One of the things that came out of the midyear retreat in Rwanda for the African-based fellows was the idea to have a small group of us host monthly discussions around different social justice and global health equity topics in an effort to increasingly get the GHC community dialoguing about health equity and justice topics.  In February we looked at the effectiveness of foreign aid & I’d share with the rest of the GHC community and our supporters what we covered:

The Effectiveness/Ineffectiveness of Foreign Aid

Within the international development community the debate over the effectiveness of foreign aid has been going on for decades, with supporters on one side arguing for more aid to developing countries and those on the other side who think aid is what is keeping developing countries poor.  Here is just a small sampling of some of the information out there on both sides of the debate:

Good aid; Bad aid

The recent book, Dead Aid, by Dambiysa Moyo, sparked a lot of discussion around the effectiveness of foreign aid.  In her book, Moyo calls for the end of foreign assistance within the next 5 years argues that foreign aid has actually hampered development by creating aid dependency among nations.  Check out her website (hotlinked above) for more info on the book and her point of view, or read a review of the book by Paul Collier, author of The Bottom Billion.

Or take a look at Ghanaian economist George Ayittey on “Dead Aid” At TED.  Check out his TED Talk and read an excerpt from an interview with him on Dead Aid, as well as the 6 institutions he thinks every African nation needs to develop.

In his interview, Ayittey brings up the doctrine of “odious debts”, which states that debts undertaken by corrupt regimes which ultimately are not used to not benefit the people of the state should not then be the responsibility of the citizen’s of that state to repay.  This argument has been used in favor of debt relief initiatives, such as the Jubilee Network, for countries who incurred huge foreign debt that was largely embezzled by corrupt dictators.

However, not everyone thinks aid should be decreased.   In a recent blog posting, Shanta Devarajan, Chief World Bank Economist for Africa, discusses why aid to Africa needs to increase, not decrease, during the global recession.

A recent article in Global Health Magazine, also brings up the difficulties NGOs face in trying to harmonize local needs with donor demands:

“In a country like Botswana where the majority of funding comes from international donors, it is challenging for organizations to keep in line with their original mandate. NGOs often shift their priorities to meet the needs of donors as opposed to the needs of the communities”

International efforts to improve aid effectiveness

Given the widely agreed upon difficulties with foreign aid, whatever side of the debate you are on, there have been international efforts to make aid more effective.  The Paris Declaration and Accra Agenda for Action (AAA) are two international efforts, led by the OECD, to coordinate foreign aid and improve aid effectiveness.   Specifically, the AAA, which builds on the Paris Declaration and was signed in 2008, calls for:

• Predictability – donors will provide 3-5 year forward information on their planned aid to partner countries.
• Country systems – partner country systems will be used to deliver aid as the first option, rather than donor systems.
• Conditionality – donors will switch from reliance on prescriptive conditions about how and when aid money is spent to conditions based on the developing country’s own development objectives.
• Untying – donors will relax restrictions that prevent developing countries from buying the goods and services they need from whomever and wherever they can get the best quality at the lowest price.

Monitoring the Effectiveness of Aid

There are many organizations that track the effectiveness of aid.  Just a couple examples are:

• AidWatchers.com – A blog by William Easterly, author of White Man’s Burden, which monitors aid; where it goes and how it’s used.  Check out this recent post for an interesting discussion on the recent disaster in Haiti and how the aid pouring in for relief efforts is being coordinated (or not).

(Plus don’t miss this hilarious post about African leaders advising Bono on reforming U2 – http://aidwatchers.com/2009/11/african-leaders-advise-bono-on-reform-of-u2/)

• The Center for Global Development – A Washington DC based think tank that has a number of resources and initiatives looking at the effectiveness of aid.  Check out this interesting blog post about the Center’s Cash on Delivery program, which links funding directly to outputs by developing nation governments.

The Center also has a HIV/AIDS Monitor: Tracking Aid Effectiveness initiative which evaluates the effectiveness of funding for HIV from the three biggest donors: PEPFAR, the Global Fund and the World Bank.  Check out this paper comparing the funding practices of all three.

