Free ebook 2 – Partner, Innovate, Evaluate: Increasing Rotary’s Impact

The second ebook in the Rotarian Economist Short Books Series has been published. Partnerships, innovation, and evaluation can increase the quality, scope, and reach of Rotary’s service work in communities. The book suggests with case studies how this can be done. All books in the series are free and available here in multiple formats.  Please share this link widely with others for them to be able to benefit from this resource. And if you like the books in the series, please consider writing a quick review at Smashwords!

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Fighting Malaria and Ebola in Mali (Partnerships Series No. 7)

As part of this series of posts on increasing Rotary’s impact through partnerships, innovation, and evaluation, I had to include Muso, a nonprofit that has successfully fought malaria and Ebola in Mali, in part with support from Rotary. As some readers may remember it, I talked about Muso in this blog previously, and this post is based in large part on previous posts. But at the risk of repetition, it is worth emphasizing again that Muso is a great example of an innovative approach that has been evaluated and has the potential of being replicated at scale thanks to partnerships.

Muso2

A Successful Pilot

Muso started in Mali as a project to provide basic care to communities, focusing initially in part on malaria. Two years ago a Harvard/University of California San Francisco study documented a tenfold difference in child mortality rates after the rollout of the Muso model in the program’s catchment area. Muso relies on professionalized community health workers to diagnose illnesses quickly in its catchment area, refer patients to clinics and hospitals as needed, and reduce financial barriers to care for families.

One needs to be careful in inferring causality between the intervention and the reduction in child mortality since the evaluation was based on repeated cross-sectional data as opposed to a randomized control trial. Still, the impact appears to have been major and obtained at relatively low cost. The Muso model was recently recognized as a finalist for two major prizes – the GSK Global Healthcare Innovation Award and the Caplow Children’s Prize.

Support to the Ministry of Health

Some successful pilot interventions in health are implemented without ever being scaled up, so that their benefits for a country’s population as a whole may be limited. This is not the case for Muso. In addition to implementing and evaluating an innovative model, Muso worked closely from the start with the Malian Ministry of Health as well as other partners to explore opportunities to expand the model nationally.

In November last year, based in part on the Muso model, Mali’s Ministry of Health Division of Community Health Systems announced a strategic plan to scale up professionalized community health workers throughout the country. How did this transformation happen? As just mentioned, Muso and other partners have been actively working with the Ministry of Health for seven years. The partnership was launched in 2008. The collaboration has been not only operational, but also scientific, with support from university researchers. Though this partnership, Muso has been able to provide technical assistance to help the Ministry develop a national plan for scaling-up the community health worker model.

Factors contributed to the success of this partnership and to the scaling-up announcement according to Dr. Ari Johnson, the co-founder of Muso, who was interviewed last year. “First, we started the partnership early on. By setting an operational research partnership at the design phase of the project, we were able to ensure that the pilot would focus on the priorities of the Ministry of Health, which meant a focus on child survival and disease-specific targets, including early effective treatment for malaria.”

A second factor for success was the ability to work with other NGOs to test the robustness of the community health worker model in different parts of the country. “The Malian Ministry of Health worked simultaneously with several NGOs on operational research to test community health workers models. This included, but was not limited to Muso with the operational research study in Yirimadjo and Doctors without Borders (Médecins sans Frontières) with another study in Kanbaga. These experiences with multiple partners in several locations provided the Ministry of Health with converging evidence for scaling up paid, professionalized community health workers,” explains Dr. Johnson.

The third factor for success was the support of international organizations. Multilateral and bilateral global health institutions are all trying to strengthen health systems in Africa. In Mali, Dr. Johnson explains that UNICEF and the Global Fund provided important support for the adoption and expansion of the community health workers model by the Ministry of Health.

Finally Dr. Johnson insists that operational research partnerships must be long-term to succeed. “Longitudinal operational research partnerships take time to implement, but over time, they help build relationships between public sector policy makers and hubs of research. These relationships become avenues for translating research into evidence-based policy change at scale.” Dr. Johnson adds that “the long view is critical, and often neglected in global health work. Short-term funding cycles push organizations to move on after a few years and abandon the foundations of a strong partnership. A long term partnership for iterative and ongoing research is crucial to support Ministries in their strategic plans and thereby achieve scale.”

