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good morning I'm alen gattino I'm here
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with Luke Disney who's the executive
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director of the Northstar Alliance
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working out of utest in the Netherlands
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and doing fantastic work uh setting up
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and managing health clinics to address
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uh uh mobile populations who are at risk
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of HIV and AIDS across Africa morning
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Luke hi elen nice to be here how are you
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doing very well thanks thanks can you
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tell us a little bit more about the work
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that Northstar is doing sure so
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Northstar Alliance was set up in 2006 by
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the United Nations world food program uh
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with support from TNT Express a express
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delivery Transport
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company and the issue really um they
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focused on was the fact that HIV at that
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point so we're talking sort of the
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middle beginning 2000s middle 2000s was
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having a devastating impact on Supply
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chains in Africa subsaharan Africa so
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from the h from the world food programs
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perspective this was really about their
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humanitarian supply chain so were they
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were trying to get food from ports out
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to Hungry
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communities and in particular in sort of
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2003 2004 they were responding to a
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crisis in Southeastern
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Africa and they noticed that they
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couldn't find enough trucks to move the
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food from the ports out to the
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communities and this was strange to them
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because normally they're pretty well
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prepared for crisis situations in these
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vulnerable areas and so they've got a
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list of all the transport companies
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they've made estimates on the capacity
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but what they hadn't calculated into
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their model was the impact of HIV which
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was you know on the Rampage at that
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point um in this part of the world so
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they were losing truck drivers or the
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local companies who they rely on were
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losing truck drivers at an enormous rate
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and that as a result was affecting their
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ability to deliver
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food at the same time so the flip side
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of the coin was when they did analysis
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into the situation um they also
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discovered that the very Supply chains
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they were setting up and you've got to
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think of sort of long Supply chains
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hundreds of trucks in some cases going
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into into areas for periods that can be
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up to two years in the case of a
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protracted relief and Recovery operation
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we're also a factor in spreading HIV so
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you have these communities isolated
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relatively isolated communities which
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all of a sudden have this huge influx of
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truck drivers coming
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in and at that point they started they
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got very concerned not only because of
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their own supply chain risk but of of
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course the ethical implications of doing
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trying to do good and at the same time
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inadvertently
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uh bringing harm to some of these
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communities so they um I I remember the
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first time that I was in Africa um in an
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isolated Community when I actually met
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somebody who had full-blown HIV um it
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was a truck driver uh named Edward and
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he was lying in on his back in a Hut in
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the middle of nowhere literally and you
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you were just thinking to yourself how
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in God's name did HIV get to this place
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and and the fact that he was a truck
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driver is probably how he contracted it
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and sadly brought it back to his village
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where infected other people so that was
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wfp's part of the story TNT Express at
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that point um was busy expanding in
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subsaharan Africa and of course as an
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express delivery company also very
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reliant on the transport sector as a
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backbone to move packages this case
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commercial Goods around so together they
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got they were they had already started
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working together on on proving Logistics
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of food delivery and they then turned
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their attention to this issue and really
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um coming at it from Logistics
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perspective as opposed to from a
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traditional Public Health perspective
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they started to say right well where
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what's the problem here and the problem
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is in subsaharan Africa and other places
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that you get truck drivers spend
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enormous amount of time away from home
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um in Africa they're on the road uh
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long-distance truck drivers can be away
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easily for up to 22 26 days a month you
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know on these long areas spending
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enormous amount of time at truck stops
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which are isolated uh parked on the side
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of the ro road where they interact with
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um women who have been forced into sex
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work because of the lack of other
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economic opportunities and really just a
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lot of the time women who have no other
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way of making their their living and
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feeding their families so you get these
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hotpots growing up what we call disease
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hotpots growing around these truck stops
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border crossings ports and this is where
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you get high-risk groups like sex
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workers interacting with what we call
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Bridge groups truck drivers who then
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take the disease HIV in this case back
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to their their families so and it's not
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just diseases like HIV we also see for
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example in the recent Ebola crisis in
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West Africa that mobile populations
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again play an enormous role in spreading
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the disease from one place to the next
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so that's that's how the whole thing got
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started and and the philosophy was well
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if it's happening at these hot spots
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then the traditional Health
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infrastructure of hospitals and high Den
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highly dense uh populations in cities
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and towns is not going to work we need
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to get the facilities or the services
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out to the people in these areas to
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prevent uh the disease from being
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transferred in the first place so we
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started by setting up small
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container-based clinics we used shipping
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containers because they're cheap and
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easy to manufacture to move around and
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also to control the quality uh and if
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you're inside one it looks like a
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doctor's office that you and I would see
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here you know we Ki them all out they've
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got air Co they've got water uh lights
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electricity of course and we started
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putting down these containers with nurse
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uh run teams of with Outreach workers at
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the uh different hotspots and then
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building networks them along the
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transport Corridor so as drivers move
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from one place to the next and sex
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workers who are also mobile we could
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start to build a continuity of care and
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and get into these hot spots uh where
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the actual transmission was happening so
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we started that in 2006 2007 Northstar
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Alliance was created as an independent
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organization to take this forward
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because obviously TNT and wfb had other
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things to do with their time and and
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since then norstar has grown now almost
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10 years later into an organization
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we've got 35 clinics uh in 13 different
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countries at the moment we've served
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over a million people uh we've actually
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helped establish uh 50 different clinics
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in Africa and transferred some of those
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to governments others to other local um
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partners and the networks continue to
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grow and expand so that's in a short
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perhaps not so
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short explanation of who we are and what
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we've done so I remember um back last
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May I was visiting one of your clinics
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in South Africa and I actually um met a
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commercial sex worker who was at the
