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good morning I'm alen gattino I'm here with Luke Disney who's the executive
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director of the Northstar Alliance working out of utest in the Netherlands and doing fantastic work uh setting up
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and managing health clinics to address uh uh mobile populations who are at risk of HIV and AIDS across Africa morning
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Luke hi elen nice to be here how are you doing very well thanks thanks can you tell us a little bit more about the work
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that Northstar is doing sure so Northstar Alliance was set up in 2006 by the United Nations world food program uh
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with support from TNT Express a express delivery Transport company and the issue really um they
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focused on was the fact that HIV at that point so we're talking sort of the middle beginning 2000s middle 2000s was
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having a devastating impact on Supply chains in Africa subsaharan Africa so from the h from the world food programs
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perspective this was really about their humanitarian supply chain so were they were trying to get food from ports out
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to Hungry communities and in particular in sort of 2003 2004 they were responding to a
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crisis in Southeastern Africa and they noticed that they couldn't find enough trucks to move the
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food from the ports out to the communities and this was strange to them because normally they're pretty well
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prepared for crisis situations in these vulnerable areas and so they've got a
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list of all the transport companies they've made estimates on the capacity but what they hadn't calculated into
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their model was the impact of HIV which was you know on the Rampage at that point um in this part of the world so
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they were losing truck drivers or the local companies who they rely on were losing truck drivers at an enormous rate
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and that as a result was affecting their ability to deliver food at the same time so the flip side
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of the coin was when they did analysis into the situation um they also discovered that the very Supply chains
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they were setting up and you've got to think of sort of long Supply chains hundreds of trucks in some cases going
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into into areas for periods that can be up to two years in the case of a protracted relief and Recovery operation
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we're also a factor in spreading HIV so you have these communities isolated relatively isolated communities which
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all of a sudden have this huge influx of truck drivers coming in and at that point they started they
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got very concerned not only because of their own supply chain risk but of of course the ethical implications of doing
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trying to do good and at the same time inadvertently uh bringing harm to some of these
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communities so they um I I remember the first time that I was in Africa um in an
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isolated Community when I actually met somebody who had full-blown HIV um it was a truck driver uh named Edward and
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he was lying in on his back in a Hut in the middle of nowhere literally and you you were just thinking to yourself how
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in God's name did HIV get to this place and and the fact that he was a truck
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driver is probably how he contracted it and sadly brought it back to his village
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where infected other people so that was wfp's part of the story TNT Express at
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that point um was busy expanding in subsaharan Africa and of course as an express delivery company also very
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reliant on the transport sector as a backbone to move packages this case commercial Goods around so together they
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got they were they had already started working together on on proving Logistics of food delivery and they then turned
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their attention to this issue and really um coming at it from Logistics perspective as opposed to from a
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traditional Public Health perspective they started to say right well where what's the problem here and the problem
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is in subsaharan Africa and other places that you get truck drivers spend enormous amount of time away from home
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um in Africa they're on the road uh long-distance truck drivers can be away easily for up to 22 26 days a month you
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know on these long areas spending enormous amount of time at truck stops which are isolated uh parked on the side
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of the ro road where they interact with um women who have been forced into sex work because of the lack of other
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economic opportunities and really just a lot of the time women who have no other
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way of making their their living and feeding their families so you get these hotpots growing up what we call disease
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hotpots growing around these truck stops border crossings ports and this is where
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you get high-risk groups like sex workers interacting with what we call Bridge groups truck drivers who then
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take the disease HIV in this case back to their their families so and it's not
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just diseases like HIV we also see for example in the recent Ebola crisis in West Africa that mobile populations
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again play an enormous role in spreading the disease from one place to the next so that's that's how the whole thing got
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started and and the philosophy was well if it's happening at these hot spots
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then the traditional Health infrastructure of hospitals and high Den highly dense uh populations in cities
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and towns is not going to work we need to get the facilities or the services out to the people in these areas to
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prevent uh the disease from being transferred in the first place so we started by setting up small
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container-based clinics we used shipping containers because they're cheap and
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easy to manufacture to move around and also to control the quality uh and if you're inside one it looks like a
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doctor's office that you and I would see here you know we Ki them all out they've
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got air Co they've got water uh lights electricity of course and we started putting down these containers with nurse
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uh run teams of with Outreach workers at the uh different hotspots and then building networks them along the
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transport Corridor so as drivers move from one place to the next and sex workers who are also mobile we could
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start to build a continuity of care and and get into these hot spots uh where the actual transmission was happening so
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we started that in 2006 2007 Northstar Alliance was created as an independent organization to take this forward
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because obviously TNT and wfb had other things to do with their time and and since then norstar has grown now almost
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10 years later into an organization we've got 35 clinics uh in 13 different countries at the moment we've served
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over a million people uh we've actually helped establish uh 50 different clinics
