EcoHealth DOI: 10.1007/s10393-013-0851-5

 2013 International Association for Ecology and Health

Forum

Assessing Global Adoption of One Health Approaches William Hueston,1 Jessica Appert,1 Terry Denny,2 Lonnie King,3 Jamie Umber,1 and Linda Valeri1 1

University of Minnesota, Minneapolis-Saint Paul, MN; [email protected]; [email protected]; [email protected] Penna Plc, Belfast, Northern Ireland; [email protected] 3 The Ohio State University, Columbus, OH; [email protected] 2

Abstract: Transdisciplinary One Health (OH) approaches have been rediscovered as a promising tactic for addressing complex health risks at the human-animal-ecosystem interface. However, there is little evidence of widespread adoption of OH approaches as the new operating normal for addressing these complex health issues. We have used a transformational change model as an evaluation tool and part of an overall assessment of the global adoption of OH approaches. This assessment establishes a point of reference for measuring progress toward OH approaches being the new operating normal. Global adoption of OH approaches will require more strategic efforts to build the case (value proposition), recruiting a broader pool of One Health champions, solidifying partnerships and unifying OH efforts. Keywords: One Health, change model, human–animal–ecosystem interface

Transdisciplinary approaches for addressing health risks have gained attention over the last decade as evidenced by a multitude of One Health (OH) meetings, conferences, and new initiatives (Bousfield and Brown 2011; Papadopoulos and Wilmer 2011). Although the OH concept is not new (Kahn et al. 2007; Okello et al. 2011; Zinsstag et al. 2011), health researchers, educators, and practitioners have rediscovered transdisciplinary approaches as a promising tactic for addressing complex health risks at human–animal–ecosystem interfaces. Adoption of transdisciplinary OH approaches represents a transformational change in the way health risks at human–animal–ecosystems interfaces are handled (Webb et al. 2010) because health professions over the last century have become increasingly more specialized and communications between them have decreased (Kahn 2006; Papadopoulos and Wilmer 2011; Zinsstag et al. 2009, 2011).

Correspondence to: William Hueston, e-mail: [email protected]

BELLAGIO ONE HEALTH WORKING GROUP Global OH transformational change was the focus of an international working group of physicians (4), veterinarians (9), and social scientists (7) invited by the authors to gather at the Rockefeller Bellagio Center in Bellagio, Italy from July 26–30, 2011. Over the course of 1 week, the working group (1) reviewed the status of OH implementation; (2) identified challenges, gaps, and opportunities; (3) captured promising practices; (4) reviewed a proposed change model as a potential evaluation tool for OH activities; and (5) agreed on a way forward to further catalyze the adoption of OH approaches globally.

ONE HEALTH IMPLEMENTATION: CATALOG A catalog of OH activities and programs was compiled to inform the working group for use at the Bellagio meeting.

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Web searches for the key phrase ‘‘One Health,’’ interviews of key informants known by the authors, and a listing of OH initiatives in Asia and Europe (Hall and Coghland 2011) were used to develop the draft catalog. Activities limited to educational offerings or specific research projects were excluded from the catalog since the primary focus of the working group was field implementation of OH approaches. Using input from the working group, a catalog of 71 OH initiatives was finalized in 2012 (http://www.cahfs. umn.edu/prod/groups/cvm/@pub/@cvm/@cahfs/documents/ article/cvm_article_419780.pdf). An abstract of each initiative describes the program activities and characterizes: purpose, scope, primary funders, participants, key collaborators, and monitoring and evaluation strategies. The definition of OH used by each initiative is recorded or, in some cases, inferred when no explicit definition could be found. The information sources for the abstracts included publications, websites, and communications with key figures involved with or knowledgeable of the initiative. Draft abstracts were shared with each initiative to solicit edits and corrections.

CHANGE MODEL The Bellagio working group also adapted a transformational change model to characterize the stages of adoption of OH. The model utilizes elements of published models and expert opinion (Kotter 1996; Stone 2010; C. Rubin pers. comm.). Five stages for achieving transformational change are described in the model (see Table 1): 1. 2. 3. 4. 5.

Mobilizing Commitment Developing Shared Vision Aligning Organization and People Operationalization Transformation

The change model does not suggest that the five stages proceed in a linear manner. Rather, the model represents a fluid process where progress through the stages may not always be sequential and transformation is achieved through a cumulative effect. Nevertheless, demonstrating success for each of the stages is essential in achieving and sustaining transformation.

