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!
New cases of polio have emerged in Nigeria. Ahead of World Polio Day, readers of this blog should know that Rotary and other international organizations are stepping up to the plate. In September 2016, Rotary committed an additional $35 million to end polio, bringing its contribution to $105 million in 2016. Two months earlier, the World Bank approved in June 2016 $575 million in additional IDA financing for Nigeria to scale up support for the North-East of the country. This includes $125 million for polio eradication over three years (2017-2019).
The World Bank program document for the additional polio financing notes that multiple obstacles remain to eradicating polio in Nigeria due to a lack of accessibility of some communities in the Northern States. This has led to special measures being introduced, including “(a) ‘hit and run’ interventions where vaccinators use any opportunity to go to difficult areas with the military and leave as soon as all children have been reached; (b)‘fire-walling’ that is, ensuring immunity in areas surrounding inaccessible villages; (c) using local people as vaccinators who can operate without drawing attention; (d) including IPV (Inactivated Polio Vaccine) in routine immunizations activities; (e) having transit bus-stop and market vaccination teams; and (f) ensuring that all internally displaced people residing in camps are covered.”
Despite these efforts, immunization coverage for polio and other vaccines in the North-East still lags far behind the national average. The $125 million additional financing for polio has two components.
- The first component provides $60 million for Oral Polio Vaccine (OPV) and other operational requirements of polio eradication activities. UNICEF will receive $50 million to procure OPV. The additional US$10 million will be used by UNICEF or WHO for a range of activities where funding gaps may be identified, including activities for Immunization Plus Days.
- The second component ($65 million) will help finance routine immunization. The inclusion of a component on routine immunization stems from the fact that it has been shown to be essential for interrupting the transmission of wild polio and thereby completing polio eradication, while also being a critical aspect of improving child and maternal health.
The program document for the additional polio financing is available here.
The difficulties in eradicating polio in the North-East are related in part to insecurity and a broader lack of services and development opportunities. The Boko Haram insurgency has deeply affected the states of Borno, Yobe, Adamawa, Taraba, Bauchi and Gombe, with negative impacts on an estimated 15 million people.
As per the press release for the additional financing package for the North-East, the other components of the package include:
- $75 million for the Nigeria Community and Social Development Project which provides immediate basic social infrastructure and psychosocial support to communities most affected by displacement;
- $100 million for the Youth Employment and Social Support Operation to provide youth, women and the unemployed (especially internally displaced persons, returnees and persons with disabilities resulting from the crisis) with labor-intensive work and skills development opportunities. Cash transfers will also be provided to displaced families and individuals as they return voluntarily and safely to and settle in their old or new communities.
- $50 million for the Third Fadama Development Project that addresses the emergency needs of farmers by improving access to irrigation and drainage services, delivery of agricultural inputs, and contributing to the restoration of livelihoods in conflict-affected households with a focus on women and youth.
- $100 million for the State Education Program Investment Project that supports the return to teaching and learning through financial incentives for teachers who have completed psycho-social training, and provide grants to schools to address their needs as identified by school-based management committees.
- $125 million for the National State Health Investment Project (plus $20 million from the Global Financing Facility) that will help to reestablish health services with a focus on maternal, newborn and child health, nutrition, psycho-social support and mental health. In communities in which health facilities have been destroyed, mobile clinics will be deployed to provide care.
As Rachid Benmessaoud, the World Bank Country Director for Nigeria explained it, “The needs are staggering. Millions of people have lost their livelihoods, schools and health facilities have been destroyed, and the psychosocial impact of the crisis must also be addressed. To help create economic opportunities for the most vulnerable, we have identified a set of initiatives that will have a quick and tangible impact on the population in four priority areas: agriculture, education, health and social protection.”
The World Bank press release on which this blog post is based is available here together with links to other related resources.
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.
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.
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.
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.
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.
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 http://www.fin4dev.org/.
by Quentin Wodon
Today is World AIDS Day. Over the last three decades, the pandemic has taken the lives of 36 million people. According to the WHO, 35.3 million people live today with HIV (human immunodeficiency virus), but only about a third (11.7 million) receives antiretroviral therapy in low- and middle-income countries. The theme for the day this year is “Focus, Partner, Achieve: An AIDS-free generation”, calling for governments, NGOs, and individuals to contribute to AIDS prevention and treatment. This post is about the role of civil society and Rotary in fighting the AIDS epidemic.
Role of Civil Society
Governments and donors play a key role in the fight against AIDS, but civil society and individuals also play an important role and that role is being increasingly recognized and supported. Last year I published with World Bank colleagues a book entitled Funding Mechanisms for Civil Society: The Experience of the AIDS Response (the book is available online without charge here). We noted that in the past decade, international funding for the HIV and AIDS response provided by governments rose dramatically.
In addition donors have increasingly shifted their financial support toward funding community responses to the epidemic. Yet little is known about the global magnitude of these resource flows to civil society, especially at the local level, and how funding is allocated among HIV and AIDS activities and services by community organizations.
Part of the study focused on the mechanisms used to fund civil society and community-based organizations (CBOs) by four large AIDS donors: the U.S. President’s Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank’s HIV/AIDS Program, and the UK Department for International Development. On average, these four donors provided at least US$690 million in funding per year for civil society organizations (CSOs) during the 2003–09 period.
Much of this funding went to large national CSOs. While part of the funding also went to smaller NGOs and CBOs, including through partnerships with the larger CSOs, in many cases only a small share of international resources trickles down to local communities. More needs to be done to support local-based organizations that are actively contributing on the ground to the fight against AIDS, often relying on volunteer work.
Role of Rotary
Rotary is active in the fight against AIDS in part through the Rotarians for Family Health & AIDS Prevention (RFHA) Rotarian Action Group. Rotarian Action Groups (RAGs) are groups are led by Rotarians in their field of expertise in order to help clubs implement projects and exchange ideas and experiences. There are close to 20 RAGs operating, and RFHA is one of them.
The signature program of RFHA is Rotary Family Health Days (the information provided here is from the RFHA website). The program promotes healthy living and disease prevention through annual campaigns in four African countries: Ghana, Nigeