29 May 2012

Al Jazeera Takes on Voluntourism


The past week has seen voluntourism looked at with a magnifying glass by Al Jazeera. The Stream (above) discusses voluntourism in the context of the recent People and Power documentary that looks at orphan-aimed volunteering in Cambodia (below).


The discussion is one that will almost always bring out polarized views between those who support voluntourism as a way for people to learn about the world around them and do some good and those who oppose the practice saying that it does more harm than good and money could be better spent. The Stream has that very discussion. What is interesting in this case is the examination from the business side. The head of Projects Abroad, the for-profit organization covered, participates in the discussion and refutes some of the characterizations in the film.

Overall, the AJ investigation shows some serious problems with voluntourism in Cambodia.
Yan Chanty and Kong Thy ended up on the streets of Phnom Penh when their French-funded orphanage, Enfant du Sourie Khmer, was closed down after it was discovered that the director embezzled money meant for the children. Now in their mid-20s Chanty and Kong tell us how the director forced them to act happy to encourage more donations. 
Both young men are deeply traumatised by their removal from their parents and life in the orphanage. Yet, Chanty and Kong are the survivors. They tell us how half of the orphanages' former inhabitants are now homeless and living on the streets, while many have mental problems and some have even died. 
And it is not just Cambodians who are said to be benefiting from the money being made in this business. International volunteering companies are also tapping into the profits. 
Having volunteered in Cambodia for the past three years, Australian Demi Giakoumis was surprised to learn how little of the up to $3,000 paid by volunteers actually goes to the orphanages. When volunteering through one of the world's leading commercial volunteering company, Projects Abroad, she says she was told by the director of the orphanage she was placed at, that it only received $9 per volunteer per week. 
Indeed, the overall picture that Demi paints of the industry is not charitable at all; children being kept in deliberate poverty to encourage ongoing donations from volunteers who have become attached to them and organisations that repeatedly ignore volunteers' concerns about the children's welfare.
The discussion in the form of aid bloggers feels a bit beaten to death. At this point I want to see actual evidence and information on the impact of voluntourism. The children should be interviewed, finances should be analyzed, volunteers should be tracked, overall tourism should be measured and more. The disagreements remain theoretical and I admit that I am more likely to find myself agreeing with people who express concerns about voluntourism. However, the lack of actual evidence and the reliance on anecodate is rendering this conversation moot at the present moment.

If anyone happens to know of some hard evidence, research and reports please do share. I think domestic examples could apply well. Volunteering is done in various ways across the US that could serve to inform how international volunteering may or may not work.

25 May 2012

Visualizing Africa's Independence


From Afrographique to mark Africa Day, which is today. I have to admit I was not aware of the event before, but the graphic is pretty neat.

24 May 2012

This and That: Writing in Other Places, Lancet Editor Solves WHO, Let's Hang Out in DC and more

Al Jazeera is doing further reporting on the voluntourism industry in Cambodia. The angle is towards the special attention towards orphans. "Having volunteered in Cambodia for the past three years, Australian Demi Giakoumis was surprised to learn how little of the up to $3,000 paid by volunteers actually goes to the orphanages. When volunteering through one of the world's leading commercial volunteering company, Projects Abroad, she says she was told by the director of the orphanage she was placed at, that it only received $9 per volunteer per week." Watch the report:


The Afrolens blog has a new podcast that shows plenty of promise. Fatuma Abdulahi and Idilay Bilan do tend to ramble a bit in the first edition by touching on varied topics in a quick manner. However, the honest conversation about culture, gender, and privilege are all important in the context of aid and development. The first episode is worth a listen, but definitely keep an eye out for what is to come.

Richard Horton is not one to hold back what he is thinking. His latest burst of thought directed at a major global health multilateral hits squarely on the WHO (HT Amanda Makulec). I can't say I get the structure and why Africa is one of the pillars but countries with major health needs and large populations such as China and India are not. Nevertheless, here you have it:


Tate Watkins reports from Haiti on the second hand clothing market. He shows how people make a living by selling the clothes and the low prices make it easier for Haitians to buy clothing. "Haiti's pepe trade is decidedly a business—not a charity. In fact, it starts with Haitian Americans buying goods at U.S. thrift stores and shipping products to Port-au-Prince and other ports. Pepe may include hand-me-downs, but the clothing is high-quality, stylish, and cheap. More important, average Haitians prefer the choice of wearing such apparel—and brands like Polo, Lacoste, and Converse—to not having access to such products at all." The important distinction here is that donated clothes are creating a market. There are problems with the fact that they undercut local textiles, but the trade does serve the purpose of spurring on local economies. It should in no way be confused with giving away clothing for free. (Tate is also keeping track of links and info about Haiti. If you are interested in the latest goings on, check out his blog.)

As things get worse in the Sahel in terms of politics, stability and food security there is no better resource than the Sahel blog written by PhD candidate Alex Thurston. He provides news and analysis that makes keeping track of the region much easier.

A few posts I had waiting to go up all managed to be published yesterday morning. In the ONE blog I list five aid videos meant for people who are rather new to the subject. Readers of this blog will likely have seen all of them already, but I hoped to provide a way to challenge people's held ideas about aid through a simple post. I also modified and updated my post about the MVP-Lancet study kerfuffle in the Christian Science Monitor. Finally, I shared the latest results from the KFF study on US attitudes concerning foreign aid and global health in the Huffington Post.

Also, I am going to be in DC June 4-6, but might now extend a few more days. I love using my time in new cities to meet up with people. Feel free to reach out if you are around that week. Don't worry if it doesn't work out. I'll be back down at the end of July for the International AIDS Conference.

Finally, we are in the midst of developing a mobile app for DAWNS. Our hope is that it will provide you with the latest humanitarian, aid and development news right at your fingertips. We will offer a freemium version where you can use a limited form of the app for free. Those who sign up or already are signed up for the digest will get a version that allows for topic searches, short story updates, links to original sources, and a feed of additional news that does not make it into the digest each day. All in all, you will have more information that is handpicked and even easier to access.

23 May 2012

What is the connection between religion and birth rate? Hans Rosling Answers

Hans Rosling brings data alive once again in his latest released TED talk. This time, he organizes countries by religion and compares the average number of children against the per capita income for each country.

Rosling opines that babies decrease per women when:
  1. Children survive
  2. Many children are not needed for work
  3. Women get education and join the labor force
  4. Family planning is acceptable
Those look like conclusions that will excite the girl-up crowd. The trouble is that knowing this information is helpful, but the order of accomplishment is a bit hazier.

Not surprising, the data shows that religion has little to do with the number of babies in the world. The section that I found most illuminating is his explanation of how the population can grow to 10 billion over the next few decades with a stagnant global birth rate.

Anyways, watch it for yourself:



Correction: I changed "determined" to "opines" to more accurately describe the four indicators that Rosling says contributes to the decline of birth rates.

