Honour to be here this evening, especially to see the room full as it is,
I'm I was actually here 13 years ago when I did the course that they mentioned the masses and African studies.
I was at St. Cross at St. Christ, and so the Connexions are just endless here this evening.
But it's my absolute pleasure to to talk about my topic this evening,
which is reflecting on on some of the failures I've had in some of the work that we've done in health care,
in different bits of Africa and on the sense that Africa works.
And so moving on and I'm interested in it looks like it's in kind of Monaco.
It looks like it's in the south of France or Biarritz or something like that, doesn't it?
It's the West Coast of Scotland and it doesn't look like this. It's usually like shades of grey and brown, but it's where I'm from.
And I'm immensely proud to come from there, but it isn't a very multicultural place.
I didn't grow up in a kind of multicultural milieu with lots of experience of other people from different parts of the world around me.
Instead, I grew up in a quite insulated place. And so most of my understandings of Africa were from the news and being as old as I am ancient.
I grew up in the 90s and my my, my dad was a big consumer of news programmes.
The Six O'Clock News, Seven O'Clock News, news night. There were question time.
All of these things I watch lots of. And unfortunately, during that period in Africa, there was, of course, lots of wars, famine Rwanda.
Lots of devastating events. And it was from these east.
I accrued my kind of rough image of what Africa was.
And of course, seeing lots of heroic journalists and humanitarians working against that backdrop, I thought, Yeah, that looks exciting.
And from my perspective, in the west coast of Scotland, with the rain coming down,
it seemed like a very kind of interesting and satisfying career to pursue.
So that was how I started today, and about 10 years later,
I find myself in Camp Cooper on the planet after working for Medecins Sans Frontieres Medical Sinfonietta, as they are that I had many,
many technical challenges when I was there and anything that I say here,
I don't mean to to lessen or look past the technical challenges that we have working in places like that.
There was a massive cholera outbreak that was Marburg, a viral haemorrhagic fever very much like Ebola.
There were drug resistant TB and lots and lots of malaria and malnutrition and things like that.
So there were lots of technical challenges, and in many ways that was that was the kind of test that I was looking for.
But much to my surprise, I also made very good friends. We went for beers.
We went for kizomba. Don't I wouldn't do any because they're safe and you're safe.
But the my point is that there was a whole rich tapestry of social connexions and
culture that I hadn't even given much thought to if I'm being absolutely honest.
And that was very impactful to me because it changed my view of of my work and gave me some more a bit more of a sense of myself,
my own place and in that context.
Towards the end of my time there, I also had a very interesting experience with them handing over a big pharmaceutical stores.
It was a big drugstore and a big pharmacy, and it was probably had about 50 60 thousand dollars worth of very rare drugs in in the stores.
And I was tasked with this quite technical challenge of handing over to the Ministry of Health,
who are picking up this task, picking up the ownership of the hospital and off the drugstore.
It's the strobe effect in the air at the moment that adds to the drama.
But yeah, the the project went quite well. I thought it was very similar to things that I'd done as an engineer previously.
We train people up. We did the paperwork. I did the computer system.
I had people working for me there who can have trained people as well, and it was a big effort.
Eventually, there was a kind of celebration in the town, handing over and pictures and all that good stuff.
And then by the next morning, about half the stock had gone after the handover and within 48 hours, every last PillPack in there had gone.
It wasn't my drugstore. At that point, we'd handed it over to the Ministry of Health and to the people that we trained.
But there was no break in. There was no kind of actual overnight theft.
It was a very organised, planned thing. It obviously happened concurrent with my efforts to hand it over.
So that was quite devastating to me.
And when I phoned up my boss and in Luanda, the kind of traditional French kind of sense, she was like, Move like these things happen.
But for me, it was it was pretty devastating.
And so I thought I better learn a little bit more about context and about culture, because when I came to reflect on it, I thought, Well,
we're handing over 50 60 thousand dollars worth of extremely rare drugs in this particular area
area where lots of people need them without a lot of faith in the institutions to use the.
Is drugs well, at the same time, we were handing over our contracts with people who may not then get any kind of pay from the Ministry of Health,
and so they were being asked to look after this really expensive set of drugs
that they probably thought were going to be squandered anyway by someone else. If they didn't, then take them.
