What do international health consultants need to know?

Bulletin of the World Health Organization, 1999, 77 (1) 97 Readers’ Forum What do international health consultants need to know? Sir – More and more consultants are offering services in countries across the globe through intergovernmental, bilateral and nongovernmental agencies, but little systematic training for such consultants is available. There are several important points that consultants need to take into consid- eration before embarking on interna- tional activities. First, they need to be clear about the assumptions underlying interna- tional aid programmes. Whose needs are being met? All too often, pro- grammes start with an assessment of what the consultant or agency has to offer, followed by a search for a willing recipient. The offer may be hard to refuse, partly because the host country is unable to assess the impact of the proposed programme, and partly because any international aid pro- gramme might bring with it a variety of benefits irrespective of the intended goal. To be successful, however, the needs of the host country must be thoroughly assessed, and the match between them and the proposed programme must be clear to both parties. Consultants need to seek out the strengths of their host country at the same time as assessing its needs, and find areas of mutual growth. Their work needs to be placed from the start on a shared power basis rather than a donor-recipient one. One way to help achieve this is through consensus conferences, in which those who would be involved in the proposed programme meet to discuss its key concepts, agree on which aspects should have priority, and express their own views on the situation and the needs they see for change. This process should be repeated from time to time, since needs change and programmes have to be flexible if they are to succeed. Normally, consultants are used in order to promote change, but the process of change should be respectful rather than critical. They should remember that their task is to improve systems, not people. One of the most difficult aspects of health care reform is to confront senior caregivers with the idea that what they have been doing for many years may be inappro- priate in the light of current knowl- edge. Sensitivity and supportiveness are needed to avoid confusing lack of knowledge or facilities with personal failure. Programmes should aim for sustainability. This is easy to under- stand in relation to technology transfer with its concomitant needs of expertise and supplies, but it is just as important if not more so for health system reforms. The best way to provide for it is to ensure that local caregivers buy in to the new system. Buy-in is more likely to happen when the bulk of the relevant decision- making group, including policy- makers, clinical practitioners, academics and caregivers, see the validity of the new ideas. Great skill may be needed to arrive at this, especially where some of the people involved are used to working auto- cratically and others democratically. Most international aid pro- grammes seek to apply existing knowledge to systems that could benefit from it, but some health intervention programmes are often carried out for the purposes of research, to find out whether a certain practice or treatment works. In these cases the research grant often only supports the application of the new approach to the experimental group. If the approach proves beneficial, however, it will be desirable for the control group as well. In this area as in many others, some rethinking of the ethical implications of grant funding policy is needed. A general solution might be for research grants to stipulate that positive research findings must be implemented locally (and interventions with negative results actively withdrawn), thus combining the aims of research and improvement of health status. All too often, international health programmes are started with humani- tarian aims but without the means of judging whether or when these have been achieved. If outcomes are not assessed, the value of the programme remains speculative. International aid workers therefore need to incorporate research components in their project design and to include some team members with specific evaluative expertise. Ideally, expected outcomes should be specified in concrete terms. Consultants need to remain constantly alert to their host culture. There is much that can be learnt during every moment of one’s stay in the host country that can shed light on the lives of programme partici- pants. Simple expedients, such as staying in small local hotels, hospitals, and private homes, though often uncomfortable, will offer some of the most valuable insights into the stresses of daily living that our collaborators face. This also helps to build up mutual trust. In this context financial aspects of the programme, and the huge cost differences that typically exist between the countries involved, should be discussed openly at the outset, rather than left to generate hidden misunderstandings and resentment. Finally, consultants should be aware that much of what has been offered with the best of intentions by people in industrialized countries to people in developing ones over the years has turned out to be less than desirable or effective. It needs to be under constant revision and improve- ment. Providing information for the host country’s consideration, rather than advocating change in a directive manner, is preferable, especially where there is uncertainty as to the efficacy of a given practice. n Beverley Chalmers WHO Collaborating Centre in Women’s Health, Centre for Research in Women’s Health, University of Toronto, Canada. Correspondence to 790 Bay Street, Toronto, Ontario, M5G 1N8, Canada. Tel: (416) 351 3800 ext 2702; fax: (905) 351 3746).