. This intersection between the two populations must be mitigated and viewed from a more economic perspective if any reform is to be truly effective.


[1]Luo, W., & Qi, Y. (2009). An enhanced two-step floating catchment areamethod for measuring spatial accessibility to primary care physicians. Health & Place , 15 (4), 1100-1107.

[2] Dewulf, B., et al. (2013). Accessibility to primary health care in Belgium: an evaluation of policies awarding financial assistance in shortage areas. BMC Family Practice, 14 (122), 2296-2310

[3] Doku, V., Wusu-Takyi, A., & Awakame, J. (2012). Implementing the mental health act in Ghana: Any challenges ahead? Ghana Medical Journal, 46 (4) 241-250

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