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in Africa and transferred some of those to governments others to other local um partners and the networks continue to
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grow and expand so that's in a short perhaps not so short explanation of who we are and what
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we've done so I remember um back last May I was visiting one of your clinics
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in South Africa and I actually um met a commercial sex worker who was at the clinics uh her name was Michelle and she
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was saying that you know she was telling me about the huge difference that the clinic had made in her life and uh she
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was saying that she wanted to become her ambition was to become kind of the the president of the sex workers and so you
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this really made me think that you're you're basically giving a voice to
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populations who don't have one in these areas and um so I was wondering if you
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could maybe tell me a little bit more about how the work that you're doing is
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moving from a sort of top- down approach towards Healthcare to maybe a more bottoms uh up approach where you're
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really involving these local populations in finding solutions to their to to these kinds of issues sure and I I think
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that's that's a lesson a really important lesson that we learned in the process I mean when we started trying to
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figure out how to do this we went in with I guess you could describe as the typical supply side mentality of an
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orthodox healthare system we will put a service in place and then expect people come to us and take up the service that
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we have put there and in order to improve and become more effective and particularly to get the people like the
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sex workers coming into our Clinic we realize very cck quickly that you can't just go and say this is what we
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think is the problem in your area you need to actually address what they experience as the problems because
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preventing disease is not something that you do by just putting in a one-off solution you need to build long-term
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relations with your key Target groups and in order to do that you need to be talking to them about what they think is
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important to them and what their health considerations are so very quickly because of that bottomup influx of of
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data or of information we were getting from the communities they were saying you know HIV is fine but I've got uh a
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child that needs to be inoculated uh I've got uh a problem with uh empyema or
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I've got a problem with uh skin rash and so a more Primary Health Care uh approach was definitely very quickly
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what they were looking for so we very quickly I think almost in the first uh half year realized that okay we've got
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to position ourselves differently because you know you need to be working with what their concerns are and I think
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you see that tendency spreading across uh not only in our sector of the healthcare industry or the healthcare uh
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field you see it other places where we've gained a lot of knowledge about what health is and are we're in the
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middle of a paradigm shift in my opinion that we're moving away from this traditional or Orthodox focus on top
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down Supply supply side Health Care Services which say okay we've got hospitals here doctors the healthcare
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establishment including the pharmaceutical industry identifying problems and trying to plug gaps which
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is moving towards working with the communities and uh people in trying to figure out from their perspectives okay
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we know they're going to be go through life as a cycle of Health feeling better
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at one point and less uh healthy at another Point that's just how we all work we're all in constant flux when it
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comes to states of health and if you start to work with these people and help them to navigate those changes in their
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pattern by leveraging the assets that are closer to them as opposed to moving into uh something you're trying to guess
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from a top down perspective as to what's going to be the remedy at a given point
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in time I think that's that's really changing how people are are focusing on
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health and what we're learning you see a very big movement now in health as an
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asset so trying to build people's capacity to leverage what's in their their local communities based on the
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knowledge that the things that impact your health are not just contagious disease there's been an enormous shift
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in disease patterns over the last hundred years where you see in the past what was killing people and and reducing
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their quality of life for diseases like tuberculosis here in the US and uh contagious disease towards what we call
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the non-communicable diseases such as uh type 2 diabetes heart disease cancers things like that which are influenced by
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a different set of factors and the vectors of transmission are not just people passing uh pathogens between each
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other they're people are being impacted by their Lifestyles and where they're
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living and as a result the way to deal with that of course needs to change as well so the hospitals the idea of
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bringing everybody together in one place to treat them is is really something that's changed in people's thinking well
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if we're trying to deal with diseases that are caused by people's local circumstances and living
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patterns hospital is not really best way to approach that is it so one thing that's really interesting about the way
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that you've actually organized to address this kind of issue and and create this bottomup kind of healthcare
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solution is you've got a model that is essentially the same for all of the countries you work in but you work in a
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number of very different countries and these blue boxes still manage to create this local embeddedness with the
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communities and so what's kind of the what's the secret to actually managing
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um that mix of uh somewhat stand ardized system that has clear processes and routines and uh ways of measuring
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outcomes but at the same time having that that local embeddedness I think I think it relates
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back to your previous question and turning of of turning your perspective upside down instead of looking at it
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from we're coming in to solve the health problem to a realization that there are
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so many different factors that influence Health that you can only provide one piece of that puzzle as a healthcare
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provider today it's very difficult for everybody to be good at everything of
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course in terms of healthcare provision the person who's going to help you prevent getting HIV is not necessarily
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the person that's going to help you quit smoking so in order to if you take that
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mentality as I'm a piece of the puzzle I'm part of a larger system which
