Health is another arena that makes vivid the ways in which the global and local interpenetrate in our everyday lives, often revealing stark social, economic, and political inequities in access to care and resources. As a Senior Manager and Group Lead for Health Systems at VillageReach, Jessica Crawford ('10, MA in Policy Studies) focuses on the “last mile”—the distance spanned when delivering healthcare to the most underserved communities on earth.
Working in Tanzania and the Peace Corps as a Community Health Educator, and later in clinic care settings, Crawford recognized that “The real problem was not that people needed more doctors but that they needed systems to support the doctors that are there.” This insight prompted her to enroll in the Master of Arts in Policy Studies. While enrolled, she began volunteering for VillageReach, a Seattle-based non-profit focused on improving access to quality healthcare in the Global South.
With VillageReach, Crawford went to Malawi to start a new training program for pharmacy assistants. At the time, there were two tiers of pharmacy training in Malawi: a five-year degree program to become a pharmacist, and a three-year diploma to become a pharmacy technician. As in the United States, those with higher levels of training generally gravitated to living and working in urban areas, leaving a lack of trained pharmacy personnel at remote health facilities. In the language of VillageReach, there was a supply chain breakdown in the last mile. Crawford helped establish a lower barrier two-year certificate training program: upon completion, certified pharmacy assistants are posted in rural areas.
Crawford, who also holds a master’s degree in Public Health, notes that “All the work that we do at VillageReach – and that any organization working on building effective public health systems does – is embedded in the policy realm. All the training I received in the Policy Studies program – stakeholder mapping, understanding people’s interests, working with governments, working with donors, working with implementing organizations, and being able to navigate that framework – is what really made me effective in my work in Malawi.” In particular she highlights the leadership and management preparation she developed in policy studies, and relied upon in her fieldwork.
Asked for an example, Crawford describes the set-up of the Malawi program. “Because of my training in Policy Studies, I knew I needed to understand the environment I was working in. On arrival, I immediately began a full stakeholder analysis – who were the players, who’s involved in what, where are the investments, what are the levers I have to pull on to get this program launched and successful, and to get real buy-in from the people to whom this will matter in the long run. VillageReach ultimately is an organization that pilots and test innovations, and scales and sustains them through other implementing organizations and entities in the public or private sector. Knowing that this was a program that I would back out of in a few years, I needed to set it up for long-term success.”
As Lead for the VillageReach Health Systems group, Crawford now works with her colleagues back in Seattle to apply these skills. As part of this effort, she notes that the work of VillageReach is not just a one-way street, moving information and services along the last mile. The last mile is a two-way street. Perspectives of those living in underserved areas need to circulate back out to the organizations and policy makers at the international level.
“A huge theme in our work is the major disconnect between global level policy and ‘last mile’ realities,” says Crawford. “If you go to, say, a health center in rural Malawi and ask them to tell about where they get their medicines, what they’re going to tell you is the policy that regulates how it should be. It’s so important that they tie things to this policy. But when you really dig in and examine things at the local level, you see all the challenges and barriers to actual implementation. This information does not flow out from the ‘last mile’ to inform policy. This is where I really think that a group like VillageReach can come in, by bringing that ‘last mile’ perspective to policy makers, whether at the country or global levels,” says Crawford, “We don’t want to just push policies down the line, not realizing that it just doesn’t work the way you say it should.”
Looking to the future, Crawford says, “The global health sector is at a really great point in time. We are now looking to really build capacity at the local level. That is my goal, that the global level stakeholders pay attention to the people at the ‘last mile’ and work to build their systems, and to support them, with their realities in mind.”
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