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Rethinking the Cookie Cutter: Observations from the International AIDS Society Conference

July 27, 2012 by

What do Sec. Hillary Clinton, Bill Gates, Elton John, UNAIDS Executive Director Michel Sidibé, Senator Lindsey Graham, and 2008 Nobel Laureate Françoise Barré-Sinoussi have in common?

They are all champions for the end of AIDS. Together with other prominent voices, each participated this week in the 19th International AIDS Society Conference. Imagine a global pep rally of scientists, health ministers, political leaders, and activists. Mix in a dissertation defense, add a Morse Code of Statistic Acronym Statistic Statistic Acronym Statistic Acronym. Now top if off with thousands of rainbow condoms, as colorful as the nations and spirited opinions there. 

This year’s conference celebrated 30 years of progress and looked ahead to challenges and opportunity. Botswanan Sheila Tlou, regional Director of UNAIDS, summarized, “We can see the light at the end of the tunnel. And it’s not an oncoming train.”

During her speech calling for an AIDS-free Generation, Sec. Clinton teased, “If you’re not getting excited about this, please raise your hand and I will send somebody to check your pulse.” If only health care delivery was that easy.

Setting financial resources and logistics aside, it’s still not just the pulse, but also the psychology. Medicine and mentality. Stigma and adherence to treatment regimes continue to pose formidable challenges. For progress, as leading scientist and AIDS Hero Tony Fauci said, the biological is inseparable from the behavioral. South Africa’s Yogan Pillay, Deputy Director General for Strategic Health Programs, similarly emphasized the importance of health ministries incorporating both a demand-side and a supply-side intervention.

Noting South Africa’s 50 million population, with 5.6 million people HIV-positive, Yogan joked, “As I get older, I’m believing more and more in a cookie-cutter approach.” There’s something to that, though local context is extremely important.

Case in point: Nigeria. 150 million people. While it’s medically possible for HIV-positive mothers to give birth to healthy babies, only 1 in 5 pregnant women in Nigeria received antiretroviral drugs in 2011 to reduce transmission of HIV during pregnancy. John Idoko, Director General of Nigeria’s National Agency for the Control of AIDS, said that oversimplifies his problem. The challenge is not just the 20 percent average coverage rate; it’s that in some districts it’s 60 percent while in others it’s 5 percent.

It’s hard not to cringe at the mention of a “cookie-cutter approach” in development, but I think I know what Yogan craves. It’s a not a cookie-cutter approach to engaging with each individual. It’s a cookie cutter approach to putting that individual at the center of integrated health program delivery. Quality of care and treatment protocol should not necessarily be determined by geography or staffing. Whether you’re in a rural or an urban environment, a low or high HIV-prevalence district, there can be a shared, or cookie cutter, approach to ensuring access, delivery and adherence to treatment.

Science, resources, and the political will of global leaders is a necessary pre-condition for the end of AIDS. Given that, country ownership of robust, integrated health care delivery systems is proving essential. Systems systematize. When it is locally-owned and driven, at some point a standardized approach is not the dreaded cookie cutter imposed from foreign donors, but instead country ownership of systems thinking.

Let’s not confuse development’s longstanding, valid cookie-cutter critique with the applicability of a call for a systematized approach to making cookies. But first, let’s work on making sure there is some serious dough to support it.


A Principal of the Portfolio Team, Kristin Gilliss (in the photo, above) manages a variety of key relationships at the Skoll Foundation. These include funded social entrepreneurs, domain experts, policy makers, corporate partners and co-funders.  Kristin develops and structures funding opportunities to drive large scale change in the focus areas of the foundation.

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