Increasing the Impact of Rotary (Partnerships Series No. 9)

This post is the last in a series of nine posts on partnerships, innovation, and evaluation in Rotary. The rationale for the series was my conviction that if Rotary is to have a larger impact globally, it must rely more than has been the case so far on partnerships, innovation, and evaluation (and in some areas advocacy, as has been the case with polio). Seven different projects or investments that have relied on partnerships, were innovative, and were evaluated at least in some way, were showcased. A compilation of the case studies together with a brief introduction is available here. Separate briefs are also available for each of the projects here.


As I mentioned it in the introduction to the series, partnerships help to implement larger projects and benefit from the expertise of organizations that are among the best in their field. Rotary’s Foundation was created almost 100 years ago (the Centennial is next year) and it has about $1 billion in assets. This is respectable, but in the world of development projects, which is in practice where Rotary is investing most of its funds, this remains small. Without innovation, the contribution of Rotary is an important drop, but still a drop in the development assistance bucket.

By contrast, if Rotary clubs and district innovate, successful pilots can then be scaled up by other organizations with deeper pockets, thereby potentially achieving much larger impact. However, for innovative projects to be recognized as such, proper evaluations are needed. We must be able to demonstrate the impact of pilot projects. Innovation and evaluation are like twins: they work best in pairs. Together, partnerships, innovation, and evaluation are the key to larger impact.

To encourage clubs and districts to think bigger and more strategically, stories of great projects were shared: an innovative financing mechanism for polio eradication; an award winning project fighting malaria and Ebola in Mali; a teacher training program that is transforming teaching and learning in Nepali classrooms; a project on obstetric fistula saving the lives of mothers and children in Nigeria; a program to invest in the writing skills of disadvantaged youth in the United States; a project to improve access to water and sanitation in Uganda; and a global network of Peace Centers and Peace Fellows to help promote peace.

Some of these programs and projects are large. Others are small. Most were implemented through global grants, but one was implemented through a district grant. All these projects have been in one way or another innovative. They have all leveraged partnerships not only to crowd in financial resources, but also – and even more importantly – to build on great expertise. And they have all relied on monitoring and evaluation mechanisms to assess their impact, at least partially.

Putting together great projects requires work. Fundraising is often time consuming in Rotary given the funding model of the Rotary Foundation that requires raising funds from many clubs and districts first before getting a match from the Foundation. Planning, implementing, and in addition evaluating projects also takes time, especially when one tries to do this in a professional way. Finally, in order to be innovative, Rotarians leading projects need to be aware of where the frontier is in their field, and what could be innovative. This also takes some time.

There is nothing wrong with clubs and districts funding and implementing traditional Rotary projects. Most projects will continue to be fairly simple, with funds provided to worthy charitable causes. These projects, as well as the volunteer time often contributed by Rotarians when implementing them, serve an important purpose. The beneficiaries of these projects are better off thanks to them. These projects help communities, and they also benefit Rotary through the goodwill that the projects create.

But if we want to raise the bar and achieve larger impact, we also need to do more innovative projects. Rotary needs to be bolder, more ambitious. It needs to better learn from its projects, both the great and not so great ones, and make sure that lessons learned are shared broadly, well beyond the Rotary family. The launch of the Future Vision model, despite some challenges, was a step in the right direction. As we celebrate the Centennial of the Rotary Foundation next year, let’s make sure that we have the right vision for what Rotary and its Foundation could accomplish in the next 100 years.

Saving Mothers and Children in Nigeria (Partnerships Series No. 4)

Over their lifetime, one in every 30 women in Nigeria are likely to die due to pregnancy and childbearing. Nigeria alone accounts for one in seven maternal deaths observed in the world today. This post, the fourth in a series on partnerships, innovation, and evaluation in Rotary, tells the story of a project that has succeeded in reducing maternal mortality in Nigeria.

Nigeria saving lives

Project and Partners

Many factors lead to maternal mortality, but a key risk is that of obstetric fistula (a hole in the birth canal). The World Health Organization estimates that each year between 50,000 and 100,000 women suffer from obstetric fistula, which by obstructing labor can lead to maternal death.

Quality assurance mechanisms in hospitals can improve obstetric services and contribute to reducing maternal mortality. This was the premise of a series of Rotary projects aiming to reduce maternal (and fetal) mortality in Nigeria led by Robert Zinser and the Rotarian Action Group for Population Growth and Development (RFPD) between 2005 and 2010.

With support from RFPD and some 200 Rotary, Rotaract and Inner Wheel Clubs, Rotary implemented a first project to improve quality assurance mechanisms in ten hospitals in Kano and Kaduna States in Northern Nigeria. Apart from funding from Rotary clubs and the Rotary Foundation, support was also provided by the German Ministry for Economic Cooperation and Development (BMZ), the Aventis Foundation and the International Association for Maternal and Neonatal Health (IAMANEH). The project was implemented by Nigerian Rotarians.