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impacts these individuals health and you focus on being as good as you can at the one piece of the puzzle
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so in our case running a Primary Healthcare Clinic in an isolated area that's the starting point but the
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more important aspect I think after that is opening yourself up to engaging the other pieces of the puzzle to connecting
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with the governments who are able to provide additional you know second tier services for example or on the other end
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to the community organizations such as youth groups or church groups who are working with the communities and by
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having a very reliable solid Anchor Point for different groups to work with um you can really find that you can fit
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into many places places because the basic ideas of health services and and Primary Health Care Services are pretty
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standard you know how you treat uh a disease like HIV is is fairly standard uh there are some variations in in
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treatment protocols but that's really to do with the pharmaceutical side but how
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you do that basic element is pretty good the mentality of how to work with other
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people is different depending of obviously at the at the superficial level with what their requirements are
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but the underlying mentality also is fairly uniform in you have to be open to it and that's
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where it starts that idea that we are one piece of the puzzle we're going to
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connect with these other people and help them and we're all in this together and
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what's I think uh especially interesting is the fact that you're connecting a
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bunch of very different puzzle pieces I mean you have partners that go from uh usaid or Global uh you know Partners to
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to help fund uh healthc care and development all the way down to the local dance troop that's doing you know
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referrals and advocacy for your clinic how do you actually manage to you know first of all establish such a diverse
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group of partnership set of Partnerships and then how do you actually manage to leverage them in ways that are going to
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improve your Healthcare outcomes so I I I think the I mean the funny thing people ask often I mean how
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do you get a big multinational company uh like Chevron or heinan to work with a local dance you know group from the
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community is is the short the flippant short answer I suppose is they don't have to work together you know we can be
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there as that linking pin because they both are reliant on highquality affordable Clinical Services
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to be able to do what they want in the case of a multinational it could be keeping their local Workforce uh healthy
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in the case of the local community organization it's the same thing their their constituents need to be be healthy
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but because we're able to leverage because we we we have that Central linking role they're both able to come
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together and in a way that they probs on their own would not dealing with each other directly um we just sort of fit a
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gap that's between there and again how do you do it um I think one of the key
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things that we've done and and it starts with that mentality of wanting to do it
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but after that giving your local teams enough agency in the field that they are empowered they understand the local
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circumstances they know which local community groups are going to be worth working with and which ones are perhaps
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not going to be as effective or or more difficult they know the local government
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uh Partners they have to work with them on a daily basis that's not something
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you can manage centrally from particularly not from from the Netherlands where our head office is
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based or our regional office in Nairobi for East Africa or or Durban for southern Africa they can't do that so
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what we've realized over the time and we were actually caught I by surprise at
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the extent to which our local teams and and we've been working with you guys to
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try and map this out and get a handle on it but when you prevented presented your
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first findings to us you know I think all of us were shocked at the vast size of the networks that we had and I
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experience it when I go and visit the clinics but truly to see to to map that all out then
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you realize all of a sudden that you're the impact you're having as an organization is much larger than you
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perhaps initially anticipated so I think a lot of times organizations see a tension between
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decentralization in the sense of giving people agency at the local level to execute and build those Partnerships but
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at the same time wanting to very be very tight in terms of their control on key things like quality for example and
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maybe even your branding in case of commercial companies as well but I don't
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see there as much inherent intention as people necessarily think there sometimes
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if people know what they're supposed to be doing and I think this is where your
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culture as an organization is very important I think it's where your your the clarity in your mission and your
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vision as what to what you want to achieve are very important if those things are clear and we train people on
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that we work very intensely with our our teams particularly at the lower management levels the people running the
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clinics to make sure that they not only that we're giving it to them and saying
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this is what you should be thinking but we've involved them in actually creating
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and defining those cultural keystones our our core values so it really is coming from them and then we've what
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we've done is just taken that codify it and repeat it and make people aware of it and constantly remind them and if
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they know that and they share that Vision it's much easier then to give them the agency to operate at a local
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level because you can rest assure that they are linking that in their own minds to what you want to achieve as a group
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anyways and they're they're a fairly exceptional group of people for having
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LED workshops with them uh last year um they're they're really extraordinary um
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one of the things they have to be really good at doing is kind of wearing different hats and adapting to very
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different kinds of Partners right they're developing these ecosystems but that means means they have to work with
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public private nonprofit sector organizations um and and bring these pieces of the puzzle together what are
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the kinds of implications of having to bring together organizations Partners from different sectors um you're talking