22 May 2012

Enough Responds to My Criticisms

John Bagwell writes an evenhanded response to my concerns about an earlier Enough Project post that cast the debate about Dodd-Frank section 1502 as 'people vs profit.' Bagwell argues at the end that the discussion about costs could be a setback for the progress made. I am curious as to what others think.

A selection of the response (bold emphasis added):
We welcome reasonable debate about section 1502 and have participated in numerous panels and forums alongside critics of both the provision itself and Enough’s approach on the issue. There is no doubt that Dizolele and Seay’s intentions are, like our own, aimed at helping the people of Congo and not on the side of industry in this “profits vs. people” narrative. However, the fact remains that their testimony was used to bolster the bottom line message delivered by Congressman Miller in his closing comments: “And let's hope that the [DRC] government and the region does something about this problem, deals with the human rights. I hate to see the burden placed on the back of American businesses. It's not Congress paying, it's American business paying.” By accepting to appear as Republican witnesses at the hearing, it’s difficult to imagine Seay and Dizolele were naïve to the fact that their testimonies would be used to support this side of the debate. 
Section 1502, which attained strong bi-partisan support in its previous life as stand-alone legislation as well as during conference committee hearings, unfortunately seems to be becoming a political football for some in Congress who seek to make it a poster child for anti-regulatory agendas. Both the positive and negative impacts of 1502 should continue to be researched and debated, but our hope is that the conversation occurs in a way that does not contribute to a narrative that dismisses the positive role and responsibility that both the U.S. government and corporate actors have to play in helping to address the crisis in eastern Congo.   
I agree with Murphy that, when attempting to address complex foreign policy issues, simply “doing something is not sufficient.” But neither is letting complexities and the pursuit of perfection lead to inaction and the abdication of global responsibility we all have in helping to seek solutions. 
If this “costs” approach—focused primarily on whether conflict minerals regulations are too burdensome for corporations but thinly veiled as a debate over whether 1502 is doing more harm than good for civilians in eastern Congo—continues to progress and leads to attempts at a repeal of Section 1502, it will set back years of work and political will generated for action—not just pertaining to Congo, but for any issue that seeks to address corporate responsibility and transparency as an entry point for tackling challenging human rights issues across the globe.
Read the full post here

Building American Support for Global Health Spending

A version of this post appeared in the PSI blog.

What do Americans think about the role of the US in global health? A Kaiser Family Foundation survey released today sought to answer that question.

As you may already know, Americans are terrible at guessing how much of the US budget is spent on foreign assistance. Previous surveys put the estimates of Americans into the 10 to 20 percent range. The latest from KFF shows an even higher average with people surveyed estimating 27% of the federal budget is spent on foreign aid.


As the chart illustrates, the reality of foreign aid spending is vastly different than its perception. Recent studies show the impact that 1% of the US budget has in developing countries. A  Stanford University School of Medicine study determined that PEPFAR saved 740,000 lives between 2004 and 2008. Also, an analysis by the Guttmacher Institute uncovered dramatic changes for every $10 million less spent on international family planning assistance. Despite representing a small sliver of the federal budget, foreign aid does a lot of good and it is especially true in the area of public health.

When people are explained how much is actually spent on foreign aid and the impact it has, attitudes quickly swing towards support.

The number of people who thought too little was spent on foreign aid doubled when learning that only 1% of the federal budget is spent on foreign aid. Looking into global health questions, the survey shows the potential for building greater support in this area as opposed to foreign aid in general.

One of the most interesting findings is where people think money should be allocated. Multi-partner organizations such as the WHO and the Global Fund receive the most support while the governments in developing countries and faith-based organizations are groups that should not be given money.


There are strong concerns about corruption. "On average, Americans believe just 23 cents of every tax dollar the U.S. spends on improving health in developing countries ends up reaching people who really need it. The public believes twice as much money—47 cents of every tax dollar spent on these efforts—is lost through corruption," says the survey.

Finally, the study shows a strong correlation between support and age, political party affiliation, and understanding of foreign assistance. Support comes from younger people, those who estimate a lower percentage of the US budget is spent on foreign assistance, Democrats, and individuals who have previously traveled to a developing country.


KFF President and CEO Drew Altman, Ph.D sums up the findings from the survey:
The message here is threefold.  First, global health aid has the potential to be relatively popular even if foreign aid is not.  It may not move votes in an election as issues like jobs and the economy can, but it could be a plus instead of a minus for elected officials.  Second, information and public education — to counter misperception — can matter to the level of public support.  But third, whether for foreign aid generally or global health more specifically, the ultimate obstacle to greater public support is the need to make the case effectively that aid is not ripped off and makes a difference.
Overall, the survey findings are very positive. It illuminates the need for more work to be done, but shows that people are generally supportive of global health. That support increases with more information about how the money is spent.  The majority of people surveyed understand that reducing global health spending will have a negative effect and  they understand that the decrease in funding will not likely be filled by other donors. However, the US public are skeptical of the impact of increased spending and fear that a large portion of money is lost to corruption.

Taken together, the survey suggests that a case can be made for increased development spending, and the audience is receptive. The challenge is reaching Americans to build a broad-based level of support. Results from the survey seem to point towards it being possible.

It is then followed by the very important question of the role the US can play in the global health space. Hopefully understanding about aid will grow as the result of building a constituency to support US foreign assistance spending. Doing it well matters as much as having the money. 

21 May 2012

In Which UNICEF Discovers RCTs...and People React

An article in Financial Times interviewing the head of UNICEF, Anthony Lake, is meant to be cutting edge, but it shows that Lake is just a tad behind on the times.
Here Lake seems to be with the new “randomistas”, who say that to find what works in aid, you need to apply the sort of randomised control trials used in medicine. For instance: how to persuade teachers in rural India to turn up at school? Esther Duflo, the development economist, arranged for classrooms to have free cameras. Pay depended on how often teachers could show end-of-day photographs with their classes. Suddenly, more teachers showed up. 
“What works” can be simple and cheap, says Lake. “A great contribution to the child survival revolution were things like oral rehydration salts. Jim Grant, my predecessor, used to walk around with a package of salts in his pocket to show how simple this was.” The sachets, which cost just cents each, have saved millions of children with diarrhoea from dying. On a macro level, too, Unicef has been measuring what works. Consequently, it’s now targeting the poorest families and countries. Lake explains: “By definition, the same immunisation programme where there’s lots of disease will save more children’s lives than where there’s less disease.” Anyway, he adds, focusing on the poorest is “right”. 
But as we talk on about aid, he throws in a corrective: “All those who work in the international community on development tend to overstate the impact of what we’re doing. What’s far more important is the performance of governments.” Governments and markets, not aid agencies, have lifted hundreds of millions out of poverty since 2000. And in some countries that remain poor, governments have improved life nonetheless. When I ask for an example, Lake cites Bangladesh. Despite its “vigorous” politics, he says, rival parties usually come together on development. Bangladesh has dealt so well with problems such as open defecation – “which you never talk about in polite company, but which kills lots of children” – that it is now moving on to even tougher issues. Lake marvels: “The biggest killer of very young children in Bangladesh is now drowning.” Unicef is teaching them to swim.
The article concludes with Lake taking about UNICEF changing its communications policies away from poverty porn. "Unicef now uses pictures of recovering children. Thanks to smart aid, more and more do recover," concludes author Simon Kuper. As a bit of a self-proclaimed smart aider, I am not so sure what that actually means. As far as I can tell, smart aid equals RCTs and shunning poverty porn.

