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Health Information Forum: Working together to improve access to reliable information for healthcare workers in developing and transitional countriesWorkshop 4: Where is the political and financial commitment to health information provision in developing and transitional countries?Venue: British Medical Association, Tavistock Square, London, WC1H 9JR Date: Tuesday 19 January 1999 Contact: Dr Neil Pakenham-Walsh E-mail: [email protected] (Workshop 5 will take place at the BMA on 16th March 1999, 4 – 6 pm. This will be an Open Forum meeting with multiple short presentations by a range of organizations in the health information sector. Please contact Neil Pakenham-Walsh if you would like to attend and/or make a presentation and/or present a poster.) Workshop 4 was the fourth of an initial series of six meetings, whose overall objectives are:
among and across the various sectors of the health information provider community, with the common purpose of improving access to reliable information for healthcare workers in developing and transitional countries. Chair: Richard Smith (Editor, British Medical Journal) Guest speakers: Patricia Butler (Chief, Office of Publications, World
Health Organization, Geneva) Participants Joseph Ana (Nigerian Medical Forum) Announcements Neil Pakenham-Walsh announced that the British Medical Association Journals Committee had awarded a grant of 3000 pounds to the Health Information Forum to cover administrative costs and special expenses such as contributions to the expenses of speakers from developing countries. Neil P-W also passed on the apologies of Dr Douglas Buchanan, who will be delivering his presentation at the next Forum meeting (March 16th). ProceedingsThe objective of the meeting was to exchange ideas and experience relating to political and financial commitment to health information provision in developing and transitional countries. Points for discussion included:
The meeting started with two presentations, the texts of which are given below. These are followed by a plenary discussion, also outlined below. Speaker 1: Dr Patricia Butler (Chief, Office of Publications, World Health Organization, Geneva) WHO's role in meeting the needs of health care workers for practical information The Constitution of WHO makes it quite clear that one of the functions of the Organization is “to provide information, counsel and assistance in the field of health”. The Organization has 191 Member States, from Afghanistan to Zimbabwe, who all have accepted the constitution, and its highest decision-making body – the World Health Assembly – consists of ministers of health or their representatives. So on the face of it the political commitment exists in just about every country in the world, and at the highest levels. What about financial commitment? Well, WHO headquarters produces some 40 books a year – official publications of the Organization that pass through my office – as well as some 500 so-called “documents”, some of them hundreds of pages long, that have not gone through such a rigorous process of editing but which also contain a great deal of invaluable information for health workers. Our publications appear in French and Spanish – and sometimes in Arabic, Chinese and Russian – as well as in English, and we encourage their production in other languages too – working with NGOs, educational institutions, and commercial publishers. WHO publications (or at least some of them) can so far be read in more than 60 languages. So in theory WHO has a financial commitment to information provision. But what does that really mean? In WHO's programme budget in recent years, the amount specifically allocated to information has become progressively smaller. To be honest, governments, and the major donors that provide funds to WHO, are often much more interested in programmes that offer visible health interventions rather than health information. Vaccination campaigns, family planning programmes, new clinic facilities – all these are appealing because they have a quantifiable and immediate impact. The impact of information is much less obvious and much more long-term. Yet, being long-term, it is also much longer lasting. The result has been that funds for information provision have been “buried” in programmes whose primary objectives are more immediately recognizable, such as vaccination or diarrhoeal disease control. And the result of that has been a fragmentation of the information provision programme, with as I mentioned 500 documents coming from various parts of the Organization, bypassing the official “publishing” programme and going to ... well in some cases, who knows? WHO has finally recognized the problem and a review of the policies and procedures for publishing and document production is currently under way. This should eventually lead to more systematic, effective and efficient publication and distribution procedures that should cut down the printing of unnecessary documentation and improve the dissemination (both free and for sale) of information that the Organization deems to be a priority. Now there's an interesting phrase – information that the Organization deems to be a priority. But just how does WHO decide on its priorities in information? Well, like the production processes, the decision-making process in the past has also very often been fragmented, inconsistent and even illogical. We're very fond of saying that we respond to needs of developing countries – in fact that is written into our publishing policy – and I think that by and large we do produce material that we believe responds to those needs. In practice, though, what we are actually producing may be what we think they should need, or