Many questions remain. What should be the health care financing system for community health workers? How can those workers be deployed across both urban and rural areas? How is the supervision of the workers to be worked out? These and other questions will need to be answered. But progress is being made.

Relevance for Ebola

How does all this relate to the Ebola crisis that recently hit West African countries? Apart from their role in preventing and treating malaria as well as other common illnesses, community health workers can be essential in the fight against Ebola. Ebola arrived in Mali through a two-year-old girl who had traveled with her grandmother from Guinea died.  Mali became the sixth West African country with a confirmed Ebola case.

Why are community health workers so important for the fight against Ebola? They are crucial in part because they tend to be trusted members of their communities. They can not only help in providing information about Ebola and promoting appropriate behaviors, but they can also help to trace and monitor those who have been in contact with the virus. This must be done for at least 21 days – the period during which symptoms do not yet emerge, and it must be continued after that period if individuals become sick. In the other countries affected by the virus – including Guinea, Liberia, and Sierra Leone, community health workers already play that vital role.

As Dr, Johnson explained it, “there is huge potential for community health workers to accelerate the effort to stop Ebola across West Africa, by supporting epidemiologic surveillance, contact monitoring, returning traveler monitoring, community engagement, and prevention counseling.”

Conclusion

Muso has piloted an innovative new model of health care delivery that appears to have contributed to reducing child mortality in its area of intervention. The model has also proved valuable in fighting the Ebola epidemics. Rotary provided crucial support to Muso when the NGO was still small and not as well-known as it is today, with fewer resources. Rotarians and Rotaractors have volunteered with Muso in Mali, and others have contributed to making the project better known internationally.

Today, Muso is scaling up, aiming to raise substantial funds to expand its program. It is also launching a rigorous impact evaluation through a randomized controlled trial to measure its effectiveness. While many organizations and individuals have contributed to Muso’s success, especially the Muso team working on the ground, at times taking substantial risks to help the population as was the case during the Ebola epidemics, Rotary and Rotarians have played a small supporting role as well.

Video on Award-Winning Muso: Reducing Child Mortality by a Factor of Ten in Mali

by Quentin Wodon

One of the great Rotary-funded projects that has been featured on this blog is Muso. The NGO has reduced child mortality by a factor of ten in its catchment area in Mali thanks in part to an innovative community health workers model. The project has received several awards as a best practice model for saving lives.

Muso baby

I hope you will enjoy the video on Muso and Rotary’s role in supporting the project now available on this blog here (the video was prepared by one of my daughters using footage made available by the Muso team). A short brief on the Muso model and Rotary’s contribution was published earlier on this blog and is available here.

If you would like to submit a video, brief, or paper on your project for this blog’s series, please send me an email through the Contact Me page.

 

 

Malaria, Ebola, and Saving Lives: Part 3 – Funding and Emergency Response

by Quentin Wodon

The first two posts in this series documented how Muso’s community health workers pilot in Mali helped reduce child mortality and the factors that made it feasible for the Malian Ministry of Health to adopt the model nationally. The relevance of the community health worker model for Ebola was also briefly discussed. This last post explains how Rotary supported Muso and, more importantly right now, how Rotarians and others can help those affected by the Ebola epidemic.

Supplies for the Ebola Response from the Monrovia Rotary Club
Supplies for the Ebola Response from the Monrovia Rotary Club

Two Grants for Muso

While Rotary has not been the only supporter of the Muso pilot, it has played an important role in funding it. Rotary has supported Muso through two so-called global grants thanks to Maria Nelly Pavisich from the Rotary Club of Washington, DC and other Rotarians from many clubs. A first grant of $60,000 was approved when Maria Nelly was with the Rotary Club of Capitol Hill. The focus of that grant was on malaria prevention and treatment. The funds were used to buy high quality insecticide bed nets, and provide diagnosis and treatment for more than 3,500 patients. During the course of this first grant, Muso grew tenfold. With new partnerships among others with the Against Malaria Foundation and CHF Muso achieved universal coverage of its interventions in Yirimadjo.