Table 1. Outline of the change model evaluation framework. Stage

Type of change

Description

Mobilize Commitment

Perspective and engagement

Develop Shared Vision

Planning and communication

Align Organization and People

Organization and people capacity

Operationalize

Implementing plan and achieving results

Transform

Sustainability of change and impact

Awareness and recognition of the benefits of change (perspective) and active engagement leading to a critical mass of people supporting the change process A compelling picture is created of what the desired future will look like once the transformational change has been achieved. This vision is widely shared and provides the foundation for strategic and operational plans Engaged individuals and groups develop the capacity (including authority, knowledge, skills, and competence) necessary to deliver the transformational change. Relevant institutions demonstrate commitment to the new vision and strategy through concomitant policy changes, resources (including funding), change of structures, systems, processes, and roles Activities are underway to implement program plans to achieve the vision. Barriers are identified and overcome. Quick wins are achieved to maintain engagement and momentum. Feedback and evaluation are used for continuous improvement and to gather evidence of the value of the change in approach Changes outlined in the vision become the new norm with continual reinforcement of new ways of thinking and behavior resulting in an organizational and professional culture that ensures continued success and impact

Assessing Global Adoption of One Health Approaches

The change model is valuable because it defines the conditions necessary for successful transformational change; it provides an organizing principle or construct that can be applied locally, nationally, or globally; and it drives activities toward impact and transformation based on the adoption and use of OH approaches.

APPLICATION OF THE CHANGE MODEL AS AN ASSESSMENT TOOL The working group recognized the change model as an assessment tool. Each of the 71 initiatives in the final catalog was individually evaluated in the context of the change model (see Table 2). Almost all of the 71 initiatives demonstrated ‘‘mobilizing commitment’’; more than three quarters were able to ‘‘align organizations and people’’; half ‘‘developed a shared vision’’; and 2 of every 5 activities and programs provided evidence of ‘‘operationalization’’. However, only 1 in 10 of the OH activities and programs offered evidence of ‘‘transformation’’. These results suggest that not all of the prerequisite stages of change had been addressed to catalyze the adoption of OH globally. Further, an aggregate evaluation of all the catalog activities and programs indicated the adoption of OH approaches is not widespread across all sectors and issues. Major challenges identified by the working group include a lack of clarity regarding the definition of OH, difficulty in identifying the scope of activities that benefit from OH approaches, and the need for more research evidence of the benefits of OH approaches. Additionally, the catalog reaffirms findings of others that the OH initiatives are primarily focused on infectious disease, with many activities and programs incorporating the human and animal components, but very few addressing ecosystem components or the incorporation of private sector partners (Okello et al. 2011; Papadopoulos and Wilmer 2011). Promising practices demonstrated by initiatives in the catalog, include evaluations to support learning from past experiences, documentation of benefits from OH approaches that gained high level political support, and the incorporation of simulation exercises that provide an opportunity to practice OH skills and create work plans. These points of consensus from the working group are in line with much of the OH literature available today (Okello et al. 2011; Papadopoulos and Wilmer 2011; VWB/VSF 2010; Zinsstag et al. 2009).

NECESSARY STEPS FOR CATALYZING GLOBAL ADOPTION OF ONE HEALTH APPROACHES The working group reached overall consensus on the need to implement a global strategy to promote the adoption of OH approaches. They unanimously supported previous OH efforts and concluded that if adoption of OH approaches is going to move to the next level of impact and importance, it is essential to create a more cohesive and defined vision and strategy. Participants agreed that advocating for OH approaches requires evidence of strong scientific underpinnings that demonstrate the approach makes biological, economic, and scientific sense. They also recognized that not all evidence is equal and that different stakeholders require different forms of evidence. Policymakers, political officials, and governmental officials have thresholds for evidence that can differ considerably from that of scientists or researchers. For some, sufficient evidence already exists for adoption of OH approaches. For others, a more comprehensive view of multiple projects is required to appropriately gauge the value of OH approaches. Although more evidence needs to be gathered, the working group agreed that efforts should continue to garner support for OH approaches among key stakeholder groups. Analyzing current OH activities and programs in the context of a change model informed the development of a global adoption strategy. The interdisciplinary working group reached consensus that global adoption of OH approaches for addressing health risks at the human– animal–ecosystem interface will require: • More strategic efforts to build the case for OH approaches using different types of evidence for different stakeholders (perhaps utilizing compelling stories or case statements and the change model described here); • Recruiting and mobilizing via global communications a broader pool of OH champions from diverse sectors, disciplines, and perspectives such as corporate, political, non-governmental, philanthropic, academic, and public policy sectors; • Solidifying partnerships through demonstration of the OH value proposition (i.e., how OH approaches deliver superior outcomes for key stakeholders); and • Unifying OH efforts to enhance opportunities for securing resources necessary for implementing and sustaining OH approaches worldwide.