The strangest line comes earlier in the story that makes it sound like RCTs are earth-shattering science that are ushering in evaluations for the very first time. "Finally, academics, donors and even some aid agencies have begun measuring what works. Very slowly, development is becoming a science," says Kuper.
As Bill Easterly put it:

Though the RCT as a tool for evaluating aid interventions has been a welcomed step, it is not the be-all-end-all that the article suggests. To some extent they show what works, but have trouble telling why. Finding what works is important to achieving long term development, but that movement did not reach its peak in 2010 or with the RCT.

One lost aspect of the conversation is that the head of a large organization like UNICEF discussing this in a public manner is a good thing. It allows for external accountability for those who can reach out to Lake and hopefully offer some suggestions on how to do better evaluations that will start to uncover the 'why' and 'how' questions rather than just 'what.'

Oh, and then you also have the kicker of this image in the article. Bravo FT, for reducing Africans into specimens and using caricature.

HT Bill Easterly, Shotgun Shack, Ed Carr and Tales From the Hood....check out their tweets for further commentary.

Bloomberg Bows to "Beltway Bandits"

Earlier this month, Bill Easterly and Laura Freschi of the Aid Watchers NYU DRI blog highlight the efforts of the Professional Services Council to overturn a USAID decision to increase spending through local contracts from 11% to 30%. This means USAID can spur local economies by supporting businesses in the countries of work. Further, it cuts out the middlemen position currently occupied by domestic contractors working internationally.

Easterly and Freschi explain:
Joining forces as the Professional Services Council and the public-facing Coalition of International Development Companies (from the website: “Did You Know…that funding through international development companies offers superior accountability and transparency?”) they have employed the Podesta Group, which, according tolobbying disclosure forms, has been hard at work “promoting the work of international development companies” in Congress at PSC’s behest. 
And the Podesta Group has delivered: House Oversight and Government Reform Committee Chairman Darrell Issa (R-California) has told USAID he will seek to block these reforms, just in time for the markup of the international affairs budget beginning next week.
Oxfam published an open letter to the US Congress in support of the announced change.
We know that as members of Congress you want to “follow the money” to protect taxpayer dollars. So do we. However, USAID’s overreliance on contractors often makes it more difficult for us to follow the money. Ultimately, our governments need to be held accountable by our own people—as you are held accountable by your own taxpayers. Bypassing local organizations and governments defeats the purpose of aid, which is to help countries help themselves. 
USAID is working to break this cycle. We hope you will support its efforts to invest modest sums—less than one third of USAID’s total investments—through local watchdogs, businesses, and governments in developing countries. More than anyone else, we know the costs of corruption, and we want to work directly with the US government to end it. Please join us and support USAID’s efforts to invest in our future.
The story got a little bit of play and twitter with the usual hand-wringing by yours truly and others. Now Bloomberg is on the beat with the story. The title, Doubling direct foreign aid could bite U.S. vendors, leaves little question the slant of the reporting.

Key parts (emphasis added):
Rajiv Shah, the agency’s administrator, says boosting direct investment in developing countries will save money and strengthen foreign institutions. “We became far too reliant on contractors,’’ he said in a March 7 speech. 
The agency wants to work with local entrepreneurs and developing countries’ governments “instead of costlier Western consultants and contractors,’’ Shah said. 
Shah’s remarks are “tarnishing the image of an entire sector,’’ said Alan Chvotkin, executive vice president of the Professional Services Council, an Arlington-based group that represents contractors. 
Pressure to meet the 30 percent direct-assistance goal may force the agency to provide funding to foreign groups “when the capability and infrastructure isn’t there,’’ Chvotkin said.
(snip)
The agency’s push to spend more money directly with groups and governments in developing countries won’t necessarily reduce U.S. contractors’ awards, said Donald Steinberg, USAID’s deputy administrator. USAID may instead choose to cut grants to U.S.-based nonprofit groups or lower contributions to international organizations, he said in a phone interview.
For someone who knows little about international development, the Bloomberg report reads as if the US is making cuts rather than a policy change. Unfortunately, the incentives are set for the lobby to maintain the contracts for its clients. When personal contracts are put ahead of achieving development goals the need for change is never more self-evident.

There are some reasons to be concerned by the changes in policy. Chovtkin points towards to infrastructure challenges that may hamper the work of local contractors. No doubt he is right, but it does not mean that USAID contracts have to jump to 30% immediately. The goal is to reach the 30% target by 2015. As we learned from the MDGs, goals are aspirational and set a benchmark to achieve, but are not always met on time.

The contractors can take the role of mentor for civil society organizations by partnering to ensure that all of the standards for implementation and data collection are met. By framing the issue as a loss of US contracts, as done by the Bloomberg piece, the opportunity to usher in an era of local contractors may be lost.

---------------------------------------------------------

For those of you who want to support Oxfam and others who are voicing their support for USAID changing its procurement procedures, go here to see the campaign and how to contact your respective congressional representative.

Update: The final two paragraphs were added to add at 11:50 AM EST to further clarify the overall post.

17 May 2012

Parallels Between a 5 Fingered Running Revolution and Aid

Nicholas Thompson writes about new trends in running and former marathoner and super coach Alberto Salazar. Salazar has become an important figure in the distance running world by focusing on the technical aspects of the sport. An extensive article in the New Yorker in 2010 looked at the obsession of Salazar and his discovery that the elite African runners used a full finishing stride when running longer distances; the complete opposite of the energy-saving short recovery that was being taught at the time. The training of Dathan Ritzenhein by Salazar is interwoven into the larger story about the changing face of distance running.

We are also in the midst of a running revolution thanks to Chris McDougall’s Born to Run. If you see people running or walking around in the five finger shoes that look like alien feet, McDougall deserves a lot of the credit. However, Thompson urges some caution about the new trend.
But there’s a danger. Our ancestors may have run barefoot, but they didn’t do it on asphalt and concrete. They didn’t do it on roads caked with broken glass. They also didn’t have potato chips and soda, or bodies shaped by days spent in offices. Running is an extremely complex physical motion. Changing your shoes might help, but the way stress is distributed across your body depends a great deal, too, on how your hold your head, and even how you swing your arms. Ultimately, we don’t really know whether the movement spurred by “Born to Run” will make us more or less hurt. My guess is that, ten years from now, we’ll see it as a useful corrective. Runners will spend much more time thinking about their form, and there will be lines of well-tested and well-designed thin shoes. But most of us, particularly those of who live in cities, will be training in relatively thick shoes. When Salazar started adjusting Ritzenhein’s form, he came down with stress fractures in his metatarsals. He’s been battling injuries since.
The caveats from Thompson are lessons that can be applied to development. The most important being the importance of understanding the present context and what contributed to the status quo. In some cases, a radical change, as the case is made by McDougall, can lead to some positive outcomes. He and other runners who now apply the techniques tell stories of avoiding injuries and experiencing better overall health.

