Interview: Julio Frenk

In Current Issue, Interviews on October 29, 2009 at 11:44 pm

A conversation with the new dean of the Harvard School of Public Health

Courtesy Wikimedia Commons

Dr. Julio Frenk is an internationally renowned global health professional who has been one of the forerunners in calling for the establishment of an implementation science to better monitor and evaluate health programs. As Mexico’s Health Minister from 2000 to 2006, he was responsible for the establishment of Seguro Popular, a comprehensive national health insurance program that has been credited with bringing access to tens of millions of previously uninsured Mexican citizens. He is currently a Senior Fellow at the Bill and Melinda Gates Foundation, lending his expertise to a variety of global problems. In July 2008, he was named the new Dean of Harvard School of Public Health, a position he currently fills.

HCGHR: Information dissemination is one of the most pressing problems in global health today. In your opinion, how can the field move forward in building sustainable and effective systems that share their methods, so that not everyone has to re-invent the wheel?

Dean Frenk: This is one of the positive sides of globalization, with all the possibilities of engaging in a process of shared learning. If we don’t study it, if we don’t evaluate it, and then make the findings available, we’re condemning the rest of the world either to repeat past mistakes or not to learn from positive innovation. This is one of the aspects where knowledge becomes a global public good. The way to achieve that is to make sure that every innovation is evaluated, and that’s the key to implementation science. I think this is one of the main areas where international collective action can work, where countries can agree that every new innovation in every country ought to be evaluated; I think there’s a role for universities to play, also for international organizations. For example, if the World Bank funds a project or the Global Fund funds a project, there should always be, built in from the beginning, an element of assessing what the situation was before the innovation and then measuring what happened with that, and then making sure that that knowledge becomes an available public good by making it available in a way that’s accessible, and where one could then have a repository of best practice internationally. So, let’s say, a Minister of Health arrives in a country, a developing country, and he or she wants to introduce health insurance for the poor; then that Minister would know exactly where to go and would be able to get good indicators as to what worked and what didn’t work and in what conditions. But that needs to be orchestrated and be financed, and we have never had as many resources for global health as today. We need to make sure that in addition to bringing together the drugs and the vaccines, that we develop innovative systems of delivery and that we actually create a science of implementation that deals with the scientific evaluation every step of the way, and make sure that that becomes available to everybody else by making knowledge truly a public good.

HCGHR: In the past, you’ve argued against what you believe to be a false dichotomy between horizontal approaches and vertical approaches in global health and in favor of a “diagonal” system. Could you explain this diagonal system and give an example?

Dean Frenk: There have been two traditions in public health. One is the vertical tradition, and it’s called this because it’s focused around a specific disease, and then you create a special system just to deal with that disease. The classical examples were the campaigns; they even used military terms like campaigns, the campaigns against malaria. So a country in the 1970s, when there was this push to try to eradicate malaria, they would create a separate organization, completely separate from the Ministry of Health, with its own logistics, its own health workers, its own vehicles, its own spraying units. It was vertical, one single disease with everything around it, from purchasing, logistics, the delivery of insecticides, to drugs to immunizations. Obviously, the health system deals with many more conditions and so people started advocating for a horizontal approach. A horizontal approach means you deal with the general issues about how you organize health care, how you finance health care, and then you deal with whatever disease comes. The horizontal approach aimed at strengthening and concentrating doctors’ training, nurses, but did not have a clear sense of priorities. The shortcomings in the case of the vertical approach is a fragmented system, very inefficient because you may have a workforce that’s only partially occupied with one disease, but they don’t know anything about anything else, plus people don’t interact with the health system like that, they don’t come in with diagnoses, they come with symptoms, with complaints, with problems. So you can’t have people pre-assigned to those disease categories, right? The horizontal approach, while being more comprehensive, had the problem that it didn’t have clear priorities, so in poor countries you would end up with health systems that cater to the needs of the better off. So you would have large hospitals in urban areas, but no primary care infrastructure in the rural areas. So to deal with the shortcomings and to try and bridge a divide between these two traditions which had been kind of in a very acrimonious debate for decades, several of us have been using the term of diagonal approach, which is just like in geometry, where a diagonal is what unites the vertical and horizontal. This term was introduced by Dr. Jaime Sepulveda, who was a member of the Board of Overseers of Harvard University and a very distinguished public health professional who is currently at the Gates Foundation. He coined this term diagonal to refer to an approach where you actually strengthen the health system but have a very clear sense of priorities among the most pressing problems of poor people and use those to drive general improvements in the health system so that then the health system can generally respond to other health problems. Good examples have been, good AIDS programs. You have a clear focus on AIDS, but then you use that. To give an example, in Mexico we’re trying to introduce insurance for poor people to deal with some very expensive diseases that were creating catastrophic expenditures. Because AIDS was such a difficult issue, we started the insurance program offering coverage for the treatment of AIDS, very expensive. But that generated all of the advocacy to create a health insurance program that now covers everything else. By focusing initially on AIDS, we were able to secure the funding, get the logistical mechanisms, enrollment of people, etc…and now that insurance program covers a whole lot of things. That’s the essence of the diagonal approach.

HCGHR: Many people have criticized PEPFAR’s exclusive focus on one disease. Do you agree with such criticisms?

Dean Frenk: Well, I think that PEPFAR offers a great opportunity to implement the diagonal approach. It is focused on HIV/AIDS treatment; I think there’s been an effort to also expand it to prevention, but it offers the opportunity, if it’s done properly, of taking the fight against AIDS in Africa and using those resources, for example, to build laboratory capacity, so that you’re not just doing test for AIDS, but you actually now have labs that can test many things, training doctors and nurses that will be there for other things. So it is an example. If it doesn’t take advantage, then yes, you could make that criticism. But I think it’s a great opportunity to adopt the diagonal approach.

HCGHR: As Dean of HSPH, what sort of initiatives do you hope to begin to lead the school in the direction of diagonal and holistic health system approaches that will be sustainable and effective in the future?

Dean Frenk: Well, I think the school has a great role to play and has been playing that role in three avenues. First, being part of the research component and carrying out a lot of these evaluative researches. The School has already been very active there. I can tell you that in my own experience when I was minister of Health of Mexico, learning from the evaluation of Oportunidades, which as I said was the product of a graduate of this school, we adopted the same strategy for the health insurance program for the poor called Seguro Popular. And the general evaluation was done here at HSPH, led by Chris Murray. So that’s a threshold for the school, and I think to continue to strengthen our capacity in the field of research is going to be one way of making that contribution, continuing to make that contribution. The second of course is in education. I would like, in addition to our degree programs, to get involved more in leadership development efforts. Again, already there’s a lot of activities in that field but I think certain forms of continuing executive education, which are more tailored to people who are already in the field and who can come for short periods of time. There’s a very successful program here called the clinical effectiveness program over the summers, and it’s meant to evaluate clinical interventions. So we’ve been talking about extending that to some of these large scale global health issues in a similar format. So in addition to continuing to train the future leaders through our degree programs, I think addition of executive and continuing education using the tools of telecommunications would be important. And then, third, I think this school has a role to play in translating knowledge into evidence so that it can be useful in policy making. Again, we have a long tradition in our department of Global Health and Population and our Health Systems Program that’s been doing a lot of this translation effort and building capacity. The team here was very much involved in the health reforming in the country of Columbia. So in research, especially rigorous evaluation, and education all through the degree programs and in new innovative mechanisms of executive and continuing education and in translation of research findings into evidence, I think this school can make a major contribution in improving global health.


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