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clinics uh her name was Michelle and she
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was saying that you know she was telling
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me about the huge difference that the
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clinic had made in her life and uh she
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was saying that she wanted to become her
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ambition was to become kind of the the
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president of the sex workers and so you
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this really made me think that you're
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you're basically giving a voice to
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populations who don't have one in these
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areas and um so I was wondering if you
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could maybe tell me a little bit more
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about how the work that you're doing is
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moving from a sort of top- down approach
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towards Healthcare to maybe a more
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bottoms uh up approach where you're
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really involving these local populations
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in finding solutions to their to to
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these kinds of issues sure and I I think
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that's that's a lesson a really
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important lesson that we learned in the
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process I mean when we started trying to
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figure out how to do this we went in
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with I guess you could describe as the
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typical supply side mentality of an
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orthodox healthare system we will put a
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service in place and then expect people
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come to us and take up the service that
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we have put there and in order to
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improve and become more effective and
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particularly to get the people like the
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sex workers coming into our Clinic
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we realize very cck quickly that you
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can't just go and say this is what we
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think is the problem in your area you
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need to actually address what they
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experience as the problems because
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preventing disease is not something that
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you do by just putting in a one-off
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solution you need to build long-term
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relations with your key Target groups
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and in order to do that you need to be
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talking to them about what they think is
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important to them and what their health
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considerations are so very quickly
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because of that bottomup influx of of
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data or of information we were getting
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from the communities they were saying
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you know HIV is fine but I've got uh a
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child that needs to be inoculated uh
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I've got uh a problem with uh empyema or
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I've got a problem with uh skin rash and
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so a more Primary Health Care uh
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approach was definitely very quickly
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what they were looking for so we very
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quickly I think almost in the first uh
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half year realized that okay we've got
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to position ourselves differently
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because you know you need to be working
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with what their concerns are and I think
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you see that tendency spreading across
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uh not only in our sector of the
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healthcare industry or the healthcare uh
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field you see it other places where
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we've gained a lot of knowledge about
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what health is and are we're in the
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middle of a paradigm shift in my opinion
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that we're moving away from this
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traditional or Orthodox focus on top
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down Supply supply side Health Care
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Services which say okay we've got
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hospitals here doctors the healthcare
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establishment including the
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pharmaceutical industry identifying
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problems and trying to plug gaps which
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is moving towards working with the
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communities and uh people in trying to
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figure out from their perspectives okay
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we know they're going to be go through
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life as a cycle of Health feeling better
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at one point and less uh healthy at
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another Point that's just how we all
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work we're all in constant flux when it
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comes to states of health and if you
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start to work with these people and help
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them to navigate those changes in their
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pattern by leveraging the assets that
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are closer to them as opposed to moving
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into uh something you're trying to guess