So what do Gen Y’ers or millennials or whatever they are calling us these days think about health care reform? Well according to some new research by the Pew Center, we are a pretty apathetic bunch. But I can’t say I was too surprised when I saw this in a Newsweek blog because since the 2008 Presidential election, our generation has been on a downward swing in political engagement. I understand that it is a mighty feat to generalize an entire generation, because there are those of us out there that are passionate about this and want to see real change—we wouldn’t be part of Global Health Corps otherwise—but I find engaging many of my peers on conversations surrounding health care reform to be very difficult. Either they don’t think it will really affect them (wrong), they just aren’t informed (sad) or they are generally fed up with Washington’s politics (most).

Maybe we are more apathetic because we have come of age in the hyper-polarized decade of Congress where we have not had the luxury of seeing many bi-partisan reforms pass. And to me, health care reform has become the poster child for millennials’ current apathy. Youth voter turnout for the 2008 Presidential election was one of the largest ever, yet for the Massachusetts Senate race youth turnout was the lowest of any age bracket. Only 15% of eligible voters under the age of 30 heading to the polls, compared to upwards of 57% for other age brackets. The election in Massachusetts characterized the apathy of millennials, and put a halt to the health care reform’s momentum.

Have we written off health care reform as falling victim to the back-door deals and compromises? Or is it because numbers and cost projections just do not resonate with us?

Congress has made health care reform about economics, not people and thus we have lost the ethical argument for reform—that everybody should have access to medical care when needed.

I think Kliff is correct when she writes: “…the more attractive part of health insurance for millennials, these poll numbers indicate, is the moral underpinnings of the bill: that all Americans ought to have access to insurance, that this is our responsibility as a nation. While 47 percent of millennials generally support health-care reform, 70 percent support the idea that all Americans should have access to affordable health insurance, the highest number for any demographic. Maybe we’re just young and idealistic, maybe we have genuinely different viewpoints than our parents; either way, that provision really strikes a chord with younger Americans. But the bill has not been sold that way—if it had, perhaps more millennials would strongly support health-care reform instead of the kind of, sort of, support we see now.”

Obama ran on a feel good platform of hope and change. And while that got the attention of my generation, when Congress began the cold, hard logistics of what reform would look like, we tuned out. Call me an idealist but when Obama meets with Congressional leaders in a televised event on Feb 25, maybe, just maybe. its time to couch health care reform not just in terms of cost or number insured, but in the moral language that had so many of us excited for health reform before party politics took a hold. And then maybe we will begin to see some of my generation’s apathy fade away.

At my last job in the US we desperately tried everything we could to avoid having meetings. We tried a “no meeting day” or tried to establish a rating system to get rid of meetings that received low scores.

In contrast, people LOVE meetings in Tanzania. Why? Because meetings here mean money.

Tanzania has the puzzling common practice of paying people to attend work meetings. They’re not paid for being the keynote speaker or even for presenting. They pay people JUST to ATTEND. So, as you might imagine, many of the training sessions or work meetings I’ve gone to have had many attendees but very little audience participation or engagement.

In response to this, Goodluck and I have tried different ways to facilitate learning and capacity building during meetings for health workers in Kilwa. Traditional trainings occur with large groups in a central location, requiring participants to travel there (and organizations to pay for their travel expenses as well as their attendance). Instead, Goodluck and I travel to them and do 2-on-1, on-site training with workers in the facility for shorter but much more focused and concentrated teaching sessions that we’ve found to be effective despite the short amount of time we spend in each facility (1-1.5 hours).

Despite the value of the on-site trainings, one of our goals is to build community between local groupings of health facilities as a means of establishing decentralized health management. Therefore, we do include one larger group training session in our training program where we pay participants to attend. However, we call it a Data Workshop instead of training and have designed a number of exercises and tests that have meeting attendees working together on analyzing data and identifying problems. In this way, we force participation and engagement much beyond the traditional sit, listen, collect money, go home that defines the current design of meetings/trainings.