Innovative Approach

Conceptually, reducing maternal and fetal morbidity and mortality can be achieved through an improvement in the quality of the infrastructure and other inputs used to provide treatment (availability of medicine, better hospital facilities, etc.) as well as improvements in the process of providing treatment (more experienced health personnel). The project team worked on both fronts.

In terms of improvements in infrastructure, a number of investments were made, including two specialized fistula wards (one for each of the two Nigerian states) with rehabilitation facilities. Medical equipment was provided to ten hospitals and some hospitals were equipped with better water supply and solar energy. Hospitals also received intrauterine devices for women requesting them for family planning as well as drugs preventing mother-to-child transmission of HIV.

To improve the capacity of hospital personnel, seven doctors were trained as fistula surgeons and 15 ward nurses were trained in fistula care. Many more doctors, nurses and midwives, and other health personnel such as traditional birth attendants were also trained on how to improve obstetric services. Hospital teams were trained in emergency obstetric care including (among others) in the use of magnesium sulfate to manage eclampsia and the use of an anti-shock garment to treat postpartum hemorrhage.

Apart from providing support to the hospitals participating in the project, support was also given to communities in the hospitals’ catchment areas. Mosquito nets were provided to reduce the risk of contracting malaria. Awareness and advocacy campaigns were held using radio, television, print media, and even drama (public plays on the streets) to inform the population about obstetric fistula, its causes and how to prevent it, and its impact on maternal and fetal mortality. These awareness campaigns enlisted the support of traditional and religious leaders who have substantial influence on behaviors in the community.

Perhaps the most important innovation was the development of a quality assurance mechanism that involved setting standards and systematically collecting data on the quality of the care being provided and the outcomes in terms of maternal and fetal mortality and morbidity. This was done through a “quality circle” process to monitor, review, and improve performance over time. Data were collected in participating hospitals, analyzed statistically, discussed by the teams, and used to assess improvements and take corrective measures as needed.


An evaluation based on the data collected by the hospitals as part of the quality assurance mechanism before, during and after the intervention suggests that the project achieved a 60 percent reduction in maternal mortality in participating hospitals and 15 percent reduction of newborn mortality.


RFPD’s obstetric fistula project combines all three ingredients of a winning combination for impact: partnerships, innovation, and evaluation.

The team established multiple partnerships for funding (the investment for the pilot project in the ten hospitals amounted to one million Euros) and implementation (securing buy-in from the hospitals, the state authorities, the communities, and even traditional and religious leaders).

The project included innovative components in the Nigerian context, especially the quality assurance mechanism and data collection process to improve the quality of obstetric care.

The project was evaluated using data from the quality assurance mechanism and the evaluation was published in an academic journal.

The project has been considered a success by stakeholders and the Kano and Kaduna state governments. This led to a subsequent project to continue to build capacity in the original 10 participating hospitals, and extend the model to 15 more hospitals (five rural hospitals in FCT Abuja, five hospitals in Ondo State, and five more in Enugu State). Additional scaling up is being considered by the RFPD team.

A brief on the project and the Nigerian context is available here.

Providing Water and Sanitation in Uganda (Partnerships Series No. 3)

As in other low income African countries, access to water and sanitation remains limited in Uganda, especially for the poor. This third post in a series on partnerships, innovation, and evaluation tells the story of how Rotary is playing an important role in helping to meet some of the water and sanitation needs of Uganda’s population.


Water Projects

A first important initiative is the Uganda Rotary Water Plus (URWP) program. URWP coordinates work on water and sanitation done by 78 Rotary clubs (virtually all the clubs in Uganda). The program was launched by the Ugandan Minister for Water and Environment in October 2011. It promotes effective service delivery to rural and less privileged communities.

Clubs develop projects for the communities they wish to serve. For this purpose, they must first build strong relationships with the community and develop a needs assessment. Having identified needs, clubs then select partners to meet those needs, including other Rotary clubs for fund raising, non-profits and/or business partners for implementations, and local authorities. Co-funding is typically provided by the Rotary Foundation (TRF) and in some cases other funding agencies.

The design of projects must be based on adequate technologies for the community context, with attention paid to gender and environmental issues. Clubs are encouraged to link the projects to other areas of focus of TRF, for example by providing water and sanitation to schools or health clinics.

The idea is that water and sanitation alone can’t transform a community; the “Plus” in URWP refers to other areas of focus of TRF such as supporting education or fighting disease.

The model also encourages local management committees to oversee facilities cost recovery through tariffs so that funds are available for maintenance.

URWP aims to raise $7 million for more than 30 projects. Rotary International is also partnering in Uganda with USAID to invest $4 million over four years through additional projects, following previous successful similar collaborations in the Dominican Republic, Ghana, and the Philippines (this broader partnership is referred to as the International H20 Collaboration).

Beyond the mobilization of funds, the URWP initiative has also succeeded in uniting 4,000 Ugandan Rotarians, more than 3,000 Rotaractors and many members of Rotary Community Corps (RCCs) behind countrywide water and sanitation initiatives. Many have volunteered their time and financial resources to support the projects.