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from a top down perspective as to what's
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going to be the remedy at a given point
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in time I think that's that's really
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changing how people are are focusing on
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health and what we're learning you see a
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very big movement now in health as an
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asset so trying to build people's
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capacity to leverage what's in their
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their local communities based on the
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knowledge that the things that impact
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your health are not just contagious
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disease there's been an enormous shift
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in disease patterns over the last
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hundred years where you see in the past
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what was killing people and and reducing
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their quality of life for diseases like
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tuberculosis here in the US and uh
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contagious disease towards what we call
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the non-communicable diseases such as uh
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type 2 diabetes heart disease cancers
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things like that which are influenced by
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a different set of factors and the
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vectors of transmission are not just
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people passing uh pathogens between each
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other they're people are being impacted
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by their Lifestyles and where they're
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living and as a result the way to deal
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with that of course needs to change as
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well so the hospitals the idea of
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bringing everybody together in one place
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to treat them is is really something
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that's changed in people's thinking well
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if we're trying to deal with diseases
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that are caused by people's local
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circumstances and living
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patterns hospital is not really best way
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to approach that is it so one thing
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that's really interesting about the way
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that you've actually organized to
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address this kind of issue and and
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create this bottomup kind of healthcare
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solution is you've got a model that is
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essentially the same for all of the
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countries you work in but you work in a
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number of very different countries and
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these blue boxes still manage to create
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this local embeddedness with the
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communities and so what's kind of the
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what's the secret to actually managing
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um that mix of uh somewhat stand ardized
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system that has clear processes and
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routines and uh ways of measuring
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outcomes but at the same time having
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that that local
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embeddedness I think I think it relates
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back to your previous question and
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turning of of turning your perspective
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upside down instead of looking at it
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from we're coming in to solve the health
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problem to a realization that there are
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so many different factors that influence
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Health that you can only provide one
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piece of that puzzle as a healthcare
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provider today it's very difficult for
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everybody to be good at everything of
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course in terms of healthcare provision
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the person who's going to help you
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prevent getting HIV is not necessarily
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the person that's going to help you quit
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smoking so in order to if you take that
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mentality as I'm a piece of the puzzle
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I'm part of a larger system which
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impacts these individuals
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health and you focus on being as good as
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you can at the one piece of the puzzle
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so in our case running a Primary
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Healthcare Clinic in an isolated
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area that's the starting point but the
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more important aspect I think after that
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is opening yourself up to engaging the
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other pieces of the puzzle to connecting
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with the governments who are able to
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provide additional you know second tier
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services for example or on the other end
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to the community organizations such as
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youth groups or church groups who are
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working with the communities and by
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having a very reliable solid Anchor
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Point for different groups to work with
