Bulletin of the World Health Organization

An interview with Sally Stansfield - Who owns the information? Who has the power?

Dr Sally Stansfield
Dr Sally Stansfield

Dr Sally Stansfield is the Executive Secretary of the Health Metrics Network. A citizen of the United States of America, she gained her medical degree at the University of Washington and later studied at Yale. From 1999 to 2006, she was the Associate Director for Global Health Strategies of the Bill & Melinda Gates Foundation. She draws upon more than 30 years of clinical and public health practice, experience in research agencies, universities, governments, nongovernmental organizations, and multilateral agencies. She has designed and managed programmes for the US Centers for Disease Control and Prevention, the US Agency for International Development and Canada’s International Development Research Centre and has advised governments primarily in Africa and Asia.

The Health Metrics Network, which is hosted by WHO, received US$ 50 million in funding from the Bill & Melinda Gates Foundation to improve the quality and reliability of health information in developing countries. Executive Secretary Dr Sally Stansfield says it’s time for the world to shift the ownership of health information to countries instead of letting donors and disease-specific programmes run the agenda.

Q: What has been achieved since the Health Metrics Network (HMN) was launched in May 2005?

A: HMN has worked with countries to produce a framework for the development of health information systems, which has been endorsed by the World Health Assembly. We initially made 65 grants to low- and middle-income countries. These grants have been instrumental in creating a massive amount of momentum and demand for the reform of health information systems. We have had requests from more than 100 countries for financial and technical support. At the outset, we found that many of the sources of health information including census, civil registration and surveys were under the control of the national statistical authorities. The health sector needs the data that is controlled by the national statistical offices to be able to make health-related decisions. In many cases, the health information system managers had never met the national authorities, so HMN has, for example, helped bring these two groups together.

Q: How does HMN fit into the jigsaw with the other organizations that are working to improve statistical feedback, such as United States Agency for International Development (USAID), the United Nations Children’s Fund (UNICEF), and Partnership in Statistics for Development in the 21st Century (PARIS21)?

A: HMN is the only mechanism within countries for joint planning and action by all of these partners, and is uniquely positioned to help transform information systems because it is a network. We help countries to align technical and financial support from all contributing partners. What HMN has added, which has not been seen in the past, is a willingness to integrate information across sources to maintain a new kind of public health intelligence instead of disease-by-disease tracking. This is especially important in the development of global health security.

Q: Are people in the developing world aware that they are missing out on the kind of information that is taken for granted in industrialized countries?

A: No, in general the statistical services in countries are managed by governments and they are used to serve the needs of government officials, so it is rare that those statistics are systematically disseminated to citizens. It is rare [also] that citizens see it as their right to be able to hold their government accountable using those statistics.

Q: If you go to a country that has virtually no civil registration, where do you start? How do you persuade countries to see investment in health information systems as a priority?

A: Often the health system is weak in those places partly because the information system is weak. We begin by helping countries conduct an assessment of their information systems. If managers have the information that they need, citizens understand that they are underserved by their health system and the political pressure to improve services becomes stronger. We can use information to inform civil society to push managers, to push local government and to push nations to improve the quality and access to health services. Strengthening civil registration – birth and death registration – is a long-term plan, and we encourage countries to invest in strengthening the system in a way that will produce some quick wins to improve health decision-making. For example, we are working with many countries to find ways to use real-time information to alert managers to problems such as drug shortages or clusters of unexplained illness.

Q: How is accountability an essential element of health system reform?

A: We are helping countries find ways to hold managers accountable for performance and to reward those who are delivering better results. That way the information system quickly restructures around incentives to make the broader health system work.

Q: Does the need for donor and disease-control programmes to produce evidence of their results prevent countries from setting up integrated health information systems?

A: Countries have always received support from donors and disease-specific control programmes that are targeted to achieve the outcomes that these programmes care most about. It’s rare that support is received to strengthen the system so that countries can pursue the results that they are most committed to. The donors and the disease control programmes should rely upon the systems in countries to get their data instead of getting the data directly themselves, or relying solely on surveys. One of the big barriers to making this happen is that people controlling the business of health development want to make sure that they can assure their flows of money by being able to show results. This is a noble goal but it’s time for the world to shift the control, shift the power, and shift the ownership of the information to the developing country managers.

Q: Is there much international receptiveness to this idea?

A: There is new commitment globally to strengthening health systems in countries. There is increasing recognition that investment solely through disease-control programmes has left countries with systems that are dysfunctional. As each disease-specific group marches through countries with its own survey, it leaves those countries with very little control of the evidence, very little ownership of the data and finally very little ownership of either the health problem or the solution.

Q: Is this a source of major irritation in some countries?

A: Yes. The countries are often quite sophisticated about the data, eager to take on the analysis and committed to making sure that the evidence is owned first and foremost within the country. It’s time for the global community to encourage the trend to use countries’ data rather than using globally generated estimates.

Q: So how do you get an integrated approach for data systems when countries are under siege from the disease-specific programmes that have a lot of money?

A: It’s possible to engage the disease-specific programmes in strengthening health systems. The Global Fund to fight AIDS, Tuberculosis and Malaria, for example, has a new commitment to use its resources not just to benefit the programmes to control the big three diseases but also to enable countries to use those resources to strengthen their systems. The tuberculosis community has realized that investment in information systems will provide much more sustainable improvements in surveillance for tuberculosis.

Q: How can WHO help countries to strengthen their own health data capacity?

A: WHO now works to adjust the statistics that come from individual countries so that they are comparable and credible. Rather than investing solely in analysis to reconcile conflicting information here in Geneva, there should be an increasing willingness at WHO to support development of that capacity in countries. I think we have to be wary of a tendency to centralize the analytic expertise in institutions in the industrialized world.

Q: You started with giving small grants to many countries but now you are isolating smaller numbers of countries for more intensive aid. Why is that?

A: The 65 grants to countries have done an immense amount to increase the demand for information system reform but we clearly need to be able to support that demand and that is a much more expensive prospect. We need to target both technical and financial resources on a small number of countries and show that an intensive approach to information system reform will deliver better outcomes. Cambodia, Sierra Leone and the Syrian Arab Republic are the first three of six countries and there may be more after that.

Q: HMN has funding to last seven years. How will you guarantee the longevity of the network?

A: The founding grant of US$ 50 million from the Bill and Melinda Gates Foundation has been augmented a bit by other donors, but it will obviously cost more than US$ 50 million to transform information systems in developing countries. We need to be very strategic in mobilizing other sources of funding. We are excited about the new global commitment to strengthen health systems. Many of our most important partners are convinced that we can harness the immense potential benefits of information and technology to transform health outcomes for the developing world. ■