So the idea that we would hand them over as an NGO working there and hope that
they would be used in some altruistic way and the way that MSF would like,
according to their high ideals, was kind of absurd.
So that setting in that place in that time, it was a high aim.
But and there's nothing wrong with high aims, but be practical about what you're doing and think about the likely outcomes of your actions.
So that was one of my first real lessons along this way.
And then luckily, very luckily, I I joined the masses that was aforementioned this young young fellow here.
I barely recognise him. But yeah, him the I was very lucky to get on that course.
I was an engineer and it was a social science master's and I went for a drink with Dave Anderson a couple of years ago,
who'd kind of, you know, allowed me to be on that course. And I asked how the course was going, and he talked about all the rich talent.
There may be people on that course here tonight.
It's a very hard course to get on and congratulations to anyone that's on it this year because he said to me,
you would never, ever get on that course anymore. It's the standards went right up.
But for me, it was a really kind of pivotal moment,
and I'm immensely grateful to the people that did take a bit of a gamble on me and did spend time to help me help me learn.
One of the first hard lessons I had was kind of about the colonial period in Africa and about how a sequence,
a whole series of young officers, young men, often Scottish, actually would go out to Africa to try and build a reputation for themselves.
That this is a wonderful backdrop of kind of perilous natural heart of darkness,
kind of backdrop in which to paint yourself as a saviour and as a pioneer and an adventurer.
And it was a bit of a bitter pill to swallow because as of course, they explain this to me,
I recognise this guy in the boat and and his aspirations and why he might be there and thought that.
And it gave me pause to think about what my own place was on these projects and what I was aiming to do.
Was I there for, for myself or for the people around me?
And that that beginning of some kind of reflexivity and the challenges that we take on in health care was really extremely important to me.
But so too is some of the theory that came up. And it's funny that I chose this to talk because I don't really love either of them.
You don't have to love the theory that that helps you learn necessarily. But Africa works.
I kind of stole the title from from from this book. And with the notion being that things that we see as is being kind of corrupt and
rob tell or talk about how that's a fairly blunt and useless term a lot of the time,
or at least disorderly and chaotic, perhaps serve some ends.
And, you know, extending from that and perhaps in a more helpful way in any kind of status quo situation where you've
got a complex set of arrangements and cultural norms that you don't that are unfamiliar to you,
there's probably somebody who gains and somebody who benefits from the way things are and
learning that and accepting that and thinking that any situation that that you're in,
you probably need to unpack that if you had to do some technical job. But then it was a really, really cool moment for me.
But also these guys on the on your right or the corner of the kind of husband and wife team and they write a lot about, well,
did write a lot after maternity in the sense that the end point or that what Africans are pursuing and what what people in Africa would
like to achieve is not necessarily some kind of has anything to do with modernity that we have in in the UK or in Europe probably does.
But you can expect that you can't assume that. And so these were really useful lessons for me in in the work that I went on to do.
Fast forward again a few years, and I'm working for Oxford Health Systems Collaboration,
a group based in the tropical medicine department here and with a paediatrician called Mike English.
Mike isn't here this evening, so I can. I don't have to worry about him blushing, but he's an amazing guy and a really hard worker.
And he's worked for about 25 years in paediatrics in Kenya, and he knew a lot about neonatal wards in Nairobi.
And he explained to me that that there were enormous ratios of babies to individual nurses working in newborn units in Nairobi.
And so a single nurse, according to the W.H.O. recommendations, should deal with a maximum of four children in the night shifts that we observed.
We sometimes saw one nurse to 40 children. And so you can imagine the quality of nursing that happens under that kind of those kind of ratio.
Isn't very high, and it results in the numbers you see it in the kind of really sad statistics that come out of those words.
So his idea was to look at this idea called tax shifting, where you would have a new cadre of staff.
We have them in the UK. They're called health care assistants and that kind of like a lower level nurse
who could do some very simple but very effective things for these babies,
such as keeping them warm and fed and clean and those kinds of things.
And so his idea was to to see whether or not this would be a good idea now in health care and in this kind of area.
Global health, the way that you would have traditionally done this is just to try it.