In March 2014 the Rotary Foundation awarded Muso an additional $151,500 grant to expand its work. The new initiative is called Thrive for Five: Improving Child Health and Survival in Mali. It will benefit 13,500 children over two years. Putting the grant together was not easy, because the Rotary Foundation requires clubs and districts to contribute before matching those contributions. As Maria Nelly explained: “We had to create a global coalition of more than 50 Rotarians from Africa, North America, Europe, and Asia. We all worked together to raise funds and provide expertise. Eight clubs and seven Districts agreed to contribute. It took hundreds of emails, multiple reports, conversations, and presentations to get there. You’ve got to have a firm commitment to reach the goal! I guess it is the humanitarian adrenaline that keeps me going.”

The donations for the $151,500 grant by clubs as well as the district (DDF) and Rotary Foundation (TRF) matching funds are visualized in the Figure below. So far, for the two global grants as well as in other ways, a total of 15 Rotary Clubs in 11 Districts, seven countries, and four continents have supported Muso. While putting these grants together was substantial work, it was all worth it according to Maria Nelly: “When you reach the goal, it feels so good! It is extremely motivating to do this work with a reputable, focused and reliable organization such as Muso. And to hear Yirimadjo survival stories from community health workers… Muso does the hard work on the ground, but as Rotarians we contribute as we can, in this case with funding.”

Funding for Second Muso Grant
Funding for Second Muso Grant

Ebola Response

Today, many Rotarians and others are asking how they can help those affected by the Ebola epidemic, especially in Guinea, Liberia, and Sierra Leone. Funding by individuals and clubs may seem small in comparison to contributions by organizations such as the World Bank ($500 million) or the United States Government (e.g., building hospitals). But while small, these contributions still make a major difference in the life of those who benefit from them.

Many Rotary districts are trying to raise funds. In my district (D-7620), the Disaster Relief Committee will fund personal protection equipment for 18 hospitals and health centers in Liberia in partnership with IMA World Health and the Christian Health Association of Liberia. The fundraising is coordinated by Disaster Aid USA and the Rotary Club of Bonds Meadow Foundation. Beyond support right away, given that the needs for assistance in Ebola-affected countries will be there for quite some time, clubs and districts could also consider global grants, as was done for Muso in Mali.  These grants take a bit of time to prepare, but they can be quite powerful.

Rotarians in affected countries are also engaged, as are many other citizens. For example, the Rotary Club of Monrovia in Liberia has established an Ebola Response Committee. The club initially purchased locally a wide range of items including examination and other gloves, mattresses for patients in treatment facilities, infra-red thermometers, boots for health care workers, and so on. The club also carried out awareness campaigns with the Liberian Nurses Association, and it is has been supporting reintegration of patients into the community. With the Ministry of Health and the NGO ChildFund, it launched the first Interim Care Center for children whose parents were in isolation in treatment centers or had been orphaned by Ebola. Right now, the Monrovia Rotary Club is raising funds to attend to the urgent needs of Ebola victims, their families, and caregivers.

When members of our club spoke to members of the Monrovia club, more than three dozen clubs worldwide had already contacted the Monrovia club to provide assistance. But much more is needed. If you, as a Rotarian or otherwise, can support those responding to the Ebola crisis on the ground in the affected countries, please do.

 

Malaria, Ebola, and Saving Lives: Part 2 – Scaling Up

by Quentin Wodon

Some successful pilot interventions in health are implemented without ever being scaled up, so that their benefits for a country’s population as a whole may be limited. This is not the case for the Muso pilot. In addition to implementing and evaluating an innovative model, Muso worked closely from the start with the Malian Ministry of Health as well as other partners to explore opportunities to expand its model nationally. This second post explains how this was achieved.

Muso2

A Successful Pilot

Recall from the first post in this series that a Harvard/University of California San Francisco study documented a tenfold difference in child mortality rates after the rollout of the Muso model in the program’s catchment area. Muso relied on paid and professionalized community health workers to diagnose illnesses quickly in its catchment area, refer patients to clinics and hospitals as needed, and reduce financial barriers to care for families. One needs to be careful in assigning causality since the evaluation is based on repeated cross-sectional data as opposed to a randomized control trial. Still, the impact appears to have been major and obtained at relatively low cost. The Muso model was recently recognized as a finalist for two major prizes – the GSK Global Healthcare Innovation Award and the Caplow Children’s Prize.

National Expansion: Four Enabling Factors

Last week Mali’s Ministry of Health Division of Community Health Systems announced a five-year strategic plan to scale up professionalized community health workers throughout the country. Just a few years ago Mali’s public health sector had no paid community health workers. Soon, they may be present in every region.

