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W.H.O. still thinks health equals medicine.

Not a WHO Director (source: JHU, Medicine)

Health related, Director-level appointments in the World Health Organization (WHO) are not front-line health workers with well-honed clinical skills. They are Senior Management/Administration. They need to understand resources, politics, and systems. They need to be able to gather, balance and weigh evidence, lead teams, provide advice, develop strategy, and monitor and evaluate performance. All this is done with the support of qualified teams. Where disease-specific knowledge is required, medicine can be useful. It is not uniquely qualifying.

A year ago I wrote that public health is not a specialisation of medicine. Sadly, no one at WHO read the blog. I know this because of the four director level (D1) positions recently advertised by the WHO African Regional Office (AFRO): (i) Regional Emergency Director(ii) Director-Communicable and Noncommunicable Diseases; (iii) Director – Universal Health Coverage/Life Course; and (iv) Director – Universal Health Coverage/Healthier Population. Under “Required qualifications”, a medical degree with postgraduate qualifications in public health is stated to be essential for the first three positions. The requirement is marginally relaxed to “ Medical or health-related degree with postgraduate degree in Public Health or Social Sciences” for the last position.

The WHO view about the relationship between medicine as a qualification and the skills and capabilities required to fulfil the job — when you actually read the duties and responsibilities — is myopic. It is myopic because it creates a baseless, blanket exclusion for potentially excellent candidates. Why limit the pool of excellence that is available? No one is in any doubt that the health problems facing AFRO are massive. Hiring the best qualified people, not necessarily the best medically qualified people, will make tackling that problem a little easier.

Much has been written in the management and leadership literature about the need for diversity of thought at senior levels of organisations. The mantra is, do not surround yourself by cognitive clones. And yet, how much more effectively could one reduce the range of thinking than by restricting the thinkers to those who have all been trained to think in the same way? By identifying medicine as an essential qualification for jobs for which medicine is patently not uniquely qualifying, WHO entrenches particular ways of thinking about health and the delivery of its mandate. D1-Directors climb the ladder to D2-Directors. If you cannot qualify to be a D1-Director without medicine, you are excluded from climbing the ladder to a D2-Director. And thus, WHO develops a culture of thinking about health in which health equals medicine.

Who will cut that Gordian knot?

Flypaper financing: The sticky world of research overheads and indirect costs

As a child, I was always a little grossed-out by flypaper. They were like sticky streamers of death hanging from the ceiling; anything that touched them was lost forever, including the eponymous fly.

Indirect costs, also referred to as “indirects” or overheads, are the flypaper of global health research funding.

Indirects reflect the money from a grant that is caught by the Finance Department before it is made available to the researcher. The money keeps the organisation going: the lights stay on, the rent is paid, the cleaners and security guards turn up, and the management services work.

If a researcher wins a $100,000 grant, after the financial flypaper has caught the indirects, she might receive $80,000. Those who do not come from the worlds of research or global health and development may be slightly appalled by this 25% overhead. Some research funders are. They see the indirect costs as a kind of sleazy tax on the worthwhile research they are supporting. Other funders are reluctant to pay indirect costs or will only pay at a significantly reduced rate, such as 8%. I should also add that there are funders that are fully aware of the issues, and will pay the indirect costs with little or no complaint.

I understand why some funders don’t like the indirect costs. They want to achieve the most significant impact possible for every dollar spent, and this means they want as much of their money to go into doing the research itself and as little money as possible going into general organisational support. Of course, they also want great researchers, good research infrastructure, and appropriate governance and compliance mechanisms. And herein lies the funder-research paradox. There is an obvious relationship between strong research organisations and strong research. Strong research organisations are strong because they have good governance, financial oversight, HR policies and procedures, procurement processes that are transparent, fair, and competitive, decent infrastructure, access to library services, and they also invest in their staff. Continuous professional development of the scientific and non-scientific staff is crucial for the development of strong research organisations. All that (infrastructure, processes and staff development) costs money above and beyond the cost of doing the research itself — and it costs more money than one might think.

Funders need to recognise indirect costs as part of their achievement, not a hindrance to it. Through their funding, they support research and research organisations.

The failure to pay reasonable indirect costs, in effect, forces a form of cross-subsidisation. I know of one university that encouraged staff not to apply for nationally competitive grants because too little was paid by the funder for indirect costs. For every grant that was won, the university ended up having to subsidise the research by picking up the indirect costs. Any research organisation that does that for too long will find itself bankrupt. That was in the Global North.

The situation is different, and in some ways worse, in the Global South research organisations. If the research organisation is essentially regarded by the (usually Global North) funder as a data manufacturer (sample collector) and not an intellectual contributor to the science, there is a greater reluctance for indirect costs to be paid. This recalls the theme of “trickle-down science” that I have discussed in another post.