You'd have taken your idea whole. You'd have done it in one situation and not done it in another and measured the
outcomes of both and then decided whether or not it was a good idea based on that.
But that hasn't really worked because in these complex health systems that have culture elements and social elements and politics and economics,
you can't you can't make those assumptions that that every everywhere you test, the idea will be the same.
And so our idea was not just to drop in this external idea and see whether or not it works,
but rather to study the context for a good couple of years beforehand, trying to learn as much as we could and then rethink about this,
this project and think about whether or not it is a good idea and make changes to the
project and to this new position such that it has got a better chance of succeeding.
So that's what we did, and I'm happy to say the the paper for that, we wrote.
There's a few papers published already on this,
but there'll be one in social science and medicine that was just accepted to anyone that's really interested.
I think I can share that with them, I'm sure. But yeah, that that that way of approaching the project was entirely new,
and I don't think I would have been able to understand it in the way that I did.
Had I not been on this journey from from before, the last thing I'd want to share with you is is pretty much my favourite project I've ever worked on.
It's it's a smartphone app that works a little bit like TripAdvisor and helps people in Kenya find laboratory services.
So the idea is that they, unfortunately, in a lot of public hospitals in Kenya and elsewhere,
we're learning when they go to get a medical lab test done, they often the testing is not available.
And so they're sent out into the private sector.
And the private sector is kind of parasitic on public hospitals in Kenya, and they don't do a very good job.
They don't really prioritise quality turnaround, turnaround time, price and classical economics terms.
This is very asymmetric the the the relationship between the patients and the providers.
And so the market is very failed. It's kind of broken.
So the idea is that by sharing some of this information to patients that they would be able to make better choices,
more rational choices and that in turn, this would condition the market. So this was the original idea.
But you know, having the experience I had, I didn't have to. We didn't stick to this too strongly.
And on my first few trips kind of, you know, doing some interviewing, trying to find out why kid on the street.
We realised that this perhaps wouldn't work very well. There was, but also on the flip side, that there was a very strong regulator in Kenya.
Now I see a strong regulator. They don't actually have a budget. The Ministry of Health gives them no money, but they do.
They are competent. They never really know their job very well.
And so unfortunately, they have to generate all of the funds they need to survive and to do that, quality tracking of medical labs from licencing.
And so inevitably, their efforts go mostly into the licencing job and not into the quality side.
And so it's starting to kind of form in my head, what could we do something with these guys and help them recover their licences?
And then similarly, they may help to regulate the market more?
And so what was one platform and one app has become three different elements the
app that helps clinicians and patients find better labs and find better prices,
quality, et cetera, et cetera, sometimes just for availability. Because if you've got TB and you need a PCR back diagnosis,
you may walk for many miles and not be able to get what you need and be mistaken in travelling to a particular hospital where they don't have it.
So it does work for different kinds of conditions. But we also have the second and third elements there,
one which is a dashboard for the regulator that helps them understand what's going
on to be to flag up labs that are underperforming and get getting bad results,
but also to recover some of their licence fees. And finally, a portal for the for the labs.
And again, I don't think we would have been able to have done this had I not have had the experience to design the project in the way that we did.
And so, yeah, I'm going to open up for questioning things. It's probably a better way to do this kind of format,
but three things for me to take away my from my learnings so far and working in health care in Africa.
And that's first to.
Flexibility that that kind of understanding our own place in in these contexts and understanding that as much as you think, you know,
there's no there's really no substitute for for doing work on the ground,
spending time speaking to the people who live in work and in the conditions that you're hoping to change.
Number two context is not something that gets in the way of your otherwise perfect project.
Context isn't something that stops you doing your job perfectly. It's the means by which you make your project work.
And as soon as you start understanding that working with context in that way,
you've got such a better chance you can try and push out context and design your your trials and so on such that they're perfect.
That's helping no one as soon as they get into the real world, the full over,
and there's a million global health interventions that have went that way.
And then third, design the projects that you've got a chance to explore these things.
If you don't, if you don't set up your project with and help educate the donor a lot of the time,
you need to do the groundwork that you need to spend time on the ground learning before you dig into,
you know, measurable results and big change programmes and all these things they want.
It's just going to be another failed project. So those are my three points.
Thank you very much for listening to me, and I think I open up for questions or yeah.