How did this transformation happen? Muso and other partners have been actively working with the Ministry of Health for seven years. The partnership was launched in 2008. The collaboration has been not only operational, but also scientific, with support from university researchers. Though this partnership, Muso has been able to provide technical assistance to help the Ministry develop a national plan for scaling-up the community health worker model.

Four factors contributed to the success of this partnership and to last week’s scaling-up announcement according to Dr. Ari Johnson, the co-founder of Muso. “First, we started the partnership early on. By setting an operational research partnership at the design phase of the project, we were able to ensure that the pilot would focus on the priorities of the Ministry of Health, which meant a focus on child survival and disease-specific targets, including early effective treatment for malaria.”

A second factor for success was the ability to work with other NGOs to test the robustness of the community health worker model in different parts of the country. “The Malian Ministry of Health worked simultaneously with several NGOs on operational research to test community health workers models. This included, but was not limited to Muso with the operational research study in Yirimadjo and Doctors without Borders (Médecins sans Frontières) with another study in Kanbaga. These experiences with multiple partners in several locations provided the Ministry of Health with converging evidence for scaling up paid, professionalized community health workers,” explains Dr. Johnson.

The third factor for success was the support of international organizations. Multilateral and bilateral global health institutions are all trying to strengthen health systems in Africa. In Mali, Dr. Johnson explains that UNICEF and the Global Fund provided important support for the adoption and expansion of the community health workers model by the Ministry of Health.

Finally Dr. Johnson insists that operational research partnerships must be long-term to succeed. “Longitudinal operational research partnerships take time to implement, but over time, they help build relationships between public sector policy makers and hubs of research. These relationships become avenues for translating research into evidence-based policy change at scale.” Dr. Johnson adds that “the long view is critical, and often neglected in global health work. Short-term funding cycles push organizations to move on after a few years and abandon the foundations of a strong partnership. A long term partnership for iterative and ongoing research is crucial to support Ministries in their strategic plans and thereby achieve scale.”

Many questions remain. What should be the health care financing system for community health workers? How can those workers be deployed across both urban and rural areas? How is the supervision of the workers to be worked out? These and other questions will need to be answered. But on the occasion of the launch of the national plan last week, Dr. George Dakono, the National Director of Community Health Systems, noted that “Muso is at the vanguard.” In recognition of the role played by the Muso team, Dr. Dakono invited Muso’s Health Systems Director, Dr. Djoumé Diakité, to present the plan at the Ministry of Health.

Relevance for Ebola

How does all this relate to the Ebola crisis in West Africa? Apart from their role in preventing and treating malaria as well as other common illnesses, community health workers are essential in the fight against Ebola. Last week witnessed the first confirmed case of Ebola in Mali. A two-year-old girl who had traveled with her grandmother from Guinea died. While no other cases of Ebola have been reported to date, many people have been in contact with the girl and more than 40 of those individuals are being monitored. Mali is now the sixth West African country with a confirmed Ebola case.

Why are community health workers so important for the fight against Ebola? They are crucial in part because they tend to be trusted members of their communities. They can not only help in providing information about Ebola and promoting appropriate behaviors, but they can also help to trace and monitor those who have been in contact with the virus. This must be done for at least 21 days – the period during which symptoms do not yet emerge, and it must be continued after that period if individuals become sick. In the other countries affected by the virus – including Guinea, Liberia, and Sierra Leone, community health workers already play that vital role.

As Dr, Johnson explains, “there is huge potential for community health workers to accelerate the effort to stop Ebola across West Africa, by supporting epidemiologic surveillance, contact monitoring, returning traveler monitoring, community engagement, and prevention counseling.”

Malaria, Ebola, and Saving Lives: Part 1 – The Muso Pilot

by Quentin Wodon

Two days ago, Mali launched a national strategic plan to scale up Community Health Workers in every region of the country. This initiative has the potential to save tens of thousands of lives. It could also significantly reduce risks related to Ebola.

This post is part of series of three that tells the remarkable story of how this happened, thanks in part to Rotary-funded Muso, a NGO that has been working closely with the Malian Ministry of Health for several years.