We went one step further in our most recent data workshop this past Tuesday. Though Goodluck and I disagree with the ‘payment for meeting attendance’ method, we still comply with the culture. After all, it does seem to be a great way to ensure people actually come. However, we thought we could change the way an attendee earned their allowance and increase participant’s interest in the material in the process. Instead of getting a flat allowance for meeting attendance, we gave our participants two data tests, one at the beginning of the day and one at the end, and told them that they’d earn bonus money depending on how much they improved (we told them this after they took the first test).

Participants’ scores on this exercise had averaged ~2 out of 8 in the past and the first test of the day with this group was no different: they averaged 2.5 out of 8. After explaining our program to them, however, participants were much more engaged throughout the rest of the day’s training and finished the second data test averaging 7.5 out of 8 as a group (a 200% increase)! The results meant both bonus money earned by participants and increased confidence in their abilities to improve how they collect and analyze data in their own facility.

On top of that, Goodluck and I are particularly excited about the fact that the district health management team in Kilwa has started to adopt and incorporate many of these practices into other meetings and trainings they run. They were also very interested to hear, and we’re eager to report, the outcomes of our “pay for performance (not attendance)” method.

Goodluck and I are always on the lookout for ways to innovate and improve existing systems in our work and redesigning the meeting has been a great achievement for us so far.

Here are some videos of us mid-data workshop!

This week, Jeff and I visited all of the Expert Clients in the 12 health centers around the district to distribute some needed supplies. Whenever we visit an Expert Client at their site, we always ask them what challenges they are facing, and work then with the Expert Client, relevant health center staff, and any other appropriate Ministry of Health or CHAI staff to try and address the issue. As we went around this week, we listened to and noted the persistent list of challenges faced by each Expert Client, such as stock outs of HIV test kits and medications, the limited capacity of HIV testing and counseling counselors to absorb the high volume of patients needing these services, and continued fear and stigma in the community towards HIV leading women to try and hide their HIV status from health center staff and Expert Clients. But amongst all the challenges, this week we were also so clearly reminded of all of the triumphs the Expert Clients create and experience everyday.

At the first ever “All Expert Client Meeting” held in December, Jeff and I asked the Expert Clients to share some of the “Success Stories” that they have experienced with their clients. Using the jargon of “Success Stories”, which I feel is a loved phrase in the public health and international development world, the Expert Clients at first gave us a bit of blank, confused stare. Once we started explaining the meaning of a “Success Story”, the Expert Clients started breaking off into their small working groups, buzzing with stories to share with one another. Six Expert Clients shared their stories with the larger group, but we asked the others to please write down one story to give to us when we next visited their site.

Honestly, we hadn’t followed-up on this since December and thought most Expert Clients had probably forgotten to write-up their story. But this week, after listening to a long list of challenges faced by one of our Expert Clients, we asked her, reluctantly, if she had remembered to write down any of success stories. Given all the challenges, I was even worried she might have been too discouraged to write anything for us. Of course I was wrong. She excitedly grabbed her notebook and showed us a story she had written on the first page. We were about to tear out the page to take with us when we realized that half of the book was full of stories of clients who she felt had been positively impacted, accessed services, or made a healthy changed since she started counseling them!

As we went from site to site throughout the week, the stories kept coming, and I saw within the Expert Clients a determination to continue to do their work, despite all of the challenges, because of the lives they see changing right before them, changing in ways they know and understand personally because they have once been there themselves! Jeff now has over 30 stories to translate for our records, and that isn’t even all of the stories!

As we are preparing for a 6-month evaluation of the Expert Client Initiative, we are designing the evaluation to contain both quantitative and qualitative data. While we will most certainly gather and critically analyze quantitative data from Expert Client records on clients and health facility records on figures surrounding HIV testing, ART enrollment, and other important health service uptake and outcome indicators in our evaluation, these numbers will reflect only part of the impact of the Expert Clients. When trying to evaluate the impact this program is having on the lives of women, children and families in Malawi, qualitative data like “Success Stories” from the Expert Clients, and the clients themselves, cannot be ignored.