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Table 2. Change model stages, types of change, and evaluation questions. Stage

Type of change

Evaluation questions and change roadmap for One Health

Mobilize Commitment

Perspective and commitment

Develop a Shared Vision

Planning and communication

Align Organization and People

Organization and people capability

Operationalize

Implementing plan and achieving results

1. Is there clear evidence that program participants recognize the need for change to a transdisciplinary, holistic, outcome model that will help to attain optimal results in tackling complex health issues and achieving sustainable change in the three domains of human, animal, and environmental health? 2. Have all relevant stakeholders (government, NGO, IGO, private sector, other) been identified and engaged? 3. Are new communities being developed that reflect professions, disciplines, agencies, and organizations working in a more integrated and collaborative way? 1. Is there a shared vision for One Health? 2. Does the vision define the desired ‘‘future state’’ for One Health in detail? 3. Is the vision based on the perspectives of a broad cross section of stakeholders? 4. Have the gaps between the ‘‘current state’’ and the vision been identified? 5. Is there sufficient change readiness and capability to lead the change? 6. Has a strategy and operational plan with clear, logical, and time bound steps been agreed upon to address the gaps? 7. Has a communication strategy been developed and implemented to communicate the vision and reinforce new thinking and behavior among the stakeholders? 8. Is there evidence of a high level of buy in for the vision? 9. Is there clear ownership for the operational plans? What evidence is there of the following being aligned with the One Health vision and strategy: 1. Relevant institutions engaged 2. Relevant policy changes implemented 3. Sufficient funding in place 4. Roles, responsibilities, and authorities clarified 5. Systems and processes established 6. One Health leadership capability developed 7. Education and capacity building addresses both short-term issues and a long-term strategy of training students in One Health throughout school system, from primary school to post-graduate 1. Are operational plans implemented? 2. Is a monitoring and action planning process in place? 3. Is there evidence of collaboration and data sharing? 4. Are barriers identified and overcome? 5. Are quick wins planned for and achieved to sustain and build commitment and momentum? 6. Do quick wins fit with long-term strategies? 7. Are contributions and achievements recognized? 8. Is there an effective and efficient use of resources? 9. Is evaluation conducted to gather evidence at the output, outcome, and impact level? 10. Are feedback and lessons learned used for continuous improvement? 11. Are successes celebrated?

Assessing Global Adoption of One Health Approaches

Table 2. continued Stage

Type of change

Evaluation questions and change roadmap for One Health

Transform

Sustainability of change and impact

1. Are new systems and structures embedded at a global and/or local level to support the transformation? 2. Is there continuous monitoring, review, assessment and sharing of best practices? 3. Is One Health Leadership demonstrated at all levels, as well as across disciplines and countries? 4. Are there collaborative and effective partnerships in place at all relevant levels? 5. Is there evidence of new collaborations, alliances and partnerships operating effectively? 6. Have additional resources been leveraged to allow expansion of the One Health effort? 7. Is there evidence that One Health has been incorporated into the organizational culture? For example: a. One Health success stories circulating b. One Health ‘heroes’ c. One Health self-reinforcement 8. To what extent: a. Has the future state/vision been achieved? b. Does it require modification? c. Have the goals and objectives been achieved? 9. What impact has been achieved? 10. Has the documented impact been shared broadly with health professionals, policy maker, politicians, partners and stakeholders?

This assessment of the current status of OH implementation establishes a point of reference for measuring progress. The change model also may provide a useful tool for planning and implementing OH approaches in order to maximize their sustainability. Ultimately the success of global OH implementation will be evident when OH approaches become the new operating normal for addressing complex health issues at the human–animal–ecosystem interface.

ACKNOWLEDGMENTS The authors would like to thank the Rockefeller Foundation for funding this project and the team at the University of Minnesota who assisted with the compilation of the Catalog of One Health Activities and Programs (Kelley Johnson and Maria Carolina Pelaez Gil) and James Nyoro for his thoughtful contributions to evaluation methods. The authors also wish to thank the One Health colleagues of the working group: Charlanne Burke (USA), Ilaria Capua (Italy), Dennis Carroll (USA), Sarah Cleveland (UK), Katinka De Balogh (Netherlands), Eduardo Gotuzzo (Peru),

Delia Grace (UK), James Hargreaves (UK), Geoffrey Kabagambe Rugamba (Uganda), Laura Kahn (USA), Danilo LoFoWong (Denmark), Sayoki Mfinanga (Tanzania), Moses Osiru (Uganda), Esther Schelling (Switzerland), Lertrak Srikitjakarn (Thailand), and Daniel Stone (USA).

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