Community Needs Assessments

Another interesting initiative that is part of URWP has been the implementation of a detailed diagnostic of water and sanitation facilities in communities of Apac District located 250 kilometers north of Kampala.

The idea behind the water and sanitation community needs assessment was to prepare an inventory of resources as well as gaps to be used by the Ministry of Water and the Environment as well as Rotary and other funders for the prioritization of investments. Teams visited communities. After an initial meeting in each community, data collection involved implementing a survey, conducting interviews and focus groups, establishing an inventory of all water and sanitation assets in the community, and conducting community mapping exercise.

Data were collected using the FLOW (Field Level Operations Watch) system developed by Water for People. The application relies on Android cell phones together with GPS data and Google Earth software to document water and sanitation infrastructure as well as its functionality.

The community needs assessments was implemented with support from the Apac government and 16 organizations. Rotaractors served as field enumerators. Data were collected for communities as well as public institutions such as schools and health centers, with ratings provided on the quality of facilities and the satisfaction of users. Tests of water quality have also been conducted in some of the areas.


URWP represents a prime example of efforts by Rotary to invest in projects that have a larger impact through partnerships, innovation, and monitoring and evaluation.

The URWP team has established partnerships with multiple NGOs as well as USAID and Ministry of Water and the Environment. It has been innovative in project design to ensure a higher likelihood of sustainability. Evaluations of the projects are not yet available (many projects are still at the design or implementation stage), but monitoring systems are being put in place.

Finally, in the case of Apac district, extensive data collection has been conducted on water and sanitation assets and gaps at the level of communities in order to inform prioritization of future investments. This should also help in achieving higher impact through targeted interventions.

A brief on the URWP initiative as well as the water and sanitation context in Uganda is available here.

Buying Down Polio (Partnerships Series No. 2)

By partnering with the World Bank in an innovative way, Rotary has successfully leveraged  its funding for polio eradication, contributing to success towards one year without polio in Nigeria and in Africa. This post, the second in a series on partnerships, innovation, and evaluation, explains how the innovative polio buy-down mechanism has worked.

Nigeria’s President vaccinates his granddaughter – Photo courtesy of Dr. Etsano.

Last month, Africa achieved a key milestone towards polio eradication, with no case of polio observed for a full year. It will still take a few weeks for the World Health Organization to officially certify this milestone, and for the region to be declared polio-free, no polio cases should be observed for a period of three years. Still, tremendous progress towards polio eradication has been accomplished. Just a few years ago, hundreds of cases of polio were observed annually in Nigeria. The country achieved its first full year without polio on July 24, 2015. This will leave only Afghanistan and Pakistan on the list of polio-endemic countries.

As noted in a recent post on the World Bank health blog, achieving one year without polio in Nigeria required persistence and courage. In some areas, professionals and volunteers who led the polio campaigns risked their life: Boko Haram assassinated nine polio vaccinators two years ago in the north of the country. Vaccinators had to rely on “hit and run” tactics to reduce exposure to risk, vaccinating children quickly in the morning and leaving the area by the afternoon. (For an understanding of the role of a wide range of people at the heart of polio eradication (in the case of Afghanistan), see the great slide show provided by the Global Polio Eradication Initiative.)

The polio campaigns also required great effort and creativity from multiple agencies, including through an innovative buy-down mechanism implemented by the World Bank and funded by the Bill and Melinda Gates Foundation, as well as Rotary International and the U.S. Centers for Disease Control via the U.N. Foundation. (The Gates Foundation and Rotary International are the two largest donors worldwide towards polio eradication over the last 30 years.) Partnership with the government of Nigeria, the World Health Organization (WHO), and UNICEF, among others, was also crucial to the success of the campaigns.

How did the polio buy-down mechanism work? The basic idea was for the World Bank to fund polio eradication projects through concessional IDA (International Development Association) loans. In the case of Nigeria, two projects worth $285 million, including additional financing, were implemented over the last dozen years. The projects included clauses that allowed loans to Nigeria to become grants if the country achieved a high level of polio immunization coverage. In other words, if the immunization targets indicated in the loans were achieved and verified independently through in-depth audits, the government would receive grant funding for polio eradication without the need to repay the loans.

For the government of Nigeria, this was potentially a great deal. And for the Gates Foundation and the Rotary Foundation of Rotary International, this was also a pretty good investment. In general, investments towards polio eradication have been shown to be fairly cost-effective. But with the buy-down mechanism, these investments were especially cost-effective.

Due to the concessional nature of IDA loans (long-term zero or low-interest loans which grace repayment periods), for every dollar contributed to the buy-down, the actual amount of resources that could be transferred to the government for the polio campaigns was two times larger. The buy-down funds were transferred by the Gates Foundation and Rotary International (in the case of Rotary in partnership with the United Nations Foundation) to the World Bank at the start of the project, and used to repay the loan at the end of the project if the target immunization rates had been achieved.

