Have you heard of SESH – social enterprise for sexual health? It holds the answer to many of the problems that the dominant model, based on centralized public clinic service delivery has failed to resolve, according to Tucker, Fenton et al. in this month’s PLoS – Medicine. The paper acclaims an alternative approach focussing on decentralized community delivery, multi-sectoral networks and horizontal collaboration.
A new philosophy to change the face of sexual health provision? The claims are certainly grandiose, and the ideas correspondingly abstract. What is SESH, in practice? Clearly, social marketing is central – a term that has been used primarily in connection with condom distribution to denote the subsidized provision of a health product through commercial outlets rather than through public clinics (http://data.unaids.org/publications/IRC-pub02/jc1195-condsocmark_en.pdf). The big idea of SESH is to extend this entrepreneurial model to a range of sexual health interventions with a view to accessing – more effectively, and more efficiently – ‘at risk populations’ (e.g. men who have sex with men (MSM)). An example would be the kind of targeted multimedia marketing campaigns to encourage testing and influence behaviour discussed by Wei, Herrick et al. (http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009337/full). The availability of effective point-of-care-testing apparently offers further entrepreneurial possibilities – and the authors invite us to step into a future in which community based-projects and entrepreneurial projects combining sexual health interventions with the provision of micro-credit or social credit transfers have become the norm for sexual health services delivery.
Of course, these are promising developments. Readers may be interested in the interventions discussed by Lorenc, Marrero-Guillamon et al. in a systematic review published by STI journal, of which a number seem to tick the SESH box (http://sti.bmj.com/content/87/4/272.abstract?sid=ccc02da0-a3ae-455c-a3f7-427891787413). But the specific contribution of Tucker et al. is the contention that these initiatives herald a new “model” of health care provision that challenges the domination of the existing “vertical” model. Tucker et al. do not make a convincing case for this. Certainly the concept of social marketing has proved its worth in the realm of condom distribution (http://sti.bmj.com/content/86/Suppl_1/i56.abstract?sid=ccc02da0-a3ae-455c-a3f7-427891787413). But its relevance surely depends on the existence of a marketable product (i.e. condom). Even if point-of-care STD tests can one day be “marketed” in the same way, Tucker et al. fail to make clear how all aspects of sexual health care could be delivered under such a model. The extension of the social marketing concept by Wei, Herrick et al. to the multimedia marketing campaigns (“a bundle of social benefits”) already seems strained. The links that the authors attempt to draw with micro-credit and social credit transfers seem tenuous. Why put the case for social entrepreneurship in terms of a paradigm shift, rather than as a useful increment to existing modes of intervention? Maybe the answer lies in a fact on which the authors lay considerable stress in their conclusion. “International funding for HIV programs”, they state, “has fallen from US$8.7 billion to US$7.6 billion, and the Global Fund to Fight AIDS, Tuberculosis and Malaria announced there would be no new programs until 2014”. Maybe it is these very conditions which make it somehow irresistible to believe that we can actually do more with less. Nothing short of a paradigm shift in sexual health care provision will mitigate the diversion of resources from the sector.