McDougall's basic argument is that early man traveled barefoot which is more conducive to a running style where the front of the food strikes first, rather than the heel. Big padded sneakers reverse this style of running. A 2010 study in Nature confirms it to be the case when comparing the way people run with and without shoes. The conclusion by McDougall is to return back to the original design. Despite the claims, adequate data is hard to find. The US military advises against the use of five fingers running shoes based on the lack of studies.

There are other factors to consider. In the past few thousand years diets have changed, the physical make up of humans has changed, we now run on abrasive surfaces like pavement, most people spend their day seated, obesity is up, we live longer and so on. All these factors matter when understanding the development of the shoe.

The discussion feels much like the larger aid and development debates. New solutions present themselves as being able to create transformative change. Then fad soon meets reality. Microfinance may be making a small difference, but it is not bringing an end to poverty. One Laptop Per Child showed no significant improvement in the education of students in Peru and a new J-PAL study is buzzing about because it gives evidence to the failure of clean cookstoves.

Charles Kenny commented yesterday on technical solutions that do work and should be used, but end up failing.
[T]wo things are clear: first, the presumption should remain that people are smarter about what works for them than you are –at least until you can prove pretty convincingly otherwise. And second, just subsidizing stuff or giving it out for free because you think it must be good for people really doesn’t cut it any more.
A series of behaviors and changes have lead to injuries among runners. In development, a series of behaviors and changes leave over a billion people in extreme poverty. For some people, it will be a simple as putting on a better pair of shoes or accessing credit. Others will require more fundamental changes in their own lives and what is around them. Silver bullet solutions are fun to consider because they provide hope, but the reality is always messier.

16 May 2012

Obscuring the Conflict Mineral Debate With Simple Stories

Update: A response to this post from John Bagwell in the Enough blog is both informative and respectful.

A blog post by Annie Callaway appearing on the Enough Project blog yesterday reviewed May 10  hearing on Dodd-Frank section 1502 by the House Financial Services Subcommittee on International Monetary Policy and Trade. Section 1502 is the part of the bill that addresses the issue of what the Enough Project, Global Witness and others have labeled 'conflict minerals.'

The advocacy organizations successfully lobbied for the inclusion of the provision to ethically source minerals. The SEC is taking a hard look at the section to determine if it causes an undue burden on the mining industry. The mining industry says it will cause a steep financial burden on the industry to implement the regulations in 1502.

The Enough blog post addresses these concerns, saying
The argument that the cost of implementation is too high for businesses has already been challenged by companies such as Motorola and Intel who are making great strides in developing responsible supply chains using minerals sourced from Congo. As Representative Jim McDermott (D-WA) noted during the hearing, “Industry has already moved to clarify this issue [of conflict minerals] because they realize the justice in it.”
As the post progresses, it sets up a pair of opposing forces. One on side are the advocates for the bill who are trying to stem the violence in the eastern DRC. On the other side are industry giants and lobbyists who care only about the bottom line. Or, as the title of the post says, it is "Profits vs. People."

Unfortunately, that obscures some of the legitimate concerns about 1502. Academic Laura Seay and activist Mvemba Dizolele also testified during the hearing. The Enough blog posts puts them into the 'profits' side of the argument saying that they
sided with House Tea Party Caucus member and Chairman of the Subcommittee Rep. Gary Miller (R-CA), as well as with industry lobby groups such as the National Association of Manufacturers by testifying against 1502.
Such a connection is unfair to Dizolele and Seay. By taking a stance that someone is either on one side or the other, the Enough Project is dismissing genuine concerns about the implementation of 1502. From what I have gathered, there is not much of a question that there are members of the mining industry who are far more concerned with maintaining their bottom line at the cost of artisinal miners and the safety of people in the DRC.

Such an abhorrent attitude rightly should be condemned. However, suggesting that people who believe that 1502 is an inadequate bill that may cause more harm than good are more concerned with mining profits that the Congolese is also wrong.

The post attempts to set Congolese expert Jason Stearns in direct opposition with Seay and Dizolele who have raised concerns in regards to the impact the legislation will have on the employment status of the artisinal miners.

It quotes a post by Stearns from this past August where he argues why he supports 1502. Stearns estimates that the numbers of jobs lost will be in the tens of thousands not the estimated hundreds of thousands that David Aronson claimed in his NYT article. One might get the impression that Stearns and Seay are in direct opposition, but just a bit of scrolling down the post reveals a discussion between the two that shows that they are largely in agreement. Stearns writes:
I fully agree with David that these action have caused a lot of pain for local mining communities. That's awful and the US & Congolese government should have thought of that. But what do you think should have happened? I know you want SSR (as do I) and the governance reform. But we have been yelling and shouting about that for at least 5+ years now. For all its flaws, the Dodd-Frank approach has shifted incentives for local politicians and businessmen so that institutional reform and demilitarization makes economic sense for them.
Seay responds saying:
I think it would have made a lot more sense for the approach to have started at the level of trying to legitimize the mines through pressure on Kabila rather than trying to reduce demand for Congolese minerals. That's admittedly an extremely complicated way to do it (especially on the question of demilitarizing the militarized mines), but it would have avoided the livelihoods problems we're seeing now, and would not have interrupted operations at non-conflict mines.
The difference of opinion about the legislation between Stearns is not very wide. Further, Seay's comments make it clear that her goals are exactly the same as that of Stearns, the Enough Project and other advocates who want to see the end of the long conflict in the eastern DRC.

It is vital that everything possible is done to get this right. The debate over 1502 is as complex and multi-faceted as the issue itself. Pure and impure interests do exist, but casting the discussion as merely people vs. profits is a rhetorical way to prevent dissent by individuals and groups that are concerned and motivated by the people side of the equation.

The Enough post ends with a video of Maxine Waters from the hearing who issues a rambling 5 minute statement in support of 1502. What stands out in her argument is the idea that there is a moral imperative to act, yet less of a concern about the impact of such actions. I have written too many times that doing something is not sufficient. Doing something can lead to harmful actions.

Certainly something needs to be done in order to alleviate the conflict in the eastern DRC. The solutions put into action should minimize damage and affect positive change. The actions of the international community have in some part contributed to the current state of the region. Further action can make it better or worse to varying extents. The least we can do is ensure that proposed actions do not cause harm.

Hospital in Bangalore Innovates to Treat Both Rich and Poor


Ten years ago, Indian cardiac surgeon Dr Devi Shetty founded a hospital he called Narayana Hrudayalaya ('Temple of the Heart') in Bangalore. His goal was to provide top notch health services to both rich and poor Indians in the same facility.

