Appropriate Research Methods

2. Introduction

Downstream vs. Upstream Approaches to Health Policy

Let’s start with an exotic example to illustrate an important concept in health policy – the problem of neonatal tetanus in South East Asia, and local efforts being made to combat this serious condition.

At one point deaths from neonatal tetanus had reached 50 percent of live births in some areas: infants with this condition occupied most of the available hospital beds.  Local health authorities, in a desperate search for a solution, sought consultant advice from overseas experts (from a major US School of Public Health).

These experts visited the region, reconfirmed (quantitatively) the needs already well understood locally and proposed the inappropriate building of neonatal intensive care units: the cost of this recommendation was absurd given the tiny amount available for health care in that developing country.  Rejecting the advice of these outside experts, and with help from locals more familiar with cost constraints, health authorities assembled kits consisting of a small handkerchief size piece of cotton cloth, a tiny bottle of Dettol (a disinfectant) some bits of soap, a piece of cotton thread and a razor blade.

This kit was distributed to Traditional Birth Attendants (TBAs).  When delivering babies these TBAs used the cloth as a clean field; they washed their hands with the soap bits; they cut the cord with the razor blade, tied it with the cotton thread and then disinfected it with the Dettol.  Within a short period of time neonatal tetanus was under control.  The cost per kit was just a few cents.

It worked – it was cost efficient, it was culturally acceptable, and it was usable by available staff within the existing indigenous system. In other words, this technology was neither high nor low, but appropriate to the problem.