Wargaming for health

by Anjali Sastry on September 27, 2009

OK, it may sound like a bit of a contradiction to bring wargames into global health, but the idea is not so much to simulate war but instead to encourage parties who have a stake–or a potential stake–in a global health issue to join in dialog, planning, learning, and negotiating, adding a level of realism to the interaction by carefully structuring the exercise and drawing on a detailed simulation model to generate feedback for participants’ simulated decisions.

We learned about one particular such exercise in 2003 in New Delhi hosted by the Global Business Coalition on HIV/AIDS (now the Global Business Coalition on HIV/AIDS, Tuberculosis, and Malaria), The Confederation of Indian Industry, and Booz Allen Hamilton (now separated in to Booz Allen Hamilton and Booz & Company).

First, to set the stage. What were the conditions facing industry, NGOs, the healthcare sector, governments and others in India then? What were the policy options available to people in these sectors? What did they need to know in order to make the most of the three-day session?

A New England Journal of Medicine series of articles offers an excellent grounding.  Start with the 2007  “HIV in India—A Complex Epidemic” by Robert Steinbrook, M.D., (NEMJ, 356(11): 1089-10930). Also see Steinbrook, 2007, “HIV in IndiaThe Challenges Ahead” (NEMJ, 356 (12): 1197-12010) and “Tuberculosis and HIV in India” (NEMJ, 356(12) :1198-1199), for a more complete picture of HIVAIDS in India at around that time.

boozdiagThe exercise itself is described in a couple of short writeups I found on company sites, the first of which is most comprehensive. See  The AIDS Epidemic: A Strategic SimulationStemming the Crisis in India and HIV/AIDS Epidemic Strategic Simulation.

A press account of the exercise summarizes the results:

Business Wire – October 13, 2003
NEW DELHI, INDIA — Public/private partnerships have a critical role to play in the fight against the HIV/AIDS epidemic in India, according to the results of a process that simulates various factors in the development of the disease and society’s reaction to it. This was one of the most important findings of an unprecedented examination of AIDS in India, which was conducted on October 11-12 in New Delhi, as part of a conference attended by over 200 leaders from government, business and non-profit organizations. This process, called a “simulation,” was the first of its kind focussing on this issue as part of an international Conclave on Accelerating the Business Response to HIV/AIDS, hosted by the Global Business Coalition on HIV/AIDS (GBC) and the Confederation of Indian Industry (CII). The global management consulting firm Booz Allen Hamilton conducted the simulation.

See “New Public/Private Partnerships Needed to Fight HIV/AIDS: Strategic Simulation Provided an Unprecedented Forum for the Generation of Ideas on Accelerating the Business Response To HIV/ AIDS in India.”

So, what were the results of this effort? It was large in scale, scope, and technical complexity; representatives of organizations who had never worked together before–or, in many cases, never addressed HIV/AIDS before–not only talked with each other but also generated new collaborations and steps. For a discussion of these results, take a look at  The AIDS Epidemic: A Strategic Simulation (the first of the reports linked above or via the diagram).

Note: We learned that the past few years have seen downward revisions to the estimates of numbers of Indians infected with HIV; see Steinbrook, 2007, “HIV in India — A Downsized Epidemic” (NEMJ, 358(2): 107-109).

{ 2 comments… read them below or add one }

Peter Hahn September 28, 2009 at 10:27 am

Hi Anjali, thanks for raising the awareness on this important topic. I thought you might find this helpful–I just posted video from the Booz Allen wargame overview meetings. Check out these videos:

Bill Thoet on Wargaming and Simulating the HIV/AIDS situation in India

Leading the Business Responses to the Global HIV/AIDS Crisis – Overview

Booz Allen’s Commitment to the Fight Against HIV/AIDS



admin September 29, 2009 at 12:43 am

Commentary passed along from Greg Snyders, a student in this year’s GHD class:

AMPATH is an innovative healthcare delivery organization and medical research/education network focused on providing integrated HIV care in western Kenya. To better reach the people in its catchment area, AMPATH is considering the implementation of a home-based counseling and testing (HCT) service in which it would employ community health workers (CHWs) to administer in-home counseling and testing services for TB and HIV. The rationale for implementing HCT is that AMPATH has seen incomplete uptake of voluntary counseling and testing services in its area, and there was a strong belief among management that moving “upstream” to the household/community-level would enable AMPATH to better treat HIV at lower cost.

So what about the costs involved? If the per-patient cost of HCT outreach from the pilot in Kosirai Division ($2.59 per patient) is scaled to AMPATH’s entire catchment area of 1.8 million people, the cost of reaching everyone would be $4.7 million. This represents roughly 50% of AMPATH’s annual operating budget from FY08, which suggests that new sources of funding would be required by AMPATH to sustain a comprehensive rollout of HCT alongside increasing expenditures from a growing enrollment of patients, even if HCT was done over the course of several years.

Notwithstanding the costs involved, one of the biggest potential obstacles to HCT is the “silo” focus on TB and HIV counseling and testing. If the rationale for HCT involves an “ethical imperative” to rollback the effects of HIV, according to the Field Director of the IU-MU Partnership, then what about the ethical imperative to treat respiratory infections among adults or diarrhea in children? If a CHW encounters a clear and treatable case of malaria during her HCT visit, what is her obligation to treat it? Or rather, what is AMPATH’s ethical obligation to empower their CHWs with the capability to treat such important causes of death in Kenya?

While HIV treatment ought to command much attention from healthcare organizations in Kenya, a high-touch outreach program such as AMPATH’s proposed HCT program ought to build in the capability to treat or refer patients with other diseases or medical problems that agents of the program will inevitably encounter on a daily basis.

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