From Al Jazeera:
"We decided to adopt all the business principles of Walmart or Henry Ford - the one thing in common is the economy of scale," Shetty explains.

At the Narayana, approximately 40 per cent of patients pay a reasonable price for their treatment, a small percentage - those who "want the frills of executive rooms" - pay a premium, a majority pays less than the market rate and 10 to 20 per cent pay virtually nothing. For the latter category, the hospital's charitable wing raises money to help compensate for the material costs of their treatment. 
In any other hospital, those who could not afford to pay their medical bills would simply be sent away until they came up with the cash, but at the Narayana the hospital's charity wing helps them to find the money.
A four episode series from Al Jazeera, called Indian Hospital, provides a look into the innovative and successful hospital. The hospital has managed to reduce costs and provide a service that reaches people at all income levels while making a profit. "Cardiac surgery costing $40,000 to $50,000 or more in the US has a baseline cost here of just $1,800," reports Al Jazeera.
"One of the co-operative societies of milk approached me to endorse a low fat milk as a good milk for people with [a] heart problem," explains Shetty. "I told them I can endorse it provided they run a health insurance [scheme] for their milk vendors and this is how the Yashaswini Micro Health Insurance was born with the premium of 11 cents per month. 
"In the first year we had 1.7 million farmers paying 11 cents a month and the government paid seven cents. There are 1,006 varieties of surgery done on the human body and all these operations are covered by this insurance. It became a big success - we have over three million farmers paying 22 cents .... Now we are helping six other state governments to launch this poor man's health insurance programme." 
 Watch the first episode at the top and see the rest of the series here

15 May 2012

Gallup Finds High Approval of Africa's Leaders

Gallup shares the results of a new poll measuring the approval of Africa's leaders in their home countries. Almost all have positive approval ratings. Of those at the bottom, Wade, Mutharika and Banda are now out of office. The findings in some countries are not likely indicative of true sentiments. Obama and Cameron sitting at around 50%, plus the more democratic African nations moving closer to the same middle range may indicate that the extreme highs are hiding the truth. One interesting thing is the high measured approval rating of the now disposed Amadou Toure of Mali.


Further questions from Gallup point towards a connection between approval rating with local economies and confidence in institutions. Also, it seems that heads of state get higher approval as compared to collective leadership of the nation.

The poll concludes:
Although today more African leaders come to office via the ballot box, many remain in power for decades -- or their son becomes the top executive at his father's death. Still, the Gallup results show that job performance approval can be relatively high -- or low -- regardless of the leader's time in office. This suggests that approval ratings of the individual's performance are not strictly related to tenure. 
Further, the findings suggest that while local economic conditions do matter, other factors may be more significant drivers of leaders' ratings, although a deteriorating economic environment can worsen residents' assessments of their political leader's performance. Governance issues, such as the honesty of elections and the judicial system, seem to matter much more in the eyes of most Africans. Other factors, such as political apathy, may play a role as many may not be interested in political affairs and tacitly approve of their leader's performance. 
The recent change of the guard in Senegal -- where the former president's approval stood at 30% -- and the deposition of Mali's president a few weeks before the end of his second term sends a mixed message about political alternation in the region. In some countries, Africans' voices come through loud and clear at the ballot box. In others, heeding the will of the people is still a work in progress.

The fact that there is not a strong relation between tenure and approval rating is a bit surprising to me. I would have assumed leaders who maintained more power would artificially inflate their approval ratings through intimidation. That appears it may not be the case in all instances.

Now I will leave it to the commentators do discuss the finer points of the survey findings.

Update: As requested by Simon. Here is data on press freedom in Africa from this year's press freedom Index. Sadly, I had a hard time separating the pure Africa data, but this map helps out a bit.


Here are the rankings and raw data.

World Bank eAtlas Brings Illustrates Open Data


The World Bank continues to be one of the leaders in open data and the visualization of that data. I recently came upon the World Bank eAtlas. It takes the data made available and maps the indicators in order to compare countries around the world.

In the screen grab above, I searched for the average age at first marriage for women. The user can hover over each of the countries to see the specific data. On the right, suggested categories that are related to the topic, such as the percentage of women who are beaten by their husbands when caught burning food, are displayed.

Users can also use the tools to see MDG progress, financial inclusion, and global development, in addition to gender as already seen. For a data nerd this is a resource that is definitely worth checking out and clicking around.

13 May 2012

Happy Mother's Day Infographic




USAID provides the above inforgraphic to illustrate the importance of saving moms at birth. Happy Mother's day to all the moms out there. Especially mine.

12 May 2012

MBAs of the Future: Sustainability and What It Means For African Nations

By Julianna Davies.

The term “business sustainability” has become a popular buzzword in contemporary MBA programs. Today business graduates are exploring the various methods by which corporate entities can become more lucrative and less wasteful. These strategies are especially needed in Africa – a continent whose valuable resources are far outweighed by human poverty and corporate irresponsibility. The response to the demand has been a drastic increase of programs offering MBA courses and on campus that focus on Africa and the struggles unique to developing countries. Corporations, too, are looking for ways to involve African nations in a more global concept of business.

Though various definitions for sustainable business exist, the term typically refers to a corporate entity that not only makes economic progress, but also implements eco-friendly measures to ensure the environment is not sacrificed for the sake of productivity. For example, Sustainable Business Forum writer Derek Wong recently named Coca-Cola – a $20 billion food and beverage industry giant – as a model for sustainable business. Under the facilitation of Partners in Project Green, Coca-Cola has not only increased revenue but also reduced its environmental impact, thanks to eco-friendly measures like energy conservation, limited water usage and recyclable packaging. Other partners in this project include Xerox, Hewlett-Packard and LoyaltyOne. Strategies such as these would greatly benefit African businesses.

Africa’s challenges on the business front are largely related to education and infrastructure. Most countries have access to abundant resources and manpower--they just lack a way to transport those critical resources into a healthy business market. Most African business owners do not attend college, and most nations lack an organized government infrastructure to effectively oversee corporate operations. The results are disastrous, wrote TriplePundit contributor Brittany Lyons in November 2011. Since many African businesses are grossly mismanaged, their day-to-day operations often wreak havoc on the environment. This depletes resources needed to sustain viability, both of company and society. Moreover, Lyons found that most Africans who earn graduate or doctorate business degrees ultimately leave the continent.
Many economic experts have characterized Africa as an economic black hole. The continent is not necessarily doomed, however. Today, many MBA programs are choosing to view the continent as a vast opportunity for growth. They are training students and future business leaders from across the globe accordingly.