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um you can really find that you can fit
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into many places places because the
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basic ideas of health services and and
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Primary Health Care Services are pretty
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standard you know how you treat uh a
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disease like HIV is is fairly standard
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uh there are some variations in in
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treatment protocols but that's really to
00:13:12
do with the pharmaceutical side but how
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you do that basic element is pretty good
00:13:17
the mentality of how to work with other
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people is different depending of
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obviously at the at the superficial
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level with what their requirements are
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but the underlying mentality also is
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fairly uniform in
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you have to be open to it and that's
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where it starts that idea that we are
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one piece of the puzzle we're going to
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connect with these other people and help
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them and we're all in this together and
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what's I think uh especially interesting
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is the fact that you're connecting a
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bunch of very different puzzle pieces I
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mean you have partners that go from uh
00:13:46
usaid or Global uh you know Partners to
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to help fund uh healthc care and
00:13:51
development all the way down to the
00:13:53
local dance troop that's doing you know
00:13:55
referrals and advocacy for your clinic
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how do you actually manage to you know
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first of all establish such a diverse
00:14:00
group of partnership set of Partnerships
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and then how do you actually manage to
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leverage them in ways that are going to
00:14:06
improve your Healthcare
00:14:07
outcomes so I I I think the I mean the
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funny thing people ask often I mean how
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do you get a big multinational company
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uh like Chevron or heinan to work with a
00:14:17
local dance you know group from the
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community is is the short the flippant
00:14:22
short answer I suppose is they don't
00:14:23
have to work together you know we can be
00:14:24
there as that linking pin because they
00:14:27
both are reliant on
00:14:29
highquality affordable Clinical Services
00:14:31
to be able to do what they want in the
00:14:33
case of a multinational it could be
00:14:35
keeping their local Workforce uh healthy
00:14:38
in the case of the local community
00:14:40
organization it's the same thing their
00:14:42
their constituents need to be be healthy
00:14:45
but because we're able to leverage
00:14:47
because we we we have that Central
00:14:49
linking role they're both able to come
00:14:51
together and in a way that they probs on
00:14:54
their own would not dealing with each
00:14:56
other directly um we just sort of fit a
00:14:58
gap that's between there and again how
00:15:00
do you do it um I think one of the key
00:15:03
things that we've done and and it starts
00:15:05
with that mentality of wanting to do it
00:15:07
but after that giving your local teams
00:15:09
enough agency in the field that they are
00:15:12
empowered they understand the local
00:15:14
circumstances they know which local
00:15:16
community groups are going to be worth
00:15:17
working with and which ones are perhaps
00:15:19
not going to be as effective or or more
00:15:21
difficult they know the local government
00:15:24
uh Partners they have to work with them
00:15:25
on a daily basis that's not something
00:15:27
you can manage centrally from
00:15:29
particularly not from from the
00:15:30
Netherlands where our head office is
00:15:32
based or our regional office in Nairobi
00:15:34
for East Africa or or Durban for
00:15:35
southern Africa they can't do that so
00:15:39
what we've realized over the time and we
00:15:40
were actually caught I by surprise at
00:15:43
the extent to which our local teams and
00:15:45
and we've been working with you guys to
00:15:46
try and map this out and get a handle on
00:15:48
it but when you prevented presented your
00:15:50
first findings to us you know I think
00:15:52
all of us were shocked at the vast size
00:15:54
of the networks that we had and I
00:15:56
experience it when I go and visit the
00:15:58
clinics but
00:15:59
truly to see to to map that all out then
00:16:02
you realize all of a sudden that you're
00:16:04
the impact you're having as an
00:16:05
organization is much larger than you
00:16:08
perhaps initially
00:16:10
anticipated so I think a lot of times
00:16:15
organizations see a tension between
00:16:20
decentralization in the sense of giving
00:16:22
people agency at the local level to
00:16:24
execute and build those Partnerships but
00:16:27
at the same time wanting to very be very
00:16:29
tight in terms of their control on key
00:16:31
things like quality for example and
00:16:33
maybe even your branding in case of
00:16:35
commercial companies as well but I don't
00:16:38
see there as much inherent intention as
00:16:40
people necessarily think there sometimes
00:16:42
if people know what they're supposed to
00:16:44
be
00:16:45
doing and I think this is where your
00:16:47
culture as an organization is very
00:16:48
important I think it's where your your
00:16:50
the clarity in your mission and your
00:16:53
vision as what to what you want to
00:16:54
achieve are very important if those
00:16:56
things are clear and we train people on
00:16:58
that we work very intensely with our our
00:17:00
teams particularly at the lower
00:17:03
management levels the people running the
00:17:04
clinics to make sure that they not only
00:17:07
that we're giving it to them and saying
00:17:09
this is what you should be thinking but
00:17:10
we've involved them in actually creating
00:17:12
and defining those cultural keystones
00:17:15
our our core values so it really is
00:17:19
coming from them and then we've what
00:17:20
we've done is just taken that codify
00:17:22
it and repeat it and make people aware
00:17:25
of it and constantly remind them and if
00:17:27
they know that and they share that
00:17:29
Vision it's much easier then to give
00:17:31
them the agency to operate at a local
00:17:33
level because you can rest assure that
00:17:37
they are linking that in their own minds
00:17:39
to what you want to achieve as a group
00:17:41
anyways and they're they're a fairly
00:17:43
exceptional group of people for having
00:17:45
LED workshops with them uh last year um
00:17:48
they're they're really extraordinary um
00:17:50
one of the things they have to be really
00:17:51
good at doing is kind of wearing
00:17:53
different hats and adapting to very
00:17:55
different kinds of Partners right
00:17:56
they're developing these ecosystems but
00:17:58
that means means they have to work with
00:17:59
public private nonprofit sector