Through this buy-down mechanism, the Gates Foundation and Rotary International were able to offset all future loan repayment obligations with a much smaller amount of funding to pay back IDA than the face value of the loans granted to Nigeria. Again, one dollar invested by these private donors generated about $2 for polio eradication in Nigeria, with a similar mechanism in place for Pakistan. The mechanism also had built-in incentives to encourage strong implementation performance by the government of Nigeria since the loans would be transformed into grants only if the specific immunization targets were to be achieved.

At the time of the first buy-down mechanism for polio, then-World Bank President James. D. Wolfensohn stated, “The partnership to buy-down loans to grants on the basis of good performance is an example of the innovative thinking occurring in the private sector and the World Bank about how to increase finances for the fight against global diseases. This financial innovation is bringing the goal of a polio-free world one large step closer to becoming reality.”

Could similar buy-down mechanisms be applied in other areas? That was probably the hope when this innovative mechanism was created for polio a dozen years ago. It seems however that with few exceptions the idea has not yet been replicated much in other development areas, even if it has been mentioned in a number of reports, including in a Results for Development report on education.

A number of conditions have to be met for this type of buy-down mechanism to be successful. But in the case of polio, it has been successful, enabling the Gates Foundations, individual Rotarian donors through the Rotary Foundation, the United Nations Foundation, and the World Bank to achieve higher impact towards polio eradication than would have been the case otherwise.

A brief on polio in Africa and the buy-down mechanism is available here.

This post is reproduced with minor changes from a post published by the author on September 2, 2015 on the World Bank’s Financing for Development blog at

Who Works the Most? Rural Women Do!

by Quentin Wodon

International days are often an occasion to provide analysis and commentary about service projects and development issues on this blog. Before the blog was launched on World Polio Day, the annual International Day of Rural Women was celebrated on October 15. The original impetus for this International Day was to recognize rural women’s role in enhancing agricultural and rural development worldwide. Rural women are essential for food security, which is why the day is held one day before World Food Day. Rural women clearly deserve recognition: in many countries, they are the ones who work the most in the household!

Women and girls carry charcoal in Uganda (Photo: C. Tsimpo)
Women and girls carry charcoal in Uganda (Photo: C. Tsimpo)

Comparative analysis of the work patterns of men and women in urban and rural areas is typically done with time use data (see this book from a few years ago on gender and time poverty in Africa). In virtually all countries, women work longer hours than men, especially in rural areas.

With Clarence Tsimpo I recently conducted a similar analysis with the latest Uganda National Household Survey for 2012/13. The survey is nationally representative and it includes an interesting module on time use. Information is available for all individuals in the sampled households on their time use allocations along five core activities: market activities (for example working for a wage), collecting firewood, fetching water, cooking, and children and elderly care. To the extent that other types of work or domestic chores are not included, the weekly workload of individuals could be underestimated with those data, but on the other hand one could argue that other activities are often performed as secondary activities in combination with primary activities.

So, how hard does Uganda’s population work? Nationally, the mean working time is 47.7 hours for the adult population aged between 15 and 60. This total includes an average of 32.7 hours in market work, 2.1 hours for collecting firewood, 3.4 hours for fetching water, 7.6 hours for cooking, and 6.8 hours for children and elderly care.

However, women work on average 55.2 hours per week, well above the average of 39.3 hours for men. Men do spend more time on market work, but women do most of the domestic chores and this leads them to work longer hours overall. For some women, the workload is much higher than those averages. In rural areas, 19.2 percent of women work more than 69 hours per week, and 8.8 percent work more than 92 hours per week. For men, the proportions are lower at 9.0 percent and 1.8 percent respectively.

Women work on average longer than men because they are involved, as men are, in farm and often other labor market work. But what differentiates women from men in terms of their total working time is the fact that the responsibility to fetch firewood and water as well as to cook and take care of domestic chores typically falls on women and their children, often from a young age.

The time needed for such chores can be consequential in low income countries. In the case of water for example, in Uganda only a very small minority of households (7%) has access to piped water in their house or yard. Under usual definitions from the World Health Organization’s Joint Monitoring Programme three in fourth households in Uganda have in principle access to an improved water source. However these sources are sometimes located far away from household’s dwellings, so that the time needed to fetch water may be substantial.

The fact that for some households, substantial time is needed to fetch water means that time may be lacking to make water safe by boiling it. As a respondent in a focus group explained it: “It’s the woman who suffers with water and that’s why we don’t expect her to travel for a long distance looking for water and boiling it as well since she has other domestic chores awaiting for her.” Not boiling water may have severe health consequences.

In addition to walking time to water sources, waiting time is also common. This is illustrated by the following comments: “They are few public taps available and, there is a lot of congestion, making it hard to access water without waiting for a period of one to two hours”; “At the shallow well, in the dry season the water is very little and after pumping five jerry cans one needs to wait for another 30 minutes”. In areas where water is scarce, congestion may lead to chaos and even fighting at water sources. Instances of abuse of children and wives have been reported, especially when wives take too much time to fetch water according to their husbands.