maybe what they would think they needed if they were as well informed as we are, or maybe what our donors tell us they think they need. More effort is needed – and we recognize this – to find out from countries where the gaps really are, and then to get feedback from them on what we produce and whether it actually meets those needs. Of course, the provision of information in itself is insufficient to bring about change. It needs to be followed up by training, encouragement and – perhaps most importantly – changes in policies to take account of the latest knowledge and guidelines that become available. We at WHO have been aware for some time that we have had insufficient follow-up to our publications and documents. We publish information and we issue guidelines that are by and large very well received - we get good reviews in the medical journals, we even win prizes from the BMA, but are we really making a difference where it counts? Are governments and their health ministries changing their policies to reflect the information and the guidelines that we give them? The answer is: not as often and not as quickly as one would expect, considering that people's health – and people's lives – are at stake. WHO is tackling this in part by incorporating the health information department with both a new department called Global Programme on Evidence, and the department on research policy and strategy. The idea is to make information provision part of a cycle of collecting data through research at country level, analysing those data to construct an evidence base, and then presenting the evidence in a form that responds to countries needs. In addition, WHO is planning to set up a new unit on Policy Dialogue and Capacity Development. The idea will be to examine seriously ways of translating guidelines into policy. There are some successes in this field and we want to emulate them. It's a recognition, of course, that WHO is not just a publisher, even a medical publisher, like any other. So, we are taking steps to solve the problem of getting guidelines reflected in policy at national level. Our contacts with ministries of health and leading academic institutions will help us to do that. But we also need to maximize our distribution of health information materials among health workers. And we need feedback from those people too. Are WHO publications and documents pitched at the right level for people's needs? Are they covering the kinds of things they need to know about? Are we giving answers to the right problems? Does our advice make sense? To do this, we know that we have to build up our links with NGOs and other organizations who have much more direct contacts with poor countries than we do. As an example of what we have done so far, WHO participated last year in two meetings organized by CODE Europe – one in Kenya and one in Senegal – which brought together international organizations, NGOs working in Africa and African publishers, to discuss how we could work together. The meetings themselves were very stimulating, some good contacts were made and as a result we have acquired new sales agents in the commercial publishing sector. Results on the NGO side are less concrete, but it was nevertheless an interesting and worthwhile first step and we hope we can build on this and extend it. And I suppose that that brings me around to the reason we are here today and, in a way, to the original question which is the theme of the meeting. Where is the commitment for information provision to resource-poor countries? Well, if Neil has done his job correctly, a lot of the moral commitment is here in this room, and together we ought to be able to mobilize the political and financial commitment. How exactly do we do that? Well, to be honest, I don't know. But I do believe that if we all work together we are more likely to come up with effective solutions than if we work separately. I don't come to you with any easy answers. I know that most of you recognize and perhaps face many of the problems that I have described - of making materials relevant, of reaching the right target audiences and of getting feedback from users on the usefulness of products. But if we can find ways of working together on our common problems, not only will we be able to convince donors and governments of the importance of valid and timely information, we will also be able to make a real difference to the lives of the people who need us. Discussion relating to WHO presentation A number of participants asked how WHO responds to the information needs of healthcare workers. The publications programme largely reflects what the individual technical programmes think are the needs. Also, some material is produced for donors. There are a handful of key publications that are particularly relevant to the needs of healthcare workers, but many publications have little or no relevance. WHO does not as yet have a comprehensive `map' of health information needs and activities, and gaps in provision of needs, nor does it have a mechanism for building such knowledge in collaboration with the wide range of players involved. WHO has, however, participated in two regional meetings recently held in Kenya and Senegal to identify and address information issues and to explore collaboration with African publishers. Issues highlighted were familiar: appropriateness/relevance of material, usefulness of products, and the role of locally adapted materials. Speaker 2: Paul Chinnock (Editor, Africa Health and Medicine Digest) Funding from the commercial sector: a case study INTRODUCTION Many of us who are regulars at these Forum meetings have said the most interesting aspect is often simply hearing about the work that other people in the group do. So I hope