Increased business opportunities are the main focus of the Sustainable Entrepreneurship MBAs for Africa (SEEMBA) program at Colorado State University. SEEMBA focuses on generating start-up companies as a crucial step toward overall job growth. As companies are founded and reliable jobs are created, entire economies get a boost. Increased household income eventually improves economic conditions and inspires social progress. The result is an 8-point cycle that ultimately arrives at more opportunities for entrepreneurs.
Another program focused on improving Africa’s economic standing is Wharton’s Wealth Generation Program, which de-emphasizes funding through charitable donations to showcase the benefits of long-term, sustainable projects. Charity programs have been a long-standing source of African revenue over the past few decades. In recent years, many African universities have also begun incorporating sustainable business into their respective MBA curricula. These include Witwatersrand University in South Africa, University of Nigeria and University of Ghana Business School.

In addition to these academic institutions, many African business education programs are leading the charge to implement sustainable practices on the continent. IFC Sub-Saharan Africa works directly with business owners to improve company management, attract investors and stimulate job growth. African Center for Education and Sustainability, Inc., emphasizes educational opportunities as an important precursor to running a sustainable business. Some programs focus on specific aspects of the African job market, such as Bayer Southern/East Africa, which works directly with farmers to improve technical strategies and effectively manage their own agro-businesses. African Wildlife Fund also educates local farmers, as well as women, about sustainable business-related projects.

Profitable, eco-friendly African businesses have been historically rare. But as sustainable business practices are explored worldwide, companies and academic institutions are working to bring this relatively new corporate philosophy to our planet’s most impoverished continent. After centuries of economic struggle, many experts agree that these steps may finally catch Africa up with the rest of the corporate world.

Julianna Davies is a part-time, freelance writer that seeks out topics around environmentally sustainable business practices and the industries/companies that implement these said practices. She hopes her writing can serve as a catalyst for holding more fruitful and engaging dialogues all across the world.

10 May 2012

Building an International Support Network for Isolated Aid Workers

Ed note: I invited Weh Yeoh of whydev, a friend to AVFTC, to write a post sharing a project that he and his colleague Brendan Rigby started. Have a read. - Tom

International development work is often difficult, exhausting, and isolating. Many people who seek to serve and live abroad often become burned out by the overwhelming nature of their work. In isolated places, often the only people you can turn to for support are your boss or your partner. For various reasons, neither of these are a good choice.

However, we know that the support of a peer is an easy and effective way to reduce stress, burnout and, just as importantly, have access to someone to bounce ideas off.

This is why we, at whydev.org, have decided to build an online platform where international aid volunteers and workers can connect and discuss their challenges and experiences, allowing them the opportunity to support others across the globe who are also making a difference. Knowing that the world of aid and development is under-resourced as is, we think our idea fits well. This service does not require more resources to be added to the sector (in the form of professional mentors, coaches or counselors), but rather, builds on existing resources that are not connected.

We would like to think that it’s the first of its kind – an international support network for isolated aid workers.

Luckily, we’re not the only ones who think this is a good idea. Since asking for expressions of interest earlier this year, we’ve had over 320 people sign up to our pilot program. This is great news for everyone involved, because the larger the pool, the more likely we’ll be able to achieve a good match.

One international aid worker said, “I feel isolated, uncertain and a little forlorn about finding my way into development-related work, and would like to have someone to share my experience with, who is perhaps also experiencing the same thing.”

It is perspectives like this that make us want to keep working towards creating this platform. But, this is where we need your help. We’ve launched a crowdfunding campaign over on StartSomeGood where people can chip in amounts of money, small or large, to help us get this project going. If you are reading this post, chances are you’re either working, studying or are at least interested in aid and development. Therefore, you’re probably the right demographic to understand the difficulties that aid workers can face across the globe.

Jennifer Lentfer, of How Matters, writes that having self-awareness of your own qualities and needs is crucial in becoming an effective aid worker. If you want to help us to build a future that supports the needs of aid workers across the globe, then this may be a worthwhile campaign for you.

If you are a frequent reader of A View From The Cave, then you would be familiar with Tom talking about the need for sustainability, no doubt. So, just how sustainable is your funding? Good question! Once the platform is built, we think that we can keep the service running by adding in a tiered system of participation, so that it is self-sustainable.

Our vision is that peer coaching should always be accessible at no cost, as we promised right from the start. That option will remain, and people will still be able to be linked up to suitable peer coaches around the world at no charge. However, we think that people may also be willing to pay a small amount of money to get a value-added service. As such, we’ll be adding in different levels of participation so that those who are willing to pay a little extra will get a little more out of it. Whatever we make from this can then be fed back into the project to account for running costs. That’s why seed funding is so vital for us – the major outlay is not running the program, but getting it off the ground.

We’d appreciate it if you would consider donating whatever you can to our StartSomeGood campaign here, and spreading the word far and wide about what we’re trying to achieve.

If you have any questions at all about our campaign, please do not hesitate to contact either Brendan or myself. We’d be more than happy to answer any questions.

For the final word on the topic, here is Brendan, speaking from Ghana:


You can donate to our campaign on StartSomeGood here.

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Weh Yeoh is a current job-seeker based in Cambodia. He is a professionally trained physiotherapist who has completed a MA in Development Studies at the University of New South Wales. With experience in the NGO sector both in Australia and in China, with Handicap International, he hopes to combine his interest in development and passion for visiting far-flung destinations in the future. You can view his LinkedIn here and follow him on Twitter here.

KONY2012: A Reflection

By Lauren Kervian

KONY 2012 epitomizes the extreme evolution of paternalism through a means that is less explicit and even more detrimental to the future of the people it aims to help. The world falls for images that operate under the umbrella of genuineness without inquiry or investigation. Africa, in both documentaries, is seen as more of a backdrop for the heroism and self-serving ends of the West than a focus. Jason Russell, in the first video, almost demands an American intervention in Uganda in order to stop Joesph Kony and the actions of Lord’s Resistance Army. His motives and the motives of the Invisible Children charity are fueled by a “Western savior-like complex”. The depressing part about all of this is not the fact itself, but that the global population has blinded itself from the truth. Leaving behind colonial racial slapstick, world powers have taken a subtle approach to assuaging their foreign interest by validating intervention and aid to Africa under the façade of do-good. Yes, the KONY 2012 movement is funded by an NGO, but its goals are realized through the enforcement of the United States Government.

The KONY 2012 videos take an overtly reductionist approach as they simplify the story of millions of Ugandan people. A multifaceted war is made into a black and white (literally), open and shut case. Uganda would be a veritable Elysium if only Joseph Kony were more famous and well-known. Therefore, conscious citizens must share this video and buy this action pack and then voilà—the day will be saved. The first film, albeit more so than the second, is a narrative of hopeless strife in a war-torn region, directly traceable to the hands of Joseph Kony. The United States, it seems, is the only one who can help sound the voices of the young kids abducted and forced to fight for an undetermined cause by the Lord’s Resistance Army. Now, this is a grave assumption of ignorance. Why, if it is a common belief that Ugandans are without say, would they employ the U.S. to be their speaker? The answer can be linked back to a Westernized propensity to be the world’s savior. There is no better place than the ”Dark Continent”, the land of the primitive and uncivilized, to begin a mission of good motive and little forethought. Yes, Joseph Kony is a man of many atrocities, but the campaign to make him infamous will do little in the way of problem solving. This is a movement of protection rather than empowerment.