What can be done to reduce the workload of women and shift some of their time from domestic chores to market work, thereby enabling women to earn additional income and help households emerge from poverty? As I already mentioned it on this blog (see the 3-part series on infrastructure and poverty: Part 1, Part 2, Part 3), better coverage of basic infrastructure services is one of the keys. In Uganda, a connection to the grid or piped water network could enable women to decrease their domestic working time and correspondingly increase their market working time by about two hours per week. The additional earnings that could be generated through this shift could reduce the share of the population in poverty by about one percentage point for each of the two basic infrastructure services.

While this would not by itself eradicate poverty in the country, it would help beneficiary households, and especially rural women, fairly substantially. But whether women work on domestic chores or market work, Uganda’s population can count on them to help carry the day.

Infrastructure and Poverty: Part 1 – Does Infrastructure Matter for Poverty Reduction?

by Quentin Wodon

World Toilet Day will be celebrated in a few days on November 19. Some 2.5 billion people do not have access to proper sanitation, including toilets and latrines. Lack of sanitation has dramatic consequences for health. Several million people, many of them children, die from diarrheal diseases every year. Many of these deaths are attributed to unsafe water, poor sanitation including lack of toilets, and poor hygiene. Access to basic infrastructure services – not only for sanitation, but also electricity, piped water, and transport – remains low in many countries.

Women in Uganda carry water (photo: C. Tsimpo)
Women in Uganda carry water (photo: C. Tsimpo)

This 3-part post series discusses the relationship between infrastructure and poverty. The focus is on Africa (the region discussed in my book with Antonio Estache published this week), but the lessons apply more broadly. I will ask three questions: (1) Does infrastructure matter and is funding sufficient? (2) Are household infrastructure needs being met?; and (3) Have reforms succeeded, and what does it mean for us?

Infrastructure Matters

Infrastructure has long been recognized as essential for growth, and growth in turn is empirically proven to be the best way to reduce poverty in the long run (reducing inequality also helps, but has a much lower impact, especially in very poor countries where there is not much to redistribute). Estimates suggest that the elasticity of GDP to infrastructure is in the 0.4 to 1.5 range. This is large – better infrastructure has a major impact on growth.

Infrastructure also matters for other development outcomes at the individual and household level. As mentioned above, many child deaths could be adverted with access to improved water sources and better sanitation. Infrastructure also helps households shift time from domestic chores to productive work.

This has gender implications. In the developing world women work on average longer hours than men. They are involved, as men are, in farm and labor market work, but in addition they have the responsibility to fetch firewood and water. This responsibility can be time consuming. As a villager from Uganda explains: “They are few public taps available here and there is a lot of congestion, making it hard to access water without waiting for a period of one to two hours”.

In work I am doing with Clarence Tsimpo on Uganda, regression analysis with the latest household survey suggests that in areas where the electricity grid or the piped water network is available, a connection to the grid or piped water network for those households not yet connected could enable women to decrease their domestic working time, and correspondingly increase their market working time by about two hours per week.

The additional earnings that could be generated through this shift could reduce the share of the population in poverty by about one percentage point for each of the two basic infrastructure services. While this would not by itself eradicate poverty in the country, it would help beneficiary households, and especially rural women, fairly substantially.

Infrastructure as a New Priority

Throughout much of the last two decades, funding allocated to infrastructure by governments fell in proportion of available budgets. It has also been said that transport was one of the forgotten MDGs (Millennium Development Goals). Today, the situation has changed and the crucial role of infrastructure is widely recognized. Yet funding remains a challenge.

According to the World Bank, private infrastructure investment in emerging markets and developing economies dropped from US$186 billion in 2012 to $150 billion last year. At its annual meetings last month, the World Bank announced the launch of a new global infrastructure facility. While developing countries invest US$1 trillion per year on infrastructure, this would need to be doubled to maintain current growth rates and meet future demand for infrastructure from firms, households, and regions.

The private sector will play a key role in future infrastructure investments, but governments will need to invest more as well. For this, they will need to rely on both their own tax revenues and the availability of foreign aid. For low income countries, concessional financing (grants or very low interest loans) will remain crucial.

When increasing funding for infrastructure, governments and donors will need to be careful to assess fiscal and institutional capacity – not all countries have the same absorptive and implementation capacity. The worst that could happen would be to have large investments in sub-optimal infrastructure projects. The risk of an increase in debt to unsustainable levels must also be managed. But many countries do have the capacity to absorb more funding for infrastructure.

This is the big picture about the relationship between infrastructure and poverty in Africa and many other parts of the world. The next post in this series will discuss whether household needs are being met, and if not, why not.

Reducing the Gender Gap in Education

by Quentin Wodon

The International Day of the Girl Child earlier this month was an opportunity to remind ourselves that girls are among the primary victims of violence, and that they continue to, in many countries, have limited education and employment opportunities.

