In the 1989 classic “Field of Dreams”, a voice tells Kevin Costner’s character, “If you build the field, they will come”. A corresponding zeitgeist that pervades many public health programs might be stated as – “build supply, demand will follow”.
Entering the world of public health to tackle the HIV/AIDS epidemic in India following a long journey with McKinsey & Co, I must confess to entertaining similar ideas, that is, if we could make condoms available to sex workers, they would start using them.
A few months into leading Avahan, the Bill & Melinda Gates Foundation’s India AIDS initiative, I sat with twenty sex workers on the mud floor of a dark hut in the outskirts of Visakhapatnam. “HIV will kill you if you don’t use condoms. You will die within ten years,” I said earnestly. They looked at each other. One, Kollamma, said quietly, “Why don’t you tell us something we don’t know? Ten years is a lifetime. Tell us how to find a life without violence from today.”
That conversation with Kollamma shook me out of my reverie. Supplying the product was not enough to make this consumer use it. She had more pressing issues on her mind—namely her safety and survival. When confronted with a public health delivery challenge the first reaction is often a series of supply-side fixes – enhancing facilities, strengthening last-mile delivery, or building capacity of health workers. The importance of these fixes is undeniable and health outcomes cannot be achieved without addressing these elements.
In my experience, the missing piece in the public health delivery puzzle has been the demand side. This requires understanding consumer behavior – obtaining an intimate understanding of how a person prioritizes health, and seeks access to health services. This can only be achieved by spending days (and nights)in the field, engaging with empathy, with the most affected communities.. The second aspect is to create more active, aware, empowered consumers –by creating awareness and also working on the issues that make them most vulnerable to bad health.
In Kollamma’s case the violence in her life was what prevented her from always using a condom. It was important therefore to address that vulnerability first. Third, and most critically, developing a sense of ownership within the community about the program.
By all means build the field, but also empower and involve the consumer –and then they will come!
– Ashok Alexander is the Founder-Director of the Antara Foundation, a non-profit committed to public health delivery at scale. As India Country Office head for the Bill and Melinda Gates Foundation, he led Avahan, one of the world’s largest HIV prevention programs. Prior to this, he was a Director of McKinsey & Co based in Delhi.
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