The images of KONY 2012 are meant to entice the observer to a certain end. The watchers of this video are bombarded with facts that make action seem easy and immediate, without questioning the White Man’s Burden complex upon which they are operating. Jacob, the Ugandan boy turned man who tells the heart-wrenching story of his captivity and brother’s death, is the source of all sympathy. He is a child that needs help and Westerners are there to provide it. The paternalism is palpable and stock in African agency is nonexistent. The inclusion of Jacob’s interview is used to emotionally manipulate the viewer into action. What is missing from the film are Ugandans talking about the meaningful strides being taken in the nation now. The movement, on the whole, isolates the duties of Americans from the Africans. The U.S. is trying to eliminate one enemy, while it ignores a million more that can take his place. Solving for the moment will only bind Africa more tightly in the chains that are foreign dependence.

Now, it is interesting that the second video was watched by only ten percent of the original viewers. Although the sequel was undoubtedly a placation tactic employed to pacify critics and well-informed individuals, it was still an attempt at remediation. There is finally a mention of the crisis being “complex” and interviews with Ugandans are more prevalent than before. This being said, it lacks answers and falls victim to the same oversimplification approach that doomed its predecessor. Sure, the filmmakers (not Russell, considering his very public arrest) try to rectify their documented ignorance, but the publication was just too little too late. People had already heard enough – their duty to the Ugandan children and to the world were made clear during the first thirty-minute segment. The pioneer version did such a great job of making the problem digestible, that it was simply a waste of time trying to actually understand the foundation behind the movement.

Why understand, when you can help now?

This is America today. The KONY 2012 movement was born out of ignorance and a nationwide willingness to play the world hero. It is almost fruitless (even if it is necessary) to condemn the videos, when their existence was tailored to fit the image the United States has promoted in the global arena. Superiority complexes and a deeply rooted colonial ideology will always found movements resembling KONY 2012. Modern day paternalism is paler, weaker, and perhaps better than before. Yet such a distinction is fundamentally irrelevant when our sin is categorically evil. We, not the documentaries, are the reason for this continued frame of reference with respect to Africa. KONY 2012 is but a manifestation of a hidden ideology – paternalism.

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Lauren Kervian is a freshman at Duke University, where she is planning to major in Molecular Biology with a minor in Russian Culture and Language. Originally from Springfield, Missouri, her hope is to one day attend medical school and become a pediatrician. Lauren is a huge Boston sports fan and has an obsession with all things chocolate.

09 May 2012

Interview with Mama Hope Founder [Video]

Guest post by Jaclyn Schiff

It happens multiple times a day. A nonprofit uploads a video to YouTube hoping to attract some attention for its cause. The result? A few hundred, perhaps even a couple thousand views. But these videos rarely attract much attention from people who aren't already involved with the cause.

Enter Mama Hope. So far, its three "Stop the Pity" campaign videos have collectively generated well over one million views on YouTube -- evidence that the organization is doing something very right. Or wrong. So I interviewed Mama Hope's founder to get the story in her own words.


This is part of a series of interviews for Pangea, a new online show for people interested in global issues. I welcome your thoughts on the interview, questions and ideas in the comments. Or catch me on Twitter -- @J_Schiff.

Tom's take: I am happy to share this video from Jaclyn. Nyla Rodgers discusses the motivations for the organization and the Stop the Pity Campaign. I wrote about a week ago that the authors of the stories need to change with the content. The video makes it clear that Rodgers is looking for ways to change the stories that are being told and who gets to tell them. She reveals a bit about projects where kids were given video cameras to tape what they want. She said one features a young boy giving a proud tour of his home and village. Hopefully, videos like that can make their way into the mix as a part of the campaign. Jaclyn asks Rodgers about the criticism from Elliot Ross in regards to the recent video, but I will not spoil her answer. What I find encouraging is an organization that is looking to try something different and is willing to talk about the process and motivations. Certainly there is room for improvement, but an open discussion is indicative of a willingness to learn.

MVP Claims Child Mortality Reduction Victory; Critics Question Study

A study published in The Lancet says the Millennium Village Project (MVP) is responsible for a decline in child mortality three times faster than comparable villages that do not receive the MVP's suite of services. The authors, including MVP founder Jeffrey Sachs, point to the results of the success of the MVPs multi-pronged approach.

The basic premise is that spending is low when examined on the individual level. Additionally, a comprehensive approach to development that addresses an individual ranging from health to schooling to agriculture will lead to overall positive gains. A modest increase in spending through foreign aid and national budgets could take on issues such as infant mortality. The MVP represents a pilot program to show if and how the approach can work.

According to the researchers, the under-five death rates in control villages declined an average of 2.6% each year over the course of a decade. The MVs averaged of 7.8% rate of decline per year.


Jeffrey Sachs, Sonia Sachs and Prabhjot Sing, all authors on the study, write in the Huffington Post about the successes found in the study. They point to five areas where the MV health systems are succeeding:
  1. Community Health Workers. The Community Health Workers (CHWs) are the cornerstone of the community-based delivery system in the MVs... 
  2. Procedures and Decision Support: The simple idea of a checklist has been pioneered in operating rooms and hospitals throughout the world. It is equally critical for community health delivery, and can make life-and-death events like childbirths much less vulnerable to human error... 
  3. Mobile phones for health management: Mobile phones are revolutionizing how poor, rural communities can escape from poverty...
  4. Low-cost devices for disease detection and management: ...Many conditions are life threatening but preventable and treatable. The Millennium Villages has applied the pioneering work of innovators to rethink in fundamental ways the design of low-cost health systems.
  5. Verbal Autopsies and Management Responses: ...By carefully tracking the likely cause of deaths on every occasion, health systems can learn about their own weaknesses, and take corrective actions. The Millennium Villages have therefore implemented a "verbal autopsy" system to try to account for each death of mothers and children, and to use this information to strengthen the health system.
Data published in The Lancet study show promise, but raise further questions. An article in Nature looks into some of these concerns.
[CGD's Michael] Clemens says that these headline figures are misleading for a number of reasons. He points out that the control-village data include retrospectively estimated figures that are probably too high. And nationwide improvements in child mortality over the three years of the study were almost as good as in the Millennium Villages, he says, so it is unfair to compare the project’s success with a more gradual decadal trend. Furthermore, deriving trends from children monitored in a few villages for just three years introduces significant statistical uncertainty, he argues. 
Using figures in the paper, Clemens calculates that the study authors can be confident only that the annual rate of decline for child mortality in the Millennium Villages lies between 1.4% and 14.3%. “If you claim to triple rates of decline you must have the evidence to back this up,” he says.
Further complicating the issue is that the evaluation is done by the people who implement the MVP. Clemens and others have criticized this decision in previous studies. For critics, a new MVP established in Ghana will be evaluated by DfID. Though it is likely all parties will not be satisfied after the independent evaluation, an outside perspective on the project in cooperation with the MVP will quiet some of the criticisms.