There has been substantial progress towards gender equity in basic education, but large gaps remain at the secondary level. In the Figure below from the World Bank’s Global Monitoring Report (GMR) just published, countries are ranked on the horizontal axis according to GDP per capita. Gaps in secondary school completion by gender are displayed on the vertical axis. The sizes of the dots represent the size of the countries’ population. Data are provided for sub-Saharan countries in orange and South Asian countries in blue. On average, a boy remains 1.55 times more likely than a girl to complete secondary school in the countries in the sample. The gaps are larger in poorer countries. But there is also a lot of variation around the regression line, suggesting that it is feasible to reduce gender gaps in attainment even in low income countries.

Ratio of Secondary School Completion Rates by Gender

Source: World Bank Global Monitoring Report.

Multiple reasons may explain why boys and girls drop out before completing secondary school. For example, in a 2012/13 survey for Uganda, parents mentioned the cost of education as the main reason for dropping out for both boys and girls. The fact that a child was not willing to continue his or her education came up next, but for girls an even more important reason for dropping out was pregnancy, often linked to early marriage. A sickness or calamity in the family was also mentioned as a reason for dropping out, as was the fact that some children did not make enough progress in school. When similar questions were asked to head teachers, differences between boys and girls emerged even more clearly. For boys, lack of interest and employment were key reasons for dropping out. For girls, pregnancies and child marriage came up strong, with these in turn likely to be related to poverty and limited employment prospects as well as cultural factors.

Because multiple reasons may contribute to gender gaps in attainment, the types of interventions that could be implemented to reduce these gender gaps are also multiple. Should the distance to schools be reduced, whether this is done by building new schools in remote areas or reducing travel time through public transportation? Should scholarships be provided to girls, as successfully pioneered by Bangladesh several decades ago? Should more female teachers be hired? Should the priority be to make separate toilet blocks available for boys and girls? Should more focus be placed on understanding and changing cultural practices? Choosing between these and many other potential interventions is often difficult and clearly responses depend on country context. But reviews of the evidence can help, and such reviews are now becoming more available thanks to a substantial increase in rigorous impact evaluations in recent years.

One such review was published in June 2014 by a team of academics led by UNESCO and funded by the UK’s Department for International Development. The review assessed the evidence on the impact of interventions for girls’ education focusing on (i) providing resources (including transfers) and infrastructure, (ii) changing institutions, and (iii) changing norms and including the most marginalized in education decision making. The review summarized the impact of different types of interventions on three outcomes: participation, learning, and empowerment. For each type of intervention and category of outcome, the evidence on the likelihood of impact was classified as strong, promising, limited, or needed (i.e., weak).

For participation, the evidence on the impact of conditional cash transfers, information about the potential employment returns to education, and the provision of additional schools in underserved and unsafe areas was found to be strong. This was also the case for the evidence on some interventions related to teacher training, group-learning, and measures to promote girl-friendly schools as well as learning outside the classroom, for example through tutoring. Several of these interventions (group-learning, programs for learning outside the classroom, and scholarships linked to student performance) were also found to have clear impacts on learning. The evidence on the impact of interventions on empowerment was generally found to be weaker.

This type of review and the studies on which such reviews are based are of high value for policy-makers. The World Bank has also started to put together a systematic database of impact evaluations and its Strategic Impact Evaluation Fund is providing funding for rigorous evaluations. What else is needed? We need more experiments and evaluations. But we also need assessments of the cost effectiveness of various types of interventions, so that Ministries of Education can make the right decision under their budget constraints. And we need more research on the political economy of program expansion to understand how great innovations can be scaled up and sustained.

Note: this post is reproduced with minor edits from a post published on October 29, 2014 on the World Bank’s Let’s Talk Development blog available at

Art of Service Delivery: Learning from Faith-inspired Health Care Providers

by Quentin Wodon

In this clinic we are accommodated well and treated respectfully… We have the opportunity to converse with the health worker, describing the illness, and when we are mistaken or do not understand, we are not threatened. They help us locate the pain and they explain everything about the disease and how to treat it. They encourage us to speak and they try to give us confidence. –Patient in Burkina Faso

At a time when many African countries may not achieve the health targets set forth in the Millennium Development Goals, the contribution of faith-inspired providers to improved health care is crucial. A recent World Bank study suggests that, while these providers’ market share and reach to the poor may be smaller than often assumed, they seem particularly good at serving their patients. Indeed, they seem to be experts in the science (or maybe in this case, the art) of delivery, a concept World Bank President Jim Kim has spoken of recently in several keynote addresses on achieving universal health coverage.

The Bank’s study provides illuminating evidence on the market share of faith-based providers, commonly believed to be responsible for a large share of the health services available in Africa. In a number of African countries, data are available on hospital beds provided by Christian Health Associations (CHAs) and the public sector (data on other private sector providers are harder to come by). As a share of the hospital beds provided by the CHAs and Ministries of Health, the CHAs often account for one-third or more of the available beds, which is indeed very large.

But when using data from household surveys, which include all private health facilities as well as traditional healers, chemical stores, pharmacists, and other health service providers, and when including countries where CHAs are not present, the region-wide market share of faith-inspired providers is smaller, of the order of 10%. Still, even if their market share is smaller than often claimed, the contribution of faith-inspired providers clearly remains significant.