that my account will also be of interest. As most people here know, I am Editor of several publications, most notably Africa Health (AH) and Medicine Digest, all of which are published by FSG MediMedia. Arguably, what I ought to be talking on is the subject I know most about - the editorial content of AH - but today's topic is where the funding comes from for health information (HI), so I shall be talking about the advertising - because this is where we get the money to support our HI efforts. Some people are scathing about advertising but many African health workers tell us that AH is the only medical literature which reaches them; without the advertising they wouldn't be getting anything at all. I am not the one who sells the advertising space for our journals so what I am giving you is the perspective of an Editor working with publications that involve this kind of funding. I am not in a 20 minute talk going to attempt an overview of all the sources of funding that could be obtained from the commercial sector (indeed I would not be the best person to do this) but I am presenting a kind of case study of my experiences. I'll give you a short history of AH and give an even briefer mention to some of FSG's other publications. I shall then sum up the pros and cons of this approach to funding, as they seem to me based on my own experience. Finally I want to try to answer two questions: 1. Can a commercial publishing organisation succeed in getting HI to front-line health workers in resource-poor countries? (Or is it only governments, the UN and the NGOs that can do this?) 2. Can HI activities be funded by the health care industry - through ads, sponsorship etc. (Or do practical and ethical barriers make this impossible?) A BRIEF HISTORY OF AFRICA HEALTH The story begins some 20 years ago and some 9 years before my own involvement began. AH was started up by Reid Publishing as a sister journal to other publications such as Middle East Health and Far East Health. Looking at those early issues (the very first one had an ad for Land Rovers on the cover!) it seems a very different publication from what it is today. The editorial focus was very broad; the journal was for anyone with an interest in health in Africa: the healthcare industry, the general public (UK and Africa), as well as health workers. It was not as profitable as its sister publications and in time Reid decided to abandon it. (It's interesting though that AH is still going and Middle East Health and Far East Health have long since gone out of publication.) At the time Reid gave up on AH (some 13 years ago) the Editor was Bryan Pearson. He decided to take the journal on himself as, initially, a one-man operation. He also took the decision to make it very much a journal for health workers. As the years have gone by, the amount of practical, particularly clinical, information in the pages of AH has increased. But, as I said, that is not the subject I'm covering today. The advertising has undergone some changes too; those lucrative Land Rover ads have long gone! Most of our advertising has been for healthcare equipment. There seems to be an industry tradition that if you have equipment ads, you don't have pharmaceutical ads and vice versa. But in the last couple of years we have succeeded in getting a few of the drug companies to advertise and indeed we are now getting more revenue from that sector than from the equipment sector. My only significant personal initiative on the advertising side was when a few years back I decided we ought to go after training institutions in the UK and elsewhere to persuade them to advertise their courses to African health workers. Course ads now account for about a quarter of our revenue. So has all this paid the bills? For a long time the answer was yes but only just! Certainly the funds have never been adequate to allow us to turn AH from a modestly sized bimonthly into a thick monthly publication. Then about three years back we hit a patch where the revenue from advertising really wasn't enough at all. (Quite simply companies seem less and less keen to advertise their goods to a continent that has no money.) At this point ODA/DFID stepped in and they have since given a grant towards each issue, which more or less meets about a quarter of our costs. Sadly, the DFID funding has now come to an end and we are solely dependent on ads once again. We expect this to be a difficult year but we have some new ideas and a new head of ad sales and all is by no means lost! HOW IT'S DONE So how does one sell advertising? Someone from DFID asked me recently, 'Are you under a lot of pressure to accept advertising?' Well, hardly. The pressure comes from our side. People don't call up saying 'We want a colour page in Africa Health please'. Our sales team has to go after people and persuade them. For every editorial member of staff one needs an ad sales person who will run up a small fortune in travel and telephone costs. Then of course they have to be paid! Selling advertising also needs a lot of skill and energy, especially when you are offering clients a market that, sadly, they are not particularly interested in. Are there other ways of getting money out of industry? We have done some projects on a sponsorship basis. Our first effort was a supplement on laboratory medicine which appeared in alternate issues of AH for about two years. The first sponsors were Murex Diagnostics. They got just one page of advertising for their money plus a logo on the front cover but they paid the costs of the entire 12-page publication. That meant I had 11 editorial pages to play with. This was excellent! Normally, I have ABOUT 1.5 pages for every page of advertising but I don't know until a couple of days before we go