Lee Crawfurd further points out the observed differences in 10 of the 18 indicators in the study are statistically insignificant. For example, the increase in the asset-based wealth index for households are nearly identical between the MVP and comparison villages.

The study does not attempt to establish any direct causality for the reduction in infant mortality to any individual aspects of the program.
As a complex intervention operating across many sectors, definitive statements about the specific mechanisms of mortality reductions are not possible. However, the project placed a strong initial health sector emphasis on so-called quick wins including optimisation of immunisation coverage and bednet distribution to all sleeping sites—with concurrent reductions in malaria parasitaemia. Early efforts to enhance health staffing and facility infrastructure, reduce access barriers such as user-fees, and increase cross-sectoral investments to improve roads, emergency transport, and mobile communication played potentially important parts in improving access to skilled birth attendance. 
This all not to suggest that the program was not successful. We have to take the gains at face value. The question is what the findings tell us about expanding the MVP. If there is little change in some areas while rapid change it others, is it possible that some aspects of the MVP are failing? Or, is it possible that some interventions are individually successful.

Given the structure of the MVP and the evaluations conducted, it is hard to tease out causality. But that is not what was intended when establishing the MVP. The theory is that they suite of interventions will make the difference rather than a few targeted ones. How can this be tested? Maybe an evaluation that looks at a host of random villages receiving some targeted interventions and others that get nothing could help to provide a comparison and further understanding as to what does and does not work.

By touting the success of the MVP, the authors are making the link between the program as a whole and the successful decline in infant mortality. The paper says the average cost per person per year is $116, of that $25 is attributed to health costs. If the idea is to increase per person spending to the same levels across SSA, the final bill would be $92.8 billion per year (800 million living in SSA). In 2009, $25 billion of official development assistance (ODA) went to sub-Saharan Africa. If countries need half of the cost to be covered by foreign government and investments the ODA to SSA would need to double.

If the health cost of $25 per person per year is the main target than it is all the more attainable to meet the individual spending needs through ODA and local government spending. The findings coupled with the outside concerns seem to point towards a positive direction that needs a bit further examination. In sum, the accomplishment of reducing infant mortality should be celebrated. Ensuring the survival of children is an important goal.

Additional reading: Matt Collin compares the results of the study to a recently publish study in The Lancet that shows an overall decline in infant mortality at the country level (see chart below): http://aidthoughts.org/?p=3330


08 May 2012

Routine Vaccination Solutions for Nigeria

Nigeria is home one out of every eight child deaths worldwide. Routine vaccinations save lives and money. The Decade of Vacines Economics projects 90% vaccine coverage against Hib, pneumococcal disease, rotavirus, measles and pertussis can save 600,000 lives and $17 billion in Nigeria over the next 10 years.

A new report by the International Vaccine Access Center (IVAC) at Johns Hopkins University identifies the challenges and solutions to increasing routine vaccinations in Nigeria. “Nigeria’s advantages are its resources. It has a strong concentration of human resources with its middle class and economy,” said Dr Orin Levine, IAVC Executive Director and study co-author.

The study, Landscape Analysis of Routine Immunization in Nigeria, was a collaborative effort between the IVAC, the government of Nigeria and Solina Health. The researchers interviewed stakeholders in 8 Nigerian states. All involved in the vaccine process, from individual mothers to national government officials, were interviewed. “The results are Nigerian solutions for challenges to routine immunizations in Nigeria,” said Dr. Levine.

Based on the interviews, the report identifies supply, human resource and demand solutions to increasing vaccination access. For example, transportation presents a challenge at nearly every level. Distance from health services is a documented challenge in Nigeria. A 2008 survey found that 36% of Nigerian women said the distance from a health facility was an impediment to accessing medical care.


The authors recommend the use of transportation contracts and distributing vehicles to smooth out the supply chain issues and bring vaccines closer to individuals.  Though transportation will present its own challenges and costs, it presents a way to reach people in remote parts of the country who are often populations with low vaccination coverage.

Simple changes like the way money is disbursed will also smooth out coverage. The highly visible national vaccine campaigns tend to provide more equitable coverage, explained Levine. At the present, money disbursed by the Nigerian government for the purchase vaccines is an annual process. Levine says, “By changing the funding mechanism to occur throughout the year, the vaccine supply can remain consistent.”
The other side of the coin is the demand side. If all the logistical problems are solved there is still the issue of parents wanting to vaccinate their children. Further, there are those who want to vaccinate their children but the schedule of vaccinations is spread out and they may miss or forget about appointments.

Levine took the time to point out that addressing the problems of demand is paramount. He saw incentives and reminders as ways to ensure that the care is delivered by providers and accessed by patients. That could look like pay for performance for individual health workers and results based financing at the state, local, and institutional levels.

Money is disbursed when specific targets are met. If a hospital wants money to fund other programs it will need to meet given targets to access further funding; an incentive to ensure more coverage of patients.
The patients can be incentivized through conditional or unconditional cash transfers. Distance between the parents and the vaccination distribution point can be a challenge, but incentives can help reduce that barrier. “You can bet people from villages that are not reached by vaccines are traveling to do commerce and other things. If you incentive parents, you will find them innovating their own transportation schemes,” said Levine.

SMS reminders have been used in the past for big campaigns. The hope is that the technology and its successes can be harnessed into routine vaccination campaigns.  There is a gap in in the immunization schedule between week 14 and 9 months. Reminders may overcome the attendance attrition.

An important component to the success of the campaign will be linking up the various actors.  Nigerian Minister of State for Health, Dr. Muhammad Pate, says awareness is an important target for the government. “In recent years we have made tremendous progress in promoting the awareness among our population, but there are still areas where the awareness is inadequate. These areas are both geographic as well as socioeconomic. For example, the upper 20th wealth quintile in the population has thirteen fold higher full immunization coverage among its children than the poorest 20th wealth quintile according to the 2008 demographic and health survey,” he said.

“This may be a reflection of inequities in access to the vaccines or disproportionate awareness among the richer more educated populace or both. Whatever the case, we are committed to ensuring that every child has an equal chance of getting protected with life-saving vaccines.”

Collaboration will lead to a successful campaign, said Dr. Pate. “If Federal, State and Local governments align their efforts towards basic services, and are supported by civil society and private sector, the impact will naturally expand beyond vaccine delivery,” he said.

Doing so will reach beyond just routine vaccinations. “It will have impact on other important services such as maternal health, prevention of parent to child transmission of HIV, treatment of other ailments like anti-malarials, zinc/ORS for diarrhea, antibiotics for pneumonia etc,” continued Dr. Pate.

The government actors indicate willingness to take action. However, Levine points out, “The challenge going forward is translating political will into action and change at the local level.”



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