I can’t believe six months has already gone by, half way through the fellowship already. Cliché as it sounds time really is flying by.  We just finished our mid-year retreat for Global Health Corps here in Rwanda and it was great to see the GHC staff and fellows from Tanzania and Malawi. One of the really cool things we were able to do was cross site learning; discussing our work’s challenges and successes.

This year many of us are working on supply chain issues and one re-occurring theme that will impact my work for the next six month is supply chain data capture. This data capture is essential forecasting pharmaceutical and consumable needs, as well as tracking stock management improvements.  In many in country supply chains in the developing world, the management of supply chain information is insufficient impacting everything from the central medical stores to the patient.  Without adequate information the health centers, district pharmacies, and central medical stores are unable to manage the supply chain efficiently.

In light of these problems, my main project for the next six months is data collection and forecasting for the district of Burera. I’ll be supporting the district pharmacy in supervising the health facilities in the district (health centers and health posts). This supervision tracks consumption, as well as stock management data, thus improving supply data capture and assessing stock management. The hope is with regular data capture, the district pharmacy will have a better idea of the supply chain reality within the district, be able to track stock management improvements, and enhance supply chain data to improve forecasting of pharmaceutical and consumable needs.

As the Burera pharmacy manager and I often say ‘petit a petit’ or little by little. It sometimes feels daunting when you see all the of the challenges that in county supply chains are facing but hopefully in the next six months we can really make an impact little by little on the supply chain here in Burera.

I just read a great article sent to me from my GHC mentor about product design and wanted to share: When Technology Flops: 6 Common Pitfalls for Product Design for Social Good

Pitfall #2 hit home for my project.

Pitfall #2: Using technology to solve a culture-based problem. Sometimes, the most fundamental issue isn’t tech-related. For instance, female infant mortality in many countries is largely the result of cultural value systems rather than lack of sufficient healthcare (although the latter is necessary as well). In these cases, well-designed medical devices aren’t going to solve the underlying problem of gender-based discrimination. Other forms of intervention are necessary for changing people’s mindsets.

Though there are many technologies that can and will help the health system in Tanzania, so much more work needs to be done that isn’t based just in developing a technological platform or tool. Unfortunately, solving culture based problems requires changing cultures which is often a much more difficult challenge to tackle with a more nebulous path towards a solution; especially when you don’t know the culture you’re trying to change that well in the first place.

Fortunately the GHC system for pairing local and American fellows has been incredibly helpful for navigating cultural issues and Goodluck and I are starting to see some real seeds of change.

Check out Paul Farmer, co-founder of GHC partner Partners In Health’s, recent congressional testimony on the opportunity that the horrific tragedy in Haiti represents to rebuild a stronger, more stable and more prosperous Haiti.  His remarks focus on the need to work with the Haitian government in rebuilding efforts and prioritize job creation as a means of not just rescuing Haiti from this current crisis, but investing in long-term development:

“In other words, if we focus the reconstruction efforts appropriately, we can achieve long-term benefits for Haiti. The UNDP is helping to organize programs of this kind, which should be supported and extended around the country. Putting Haitians back to work and offering them the dignity that comes with having a job and its basic protections is exactly what brought our country out of the Great Depression.

This was always the right thing to do, and aid programs persistently fail to get it right. So here is our chance: if even half of the pledges made in Montreal or other such meetings are linked tightly to local job creation, it is possible to imagine a Haiti building back better with fewer of the social tensions that inevitably arise as half a million homeless people are integrated into new communities.”

Check out this link on the importance of good management and leadership for improving health outcomes in the recent issue of Global Health magazine.

http://www.globalhealthmagazine.com/cover_stories/leadership_and_management

If 6 months ago you had told me I’d be posting articles about management on this blog, I probably would have politely nodded and internally thought you were nuts.  Management has never been my strength.  But this year I have become increasingly convinced of not just the importance of good management, but the centrality of it, for producing effective results.  Good management can look different in different countries, different organizations and with different personal styles, but whatever it looks like, I think strong management and leadership is essential for motivating a team, driving a vision forward, and making change happen.