to press how many pages that will amount to. Sponsorship thus has clear advantages over ad hoc advertising sales. However, sponsorship deals don't seem to last very long and despite a change of sponsor our lab supplement has long gone. Likewise a dental supplement is over and done with. At present we have a four-page section bound-into each issue is sponsored by Merck; it covers specifically AIDS. And what about the ethical problems? Have we had complaints from readers about the ethics of any of our ads or our articles? No we haven't. And have we been pressured by advertisers to publish articles urging readers to use their products? Not too often. Some companies have said they will advertise only if we devote a whole article to the merits of their latest widget. We say no and I don't think, in the long term we lose a lot by this. We might gain one ad from one company by bending to pressure but we would alienate rival companies and generally lose respect. What we must do, however, is include articles (albeit independent articles) on certain topics in order to attract in clients active in those areas. Thus we have had articles on renal dialysis, which have told the reader nothing very new, in order to get ads for kidney machines. This happens less often these days. Most sensible clients take the attitude that they would like to appear in a magazine of good quality overall, whether or not their own particular area of interest is covered this month. However, fairly obviously, if our main focus is going to be malaria for example, my sales colleagues will be chasing particularly hard the people who make malaria pills and insecticides. OTHER PROJECTS Another development has been that we won the contract to do the editorial work on Medicine Digest (MD), for its publishers MediMedia. They attend to the advertising, printing, distribution from Hong Kong so we are not involved in that. In the manner of the American who liked his electric razor so much he bought the company that made it, MediMedia liked the work we did on MD so much they bought us! Being part of a major international group should give us more security. The story of MD will be of interest to this audience. It was launched in Nairobi a quarter of a century ago with Hugh de Glanville as its Editor. It was distributed in Africa and the Middle East. Ownership of the journal changed hands several times, though Hugh remained Editor for 23 years. Its circulation expanded into other developing and tropical regions and, by the time MediMedia were in control, Southeast Asia and China were the biggest circulations. Many people who have worked in Africa have told me that MD, not AH, was by far their most important access to the medical literature. Sadly it lost money in Africa (and in the Caribbean and Middle East) for many years before MediMedia finally withdrew it from those regions. Also very sadly, following the southeast Asian crash, it has been withdrawn (one country at a time more or less) from Southeast Asia. It is now only seen in China. Many people are very upset about its loss. We have along the way published other journals and even (thanks to DFID) three books. (They paid for the printing.) At the moment, we have just one other journal currently in publication and that is Caribbean Health (CH), launched last year, with an associate editor in the British Virgin Islands, along very similar lines to AH. Indeed, where appropriate, some articles are used in both journals. CH is going well. PROS AND CONS On top of the fact that advertising brings in the money there are one or two other advantages: 1. Contacts. I have, on a few occasions, been introduced to some good writers by advertising clients. Merck for example have put me in touch with various East African professors who previously I had no knowledge of. 2. Popular 'image'? We think that some readers, particularly the more senior ones, like the glossy style and the high-tech advertising. They feel they are not being palmed off with something done on the cheap for the third world. I am a bit uncomfortable with people who take that kind of attitude but if we can grab the attention of senior people and then argue the case for revitalising PHC then it is no bad thing. Now a look at the negative aspects. 1. Additional costs. I've already mentioned the cost of running a sales department. To please our advertisers we must use better quality paper and print some sections in colour. We also run a reader enquiry service to put readers in touch with advertisers. The costs all ad up. Obviously there is still a profit in selling an ad but not as much as it might appear. 2. Restrictions on circulation. Most publications who take ads feel they have to offer clients a guarantee that they really are sending copies to as many people as they claim. So they sign up with the Audit Bureau of Circulations. This costs more money. The ABC also has rules. To take just one example, all copies must go to named readers, so we shouldn't send to 'The Librarian'. In fact we shouldn't really be sending to a librarian at all as our defined readership is healthcare providers. We have always bent the rules a little bit and some libraries have got copies. In the end, however, we had to leave ABC as we wanted to send a bulk supply of journals to a contact in Nigeria who would put them in the post there which is much cheaper than posting individual copies from the UK. ABC would not allow this. I'm not sure how much oru withdrawal has hurt our advertising sales. We don't have so many rules to stick to now but we still feel we should meet our promise to advertisers that their ads will be seen by senior figures who make purchasing decisions. That means we go to a lot of senior people who probably could afford to pay but we miss out a lot of deserving junior staff, as there isn't enough money to send copies to all those who apply. 