Having argued, however, about the necessity for indirect costs for research organisations to survive and develop, there can be a darker side to indirect costs. It is the daisy chain of financial flypaper — reminiscent of a recent story I read of a botched assassination in China. A hitman subcontracted an assassination to a colleague, who subcontracted the assassination to another colleague… Five assassins were in the daisy chain and each one took money off the top, before passing on the residual. In global health and development, the financial daisy chain can be seen in large contracts awarded to management companies that skim money off the top as indirect costs, and hand on the residual…

Multilateral agencies can do this with sub-awards. They receive a grant from, say the Gates Foundation, they’ll take out the indirect costs and pass on the residual to an implementing agency — often cautioning them not to overcharge indirect costs. It can also arise from the use of sub-awards offered by research organisations. I have even heard about organisations taking indirect costs from a grant and then a management fee associated with a sub-award before passing it on to the sub-awardee, which will need to remove indirect costs before passing on the residual to the researcher. This can even happen within the same organisation. I win a large grant. The organisation takes out indirect costs. When I pass on a sub-award to a colleague, like a hitman, I take out my management fee first.

Let me say it again, funders need to recognise indirect costs as part of their achievement, not a hindrance to it. Research organisations, however, need to be clear about which part of an award should truly carry an indirect cost and which parts should not.

A literary bibelot

Within a minute I swung from apoplectic to flummoxed.  My erudition had been called into question with an unkind gibe. A friend — truth be told, an impious ragamuffin — started this small, mental kerfuffle by suggesting I would not be able to use a set of 21 words in a single blog post. Was this louse, this piebald swiller serious, or was it waggish humour? Apparently, he was serious. There was no playfulness here.

I confess the challenge did give me the collywobbles. Could I obfuscate? Could I substitute an alternative, thesaurus challenging vocabulary and get away with it? Perhaps there was a set of lexical dregs or suppositious words to hornswoggle the reader. I had it …. a story laden with sesquipedalian, polysyllabic nonsense.

“The mountains ached for the moon to rise and break the thick, tenebrous night. The canvas of a small ketch caught the zephyr wind to pull it across the ….”

Ugh! Jabber! I had macerated this nubbin long enough. If I wasn’t careful I would choke on the challenge, and no wine to quaff. On the other hand, there would be a simple joy in succeeding. With an exuberant ululation from the balcony, I would announce my victory to the world, and he (he who had created this casus belli) would withdraw — vamoose — tail between the moose’s legs.

There was one small problem. Yenta. As in, “she’s such a Yenta”;  a person, especially a woman, who is a busybody or gossip. It was a little too xenophobic for my taste, not to mention misogynistic. What to do? I could not meet the challenge. Hubris won. Who was the moose now?

Relativity in a pandemic

A busy McDonalds is like a well-greased machine. A coordinated team of short-order cooks; staff behind the counter ready to take your order. Queues of people waiting impatiently to pick up their triple burger, hold the onions, no cheese and a flurry of fries. A Manager hovers. Joel, someone’s vomited in the toilets. Sarah, supersize the “meal”. Dinesh, where’s the lady’s McMac?

Time is money. The faster people move through, the greater turnover. The greater the turnover, the greater the profit. It is not just time that is money, space is money too. The more space you have, the more seats you can fit; the more customers you can welcome; the more deep-fryers you can install; the more fries you can produce. Space is money on both sides of the ledger. You have to pay for space, so the space you have needs to be efficiently packed with people.

This is the space-time continuum of business profits. To increase profits, increase trades per unit time and increase customers per unit space.

And then came lockdown! Sand was poured into the cogs of the well-greased machine.

Fortunately, governments have promised a return to “the new normal”. It will be like coming back to a restaurant you have never visited before. When you do return, the McDonalds has changed. Behind the counter, there are fewer people. There are half the numbers of Dineshs to take your order, and fewer short order cooks called Sarah. (The unemployment queues are a little longer. Joel is there.)

No more walking through the front door – there is a limit on the number of people allowed in – but I’m sure it will be worth the wait. Once in, the restaurant feels familiar but somehow more spacious. The bustle and the impatience at the counter are gone. People are standing a prescribed two meters apart. Everything moves a little slower. When you pick up your order and turn to find a table, there is a “wow!” moment. Tables are no longer packed together. There are fewer people seated, and the seating is further apart. You were surprised, however, when you paid – those prices had really gone up. It was no longer a cheap, thoughtless bite-to-eat.

The whole thing takes much longer than you expected, which means you will be late back to the office. Maybe you will think twice, or three times, before coming back, and as you leave, you notice the “To Let” sign in the window.

The neighbourhood has also changed. The cheap but cheerful family restaurant is gone. It survived on volume trade. A well-spaced, sit-down service on melamine plates is too incongruous and too expensive to survive. The “all you can eat” buffets of carbs and fat have also disappeared – too many opportunities for “a Covey” to lick all the serving spoons or sneeze on the mac and cheese.

Fortunately, the internet will save us. Thank you, Google!

Without ever having to see or talk to another human being, you can do it all. You can sit, safe and alone in your bed-sit enjoying a lukewarm meal delivered in takeaway containers. There is an obligatory under-growth of warm, wilted lettuce nestling the spring-rolls; the fries have a flaccidity reminiscent of a moment you’d rather forget; the oils have begun to congeal. The whole experience is perfumed with cardboard and polystyrene. Delicious!