Muso baby

Roll back a few years and meet Djeneba, a young girl living in Yirimadjo in Mali (West Africa), one of the poorest countries in the world. Today she goes to school but her life was once threatened. At the time her family was living on less than a dollar a day. Djeneba started getting high fevers but her parents did not have enough money to pay for care. They tried to break the fever by bathing her in herbal remedies and buying unregulated pharmaceuticals but the fevers persisted and became increasingly severe.

Fortunately Djeneba lived in a community were Muso was being implemented. Families could receive healthcare for free or at very low cost. Sira, one of the community health workers trained by Muso became aware of Djeneba’s situation after one particularly nasty fever, and wrapped Djeneba in wet towels to stabilize her fever. She sent Djeneba by ambulance to a large hospital in the capital city of Bamako where she received comprehensive treatment. During the ambulance ride Djeneba lost consciousness and she was diagnosed with advanced cerebral malaria. During the first 10 days of her stay in the hospital she was in a coma. But after three weeks in the hospital and lifesaving medication she was released happy and healthy.

When Djeneba returned home Sira taught her parents how and when Djeneba should take her medication at home. Everyday Sira visited Djeneba to care for her. Two weeks after her recovery, Sira saw Djeneba with a school backpack entering her house. Sira’s diligence and attention towards Djeneba saved her life and got her back on track in school.

Djeneba’s story is not unique. Half of the world’s population is vulnerable to malaria. Every year, 665,000 people die from malaria episodes. Many are children under five. Muso is on the frontlines of providing timely, proactive health care to poor communities and hard-to-reach populations so that the lives of children like Djeneba can be saved.

“Most children killed from malaria die within 48 hours of the moment they say ‘Mommy I’m sick.’ We already have the tools to avert nearly all deaths from malaria, but they are not reaching the children who need them early enough. Our idea is simple but powerful: if we reach every child early, we could avert nearly all child deaths from malaria. But to reach every child early in the world’s poorest communities is a big challenge. To make this happen, we had to challenge the conventions of traditional health systems. Traditional health systems are reactive. Medical providers like me are expected to wait for patients to come to us. Muso’s health system takes a proactive approach, deploying Community Health Workers to search actively for patients door to door”, says Dr. Ari Johnson, co-founder of Muso.

As explained in a previous post on this blog, Muso works in communities through a four-step approach. The first step consists of mobilizing the existing health care delivery system. This includes selecting, training, employing and supervising local individuals who go door-to-door and identify children sick with malaria and other illnesses. These community health workers diagnose malaria in the household and treat simple cases. The second step consists of removing barriers that prevent people from accessing care when needed. By eliminating point-of-care user fees, Muso ensures that even the poorest can benefit from life-saving comprehensive and universal care, whether at home, in community health centers, or in referral hospitals. The third step consists of creating rapid referral networks by training communities in identifying health risks, prioritizing rapid treatment, and navigating the health system. The final step consists of clinical capacity building. As Muso systematically removes access barriers to achieve universal health coverage, it reinforces the ability of the public sector to provide quality care to its patients.

How do we know that Muso has been successful? A recent study published in the peer- reviewed journal PLoS ONE is very encouraging. The study documents a ten-fold difference in the rate of child mortality in the three years after the launch of Muso. At baseline the rate of child mortality was 15.5 percent. After three years, it dropped to 1.7 percent. During the same period, there was a ten-fold increase in the number of patient home and clinic visits in the catchment area, a doubling of the rate of rapid access to malaria treatment for children in need, and a reduction by one third in the share of children becoming sick with fever.

The Muso team has been interviewed among others by the BBC, ABC News, Reuters, and the New York Times and the project recently received two global awards. First, the 2013 GSK Global Healthcare Innovation Award recognized the project as one of five effective new models for better chances of child survival. In addition the Caplow Children’s Prize named the project one of eight finalists for its global award that also identifies some of the world’s high-impact new models for saving children’s lives.

Part of this story was already told on this blog. But the announcement two days ago of the adoption of a national strategic plan in Mali to scale up Community Health Workers is a major new development that warrants telling this story again in more details. The story continues to have relevance for malaria and child mortality, but it also now has relevance in the context of the Ebola epidemic. The relevance of the Muso model for Ebola and the role that Rotary played in supporting Muso will be discussed next.