Consider next the issue of reaching the poor. It is also often believed that faith-inspired providers reach the poor as a matter of priority, while private, secular providers reach mostly wealthier households. There is truth to this, but data from household surveys suggest that differences in beneficiary incidence between various types of providers are smaller than often believed and that none of the three types of providers (public, faith-inspired, or private secular) serve the poor more than the better off in absolute terms.

Especially for faith-inspired providers, this occurs in part due to a need for some level of cost recovery. As faith-inspired providers often receive only limited support from governments, they have no choice but to charge for care which may make it difficult for the poor to visit. Households often prefer faith-inspired facilities, but they cannot always afford them, even when the facilities make special efforts to make their services affordable.

Consider, finally, the quality of health services, which is arguably the most important issue. Data from household surveys suggests that faith-inspired providers enjoy higher satisfaction rates than both public and private secular facilities. This explains why it is often reported that patients are willing to walk long distances to visit faith-inspired facilities – a finding is supported by both quantitative and qualitative evidence.

What seems to drive the higher satisfaction rates with faith-inspired providers is the quality of the service provided and the respect with which patients are treated. As one patient said, “Human warmth is very present in this center. There is a true closeness between the patients and the sister and her colleagues. One is spoken to, touched and accepted.” Evidence shows that many faith-inspired providers work more closely with communities, and that they succeed in promoting health through preventive services as well as nutritional and educational programs.

In sum, while faith-inspired providers may have lower market shares than commonly believed, and while they may not always be located in poor areas or serve primarily the poor, they provide vital services that are seen by patients as being of higher quality than the services provided by other providers. The evidence clearly points to a major role played by these providers, but more importantly it calls for stronger public-private partnerships than are currently observed. In addition, mechanisms should be put in place so that other care providers can learn from those faith-inspired providers that seem to excel at the science – or perhaps the art – of delivery.

Public, Private Secular, and Faith-inspired Schools: How Do They Differ?

Private secular schools are also growing, albeit for different reasons related more directly to the perceived quality of the education they provide. Both types of private schools can usefully complement public schools and provide choice to families. And yet, relatively little systematic evidence is available on the market share, reach to the poor, cost for families, and quality of both types of schools.Two recent World Bank studies help bridge that gap in knowledge. The first study provides a comparative assessment of the role of public, private secular, and faith-inspired schools in sub-Saharan Africa. It is based on a systematic analysis of nationally representative household surveys for 16 countries that identify separately public, private secular, and faith-inspired schools, as well as in-depth qualitative data collection in two countries (Ghana and Burkina Faso).The second study focuses on the experience of the Jesuit-run Fe y Alegría network of schools in Latin America. That study combines articles that assess (quantitatively) the performance of the network’s schools with other articles looking at the schools’ pedagogical practices.

The first study on sub-Saharan Africa suggests that the market share of faith-inspired and private secular schools is smaller than often claimed, but still substantial. Across the 16 countries, the average market share for faith-inspired schools is at 14% at the primary level and 11% at the secondary level. The corresponding market shares for private secular schools are 12% and 16%. These estimates from household surveys are of an order of magnitude similar to the statistics on the market share of the private sector as a whole, reported by the UNESCO Institute of Statistics on the basis of administrative data provided by government.

The household surveys also suggest that public schools reach the poor more than faith-inspired schools, while private secular schools are the least ‘pro-poor’. This is not surprising given that the cost for households of private secular schools is higher than that of faith-inspired schools, with public schools being the most affordable. The fact that faith-inspired schools do not reach the poor in priority, statistically speaking, does not mean that they do not aim to do so. But they operate within tight budget constraints, especially when support from governments is limited, and this requires some level of cost recovery from households. Some private secular schools also aim to reach the poor, but this tends to not to be a widely shared feature of these schools.

Finally, and most importantly, the data suggest that both faith-inspired and private secular schools have higher satisfaction rates among parents than public schools, with private secular schools performing best according to that metrics.

Tentative evidence also suggests that student performance in terms of literacy and numeracy, as well as test scores, is also often (but not always) higher among faith-inspired and private secular schools than in public schools. In the case of faith-inspired schools, qualitative evidence suggests that the emphasis placed on religion for Islamic schools and values more than religion per se in Christian schools is appreciated by parents. In other words, these schools are highly valued and could probably be better supported by governments and donors provided that they also teach secular topics, which is often the case.

Why is the quality of education provided apparently higher in faith-inspired and private schools than in public schools?

Part of the explanation could come from teacher motivation. For example, teachers in faith-inspired schools might be “working for God” (to use the title of an article on faith-inspired health care by Reinikka and Svensson). If only motivation were at play, the ability to scale up those schools, or replicate their success in other schools might be limited, as reservoirs of highly motivated teachers are probably finite.

But while motivation plays a role, the management and teacher training systems that well performing faith-inspired and private secular schools have managed to put in place also matter greatly. This is clearly apparent in the second study on Fe y Alegría schools in Latin America. The management teams of the schools spend significant time and have succeeded in fostering a culture of accountability and dedication in the school that helps to place service to students at the very core of the teacher’s mission.