00:18:01
organizations um and and bring these
00:18:04
pieces of the puzzle together what are
00:18:06
the kinds of implications of having to
00:18:07
bring together organizations Partners
00:18:09
from different sectors um you're talking
00:18:11
about or organizational culture
00:18:13
obviously that's going to be very
00:18:14
different um in terms of the way you're
00:18:16
going to partner and approach with a
00:18:17
public or nonprofit or private sector uh
00:18:21
company
00:18:22
MH I I think um it starts with uh a
00:18:28
natural that that natural um building on
00:18:31
the natural culture of the company is a
00:18:33
starting point but it's not sufficient
00:18:34
in itself I think you have to go beyond
00:18:36
and what we try and work on in groups
00:18:39
and our training programs is helping
00:18:41
people to understand and
00:18:43
identify pitfalls that they can get
00:18:45
themselves trapped into sometimes by
00:18:49
some people who don't and particularly
00:18:51
in certain cultural circumstances at
00:18:53
local levels there may be enormous moral
00:18:56
pressure or community pressure to go in
00:18:59
a certain
00:19:00
direction and to try and give them uh
00:19:03
the tools and uh awareness to try and
00:19:06
protect themselves from getting into
00:19:07
those positions and if they do get into
00:19:09
those positions how do you get yourself
00:19:11
out for example if you're working with
00:19:13
uh a local communities in in some parts
00:19:16
of Africa you may have to deal with uh
00:19:18
the village Chief headman uh who has
00:19:21
certain ideas of how his community
00:19:23
should be run which may be very much at
00:19:25
odds with how the local uh government
00:19:27
authorities think that you should be
00:19:29
delivering your health care
00:19:30
services so how does the local clinical
00:19:32
officer balance those two things because
00:19:34
those are very competing uh edges now he
00:19:37
or she and most we have a lot of females
00:19:40
running our our um
00:19:43
clinics will know what we want to
00:19:45
achieve but still sitting between those
00:19:47
two fires is pretty intense and and can
00:19:50
get very uncomfortable very quickly so
00:19:52
what we've tried to do is build in
00:19:53
escalation mechanisms as well where they
00:19:55
feel that they're under so much pressure
00:19:57
we try and give them as I said
00:19:59
techniques are saying right well don't
00:20:00
commit yourself in this when you enter
00:20:02
into a conversation be conscious of the
00:20:03
fact that you can't go beyond this line
00:20:05
and if you feel yourself pressured to do
00:20:07
that and you're in a tight situation and
00:20:09
we've tried to build escalation measures
00:20:10
so they can always kick it up the
00:20:12
management line and then we can bring in
00:20:14
somebody who doesn't have that local
00:20:16
pressure and that's really effective
00:20:17
sometimes it's just you know I'd love to
00:20:19
help you but my hands are tied oh so
00:20:22
you've uh nicely exploited that bottom
00:20:23
up uh uh concept into the the
00:20:26
organization itself as well I think you
00:20:28
know every every individual um is used
00:20:32
to wearing different hats I mean all of
00:20:34
us um you know whether it's be your
00:20:37
professional hats or your personal life
00:20:39
your your friends compared to your
00:20:41
family there's we're all used to wearing
00:20:42
different things and I think
00:20:44
instinctively a lot of us can figure out
00:20:46
that we're going to get into trouble
00:20:48
sometimes and there are conflicts we
00:20:49
face on a daily basis you know do I go
00:20:50
to my daughter's dance recital or do I
00:20:52
go to that meeting um I think
00:20:55
recognizing that is a natural healthy
00:20:56
part of any management progam process is
00:20:59
important and building in enough
00:21:02
flexibility into your system that helps
00:21:04
people to navigate that in a way that
00:21:06
they're going to feel comfortable with
00:21:07
and spending time talking about those
00:21:09
conflicts so one of the things at the
00:21:10
workshop you were with uh us in South
00:21:13
Africa recently we did spend time going
00:21:16
through role playing situations with our
00:21:18
teams how do you deal with this sort of
00:21:21
thing getting them to share and and a
00:21:24
lot of it's not us going in and teaching
00:21:25
them what to do a lot of it's letting
00:21:27
them share their experiences and talking
00:21:29
about how they solved it because again
00:21:31
their local
00:21:32
knowledge of those situations is far
00:21:35
superior to anything that we're going to
00:21:37
be able to put in in many cases uh from
00:21:40
an external perspective so just by
00:21:42
acknowledging and running them through
00:21:44
it giv the opportunity to practice
00:21:46
exchange ideas can be you know it's not
00:21:49
something that's rocket science but it's
00:21:50
something you have to consciously
00:21:53
recognize as being important MH so these
00:21:56
tensions are they something you
00:21:57
experienced yourself you you started out
00:21:59
in the private sector and then moved
00:22:00
into the nonprofit sector um you know
00:22:03
bridging those two worlds what are the
00:22:04
kinds of tensions that you've
00:22:05
experienced personally in in from a
00:22:08
career perspective moving from from one
00:22:09
sector to the
00:22:11
other yeah not perhaps as many as people
00:22:15
would think
00:22:17
um I I think sometimes people have an
00:22:19
artificial um division in their mind
00:22:23
between and it particularly revolves
00:22:25
around the issue of discipline that that
00:22:26
corporations and the private sector is
00:22:28
by nature very disciplined and NOS are
00:22:32
by Nature not very disciplined and that
00:22:34
is complete fallacy I mean obviously I
00:22:36
think if you look at the vast number of
00:22:38
uh private sector companies that U go
00:22:41
under on a given year uh or don't make
00:22:44
it past their third birthday um or if
00:22:46
you've walked into and had an
00:22:48
interesting customer support uh issue
00:22:51
which many of us have whether it's on a
00:22:53
variety of services then you start to uh
00:22:56
poke through that that veneer quite
00:22:58
quickly on the other hand working with
00:23:01
um a lot of um nonprofits I've seen a a
00:23:05
level of professionality and discipline
00:23:06
that is equal if not surpassing uh a lot
00:23:09
of the NOS the difference of course at
00:23:10
the end of the day is financial reward
00:23:12
in a lot of cases you and that attracts
00:23:14
perhaps different sorts of people into
00:23:16
it um you're not going to become
00:23:18
extremely rich in most cases working in
00:23:20
the nonprofit sector but increasingly a
00:23:22
lot of people are making other choices
00:23:23
in their lives and that's maybe not
00:23:25
their biggest motivation as long as you
00:23:27
can pay your bills
00:23:28
but it's you know so I haven't noticed a
00:23:31
huge difference in in in in that respect
00:23:35
what has surprise me is the amount of
00:23:36
competition that you see in the
00:23:38
nonprofit sector I you know coming out
00:23:40
of the commercial world I thought oh
00:23:41
we're now all going to work together and
00:23:43
it's going to be a better world but
00:23:44
again there is you know competition for
00:23:46
scarce resources and that's something I
00:23:48
think where Northstar has tried to to do
00:23:50
things differently and and positioning
00:23:52
ourselves at somebody who we try and
00:23:53
work with anybody we say in
00:23:56
principle um and to try and really fit
00:23:59
into that that piece of the puzzle
00:24:01
mentality um but it doesn't completely
00:24:04
eliminate that drive for competition at
00:24:06
the end of the day unfortunately Luke
00:24:08
thanks a lot for sharing your experience
00:24:10
and the great work that your
00:24:11
organization is doing my pleasure thanks
00:24:13
very much for having
00:24:24
me