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about or organizational culture obviously that's going to be very different um in terms of the way you're
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going to partner and approach with a public or nonprofit or private sector uh company
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MH I I think um it starts with uh a natural that that natural um building on the natural culture of the company is a
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starting point but it's not sufficient in itself I think you have to go beyond
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and what we try and work on in groups and our training programs is helping people to understand and
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identify pitfalls that they can get themselves trapped into sometimes by some people who don't and particularly
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in certain cultural circumstances at local levels there may be enormous moral pressure or community pressure to go in
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a certain direction and to try and give them uh the tools and uh awareness to try and
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protect themselves from getting into those positions and if they do get into those positions how do you get yourself
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out for example if you're working with uh a local communities in in some parts
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of Africa you may have to deal with uh the village Chief headman uh who has certain ideas of how his community
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should be run which may be very much at odds with how the local uh government authorities think that you should be
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delivering your health care services so how does the local clinical officer balance those two things because
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those are very competing uh edges now he or she and most we have a lot of females
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running our our um clinics will know what we want to achieve but still sitting between those
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two fires is pretty intense and and can get very uncomfortable very quickly so what we've tried to do is build in
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escalation mechanisms as well where they feel that they're under so much pressure
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we try and give them as I said techniques are saying right well don't commit yourself in this when you enter
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into a conversation be conscious of the fact that you can't go beyond this line
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and if you feel yourself pressured to do that and you're in a tight situation and
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we've tried to build escalation measures so they can always kick it up the management line and then we can bring in
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somebody who doesn't have that local pressure and that's really effective
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sometimes it's just you know I'd love to help you but my hands are tied oh so
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you've uh nicely exploited that bottom up uh uh concept into the the organization itself as well I think you
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know every every individual um is used to wearing different hats I mean all of us um you know whether it's be your
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professional hats or your personal life your your friends compared to your family there's we're all used to wearing
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different things and I think instinctively a lot of us can figure out that we're going to get into trouble
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sometimes and there are conflicts we face on a daily basis you know do I go to my daughter's dance recital or do I
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go to that meeting um I think recognizing that is a natural healthy part of any management progam process is
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important and building in enough flexibility into your system that helps people to navigate that in a way that
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they're going to feel comfortable with and spending time talking about those
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conflicts so one of the things at the workshop you were with uh us in South Africa recently we did spend time going
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through role playing situations with our teams how do you deal with this sort of
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thing getting them to share and and a lot of it's not us going in and teaching
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them what to do a lot of it's letting them share their experiences and talking
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about how they solved it because again their local knowledge of those situations is far
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superior to anything that we're going to be able to put in in many cases uh from
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an external perspective so just by acknowledging and running them through it giv the opportunity to practice
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exchange ideas can be you know it's not something that's rocket science but it's
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something you have to consciously recognize as being important MH so these tensions are they something you
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experienced yourself you you started out in the private sector and then moved into the nonprofit sector um you know
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bridging those two worlds what are the kinds of tensions that you've experienced personally in in from a
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career perspective moving from from one sector to the other yeah not perhaps as many as people
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would think um I I think sometimes people have an artificial um division in their mind
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between and it particularly revolves around the issue of discipline that that corporations and the private sector is
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by nature very disciplined and NOS are by Nature not very disciplined and that is complete fallacy I mean obviously I
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think if you look at the vast number of uh private sector companies that U go under on a given year uh or don't make
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it past their third birthday um or if you've walked into and had an interesting customer support uh issue
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which many of us have whether it's on a variety of services then you start to uh
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poke through that that veneer quite quickly on the other hand working with um a lot of um nonprofits I've seen a a
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level of professionality and discipline that is equal if not surpassing uh a lot
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of the NOS the difference of course at the end of the day is financial reward in a lot of cases you and that attracts
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perhaps different sorts of people into it um you're not going to become extremely rich in most cases working in
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the nonprofit sector but increasingly a lot of people are making other choices in their lives and that's maybe not
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their biggest motivation as long as you can pay your bills but it's you know so I haven't noticed a
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huge difference in in in in that respect what has surprise me is the amount of competition that you see in the
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nonprofit sector I you know coming out of the commercial world I thought oh we're now all going to work together and
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it's going to be a better world but again there is you know competition for scarce resources and that's something I
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think where Northstar has tried to to do things differently and and positioning ourselves at somebody who we try and
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work with anybody we say in principle um and to try and really fit into that that piece of the puzzle
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mentality um but it doesn't completely eliminate that drive for competition at
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the end of the day unfortunately Luke thanks a lot for sharing your experience and the great work that your
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organization is doing my pleasure thanks very much for having me