Overall, the message from both studies is that while it is not necessarily easy, fostering a culture of great service to students can be achieved, and the experience of faith-inspired and private secular schools is useful to better understand how it can be done.

The message is not necessarily to scale up provision of education by faith-inspired and private secular schools, but rather and more importantly to support existing schools that provide a great education to children. This is especially important when schools also aim to reach the poor. We should learn from their successes and see how they might be replicated in other types of schools.

Note: this post is reproduced with minor changes from a post on the Education for Global Development blog of the World Bank available at

Water and Sanitation for Health: Why Is Progress Slow?

by Quentin Wodon and Clarence Tsimpo

Today is World Habitat Day. Created almost 30 years ago, the day promotes adequate shelter for all. Why should this be mentioned in a blog on investing in health? Because adequate shelter, including access to safe water and sanitation, is essential for health. Several million people, many of them chidren, die from diarrheal diseases every year. Many of these deaths can be attributed to unsafe water, poor sanitation and poor hygiene.
Hand washing in practice

Given the importance of water and sanitation for well-being and health, one would hope to see rapid progress in access, but this is not the case. Trends in coverage of piped water and sanitation prepared for a World Bank study on Africa’s infrastructure a few years ago suggest stagnant rates (more progress is being achieved for electricity, and course, cell phones). Water networks are expanding, and latrines are being built, but too often this only enables countries to keep up with pressure of population growth and the reduction in household size (the smaller the average household is, the more households need to be served for any given population).

Uganda is a good example. Despite rapid growth in the water network in recent years, on a small minority (7%) of households had access to piped water in the latest survey for 2012/13. Under usual definitions from the Joint Monitoring Program of the World Health Organization (WHO), three in four households have access to an improved water source, but some of the sources imply out-of-pocket costs or opportunity costs for the time needed to reach the source. The situation is similar in many other low-income countries.

Why is progress slow? Apart from increasing demand, findings from qualitative fieldwork suggest that supply factors are also at play. In the case of water, these include lack of infrastructure functionality(facilities may notbe working properly, even shortly after being installed), lack of local responsibility (poor leadership may hinder investments in water supply or leadto lack of maintenance) and scarcity (in some communities, water is simply not easily available).These factors tend to be organizational in nature, or physical in the case of water scarcity. But in addition, one should not underestimate the role of culture, tradition, and behaviors.

For example, households know that boiling water is one of the best ways to make it safe. But a minority (less than 40%, according to the latest survey) do it. A few quotes from qualitative fieldwork illustrate why: “We do not have time to boil this water because of the demanding household chores. We feel it is a waste of time since this water looks clean.”“We are aware this water is bad, but it takes a long time to bring the water to boil and firewood has become scarce.”“I am about 57 years old and I have been living on un-boiled water without falling sick. What matters to us is for the government to expandthe availability of water points, not to tell us to boil the water.”

Adequate sanitation is also essential for health. Yet again, in many low-income countries, only a small minority of households has access to improved sanitation. Part of this may be due to a low priority assigned to sanitation in terms of public funding. But part of it is also due to cultural and traditional norms, as well as lack of income or time. Poor terrain or soil type and a lack of land to build latrines also play a role in some areas.

When public latrines are available, there is often a consensus on charginguser fees to ensure maintenance, but enforcement is weak. The same is true for by-laws in areasrequiring households to build their own latrines, which are often expensive to build, at least for the poor.

Focus group participants were asked why they pay for cell phones but not for latrines. They responded that latrines have a much larger one-time cost, but also that having a cell phone is a sign of modernity and important for one’s status in communities. Clearly, more needs to be done to convince households of the importance of latrines, for example through sanitation marketing campaigns.

Finally, in terms of health benefits, there is perhaps no more cost-effective intervention that the promotion of hand washing, but only a small minority of Uganda’s households (less than one in ten) has a facility to wash hands with both soap and water. Information campaigns are held, but, as aparticipant in focus groups noted, “many of the community members do not attend them, saying that these trainings are a waste of time.”

Sometimes even children contribute to low uptake of the practice: “We used to have hand washing utensils, but the children would play with them and waste the water, so we gave up”. More fundamentally, local leadershipappears to be one of the keys: “Local leaders have campaigned, but there is poor adoption, because hand washing is viewed as a very strange practice to the local culture. Local leaders themselves are not visibly seen practicing hand washing… You cannot simply continue telling people about what they should do, but do not see you doing!”

Studies from the Bank’s Water and Sanitation Program suggest that the cost of lack of sanitation is high. As in other low-income countries, Uganda has invested over the years in safe water and sanitation. But the constraints faced by households and communities are complex. The qualitative work implemented in 14 districts suggests that solutions often must be context- and community-specific. This may not lead to cookie-cutter solutions, but it is important to document precisely because of the variety of local circumstances.

Note: This post is reproduced with minor modifications from a post in October 2014 on the Investing in Health blog at the World Bank, available at