Fighting Malaria and Reducing Child Mortality by a Factor of Ten

by Divya Wodon, Naina Wodon, and Quentin Wodon

Mohammad, a three-year-old boy, lives in Yirimadjo, a community in Mali. A few weeks ago he woke up feeling ill with a high fever. That same morning, Kumba, a community health worker with the nongovernmental organization Muso, visited his family’s home during her daily door-to-door active case-finding visits. On discovering that the child had a fever, she administered a rapid diagnostic test for malaria, and he tested positive.

Kumba administered free Artemisinin-Based Combination Therapy on the spot, counseling Mohammad’s mother on how to take the oral pills the following two days. Mohammad was able to start curative treatment for malaria within four hours of falling ill. Kumba visited him the next day, and the day after that, to make sure he was taking his medication and improving.

Because most children who die from malaria are killed within 48 hours of symptom onset, speed matters in providing treatment. Mohammad’s treatment was more effective and less expensive than might have been the case if he had started treatment at a later, more severe stage. And early, proactive health care may have saved Mohammad’s life.

Roughly 3.3 billion people, or half of the world’s population, are vulnerable to malaria. Every year, some 216 million cases of malaria occur, and 665,000 people die from those episodes. Many of those deaths occur among children under five. More generally, more than 6 million children under five die every year worldwide from malaria and other curable diseases. Many of these illnesses can easily be prevented through simple tools such as bed nets or easily treated by oral medications at home if caught early.

Muso is on the frontlines of providing timely, proactive health care to poor, hard-to-reach populations in Mali, said Dr. Ari Johnson, co-founder of Muso, at a recent World Bank seminar, and thus is effective in reducing malaria deaths.

The group works in communities through a four-step approach. The first step consists of mobilizing the existing health care delivery system. This includes selecting, training, employing and supervising local individuals who go door-to-door and identify children sick with malaria and other illnesses. These community health workers diagnose malaria in the household and treat simple cases. When care is needed from a doctor, they refer patients to government health centers.

The second phase consists of removing barriers that prevent people from accessing care when needed. As in Mohammad’s parents’ case, most families in the regions covered by Muso are poor and do not have enough money to pay for hospital fees. In addition, many are not able to get to the hospital in time for treatment.

Even when families can scrape enough money together to go to the hospital, they fear they will be diagnosed with an illness or disease which would cost a lot of money for medication. By eliminating point-of-care user fees, Muso ensures that even the poorest can benefit from life-saving comprehensive and universal care, whether at home, in community health centers, or in referral hospitals.

The third step consists of creating rapid referral networks by training communities in identifying health risks, prioritizing rapid treatment, and navigating the health system. These networks are essential for community organizers, religious leaders, and educators to help families in need and bring children and adults suffering from malaria to community health workers or to centers where care is provided.

The fourth, and final, step consists of clinical capacity building. As Muso systematically removes access barriers to achieve universal health coverage, it also reinforces the ability of the public sector to provide quality care to its patients. This includes expanding infrastructure and training providers.

Ten-fold Reduction in Deaths

How do we know that Muso is successful? A study recently published in PLoS ONE documents a ten-fold reduction in child mortality in Yirimadjo, Mali, after the launch of the Muso model.

At baseline, the child mortality rate was 15.5%. After three years, it plummeted to 1.7%. During the same period, the study documented a ten-fold increase in the number of patient home and clinic visits; a doubling of the rate of rapid access to malaria treatment for children in need; and a reduction by one-third in the share of children becoming sick with fever. Because the study was not based on a randomized controlled trial, but on repeated cross-sections in Muso’s area of intervention, it is important to exercise caution in assigning causality. Nevertheless, the results are very encouraging.

The Muso team recently received two global awards The 2013 GSK Global Healthcare Innovation Award recognized Muso as one of five effective new models for better chances of child survival. The Caplow Children’s Prize named Muso one of eight finalists for its global award that identifies high-impact new models for saving children’s lives.

Note: This blog is reproduced with minor changes from a post on the Investing in Health blog at the World Bank, available at http://blogs.worldbank.org/health/. The blob benefitted from substantial inputs and comments from Ari Johnson – including for Mohammad’s story – and is adapted from a section of a 2014 Palgrave Macmillan book on Rotary by the blog’s authors. The book featured Muso because it received support from several Rotary clubs. This includes a recently approved global grant from the Rotary Foundation thanks especially to Maria Nelly Pavisich from the Rotary club of Washington, DC.