3. Pages lost to low-priority topics. I have mentioned the need to cover certain topics regularly to encourage certain clients even though in terms of healthcare priorities these topics are not so important. We also lose a page in most issues by devoting it, with a suitable disclaimer, to press releases describing new products on the market. This is in the hope that we will please clients. 4. Ethical issues. I've mentioned that these don't seem to have been a problem. AH is seen by MaLAM who have only had one minor criticism of one ad so far, which the client has said they will not repeat. We have always said we would not look for baby milk ads. We have recently been asking around quite widely about whether people think such ads would now be acceptable on ethical grounds given what is now know about vertical transmission of HIV but, so far, everyone has given the idea of baby milk ads a thumbs down so we will not be changing our policy. 5. Uncertainties. Whatever sort of funding you go for there are doubts about how much money there will be and for how long but, as I generally don't know until just before we go to press how many pages we will be able to afford to print, you can imagine this causes a lot of frustration. In the last issue of AH we had to drop 8 pages for example. But at the end of the day we still managed to produce a useful journal, albeit shorter than we would have liked, and to post it to people who we know will find it helpful. That's what it's all about. CONCLUSION So to return to my two introductory questions. Can a commercial publisher deliver the goods? My conclusion is yes but only if, as part of its mission statement, reaching underserved health workers is defined as a priority goal. FSG doesn't have a mission statement as such but Bryan Pearson, as the man in charge, has always been quite clear that this is what he is trying to do. I do however doubt whether many companies have the kind of commitment needed. And can advertising/sponsorship be a source of income for HI work? My answer to this is a definite yes. I think we have proved that it can. It may not be enough to be a journal's only source of funding but it can be used as the main source. During our period of DFID support AH was a 'mixed funding' publication and I think this has set an important precedent. Our theme for the evening has been 'where is the commitment to HI provision?' I cannot argue that our advertising clients are all 'committed' but they can most certainly be used a source of funding. The private sector is part of the picture and we should not neglect it. Discussion relating to Paul Chinnock's presentation Fred Bukachi said that, in his experience as a doctor in Kenya, Africa Health was highly relevant and realistic, and had a wide appeal. There is a need to increase its availability to district level – many of the current free subscriptions are at senior level and funds do not allow for distribution of free copies to all those who ask for the publication. In discussing ethical problems with advertising, Joseph Ana indicated that there was often pressure on publications to accept advertising, in view of their dependence on advertising for survival, and that this problem is perhaps even more difficult for local publications. Richard Smith confirmed that some local editions of the British Medical Journal had not succeeded because of problems with advertising. Clarity of communication Andrew Herxheimer pointed out the need to define oneself when using the term `health information', as it means different things in different contexts. He suggested that effective discussion might be more achievable if there were a `taxonomy' of health information. Others agreed and stressed, in particular, the need to focus on a defined target audience in discussing health information issues. Measuring impact Measuring and demonstrating impact was seen to be a key issue in promoting financial and political commitment. There were a number of related problems:
Nevertheless:
Participants agreed that Evaluation was such a key issue that it would be appropriate to devote a whole workshop to this subject (see below). Recognition of the importance of information A number of participants expressed the view that the issue of access to practical health information continues to have low priority among funding agencies and major organizations as compared with, for example, their massive expenditure on infrastructure development. A number of participants suggested the need for lobbying to ensure that major new healthcare projects included an adequate percentage for funding of related information needs. The view was expressed that there is a strong and widespread moral commitment to health information access, but the political and financial commitment continues to be lacking. The question is, how do we convince the 'purse holders' that such commitment is a vital investment for capacity-building and sustainable improvements in health and healthcare. Proposed ActionsA number of participants expressed a need to increase cooperation not only among ourselves, but also with (and among) the major players, including the World Health Organization:
Participants agreed that Evaluation was such a key issue that it would be appropriate to devote a whole workshop to this subject. Initial suggestions included the involvement of one or more health economists as well as small-group discussion format. The need for a target-audience-defined approach (as pointed out by Andrew Herxheimer above) was seen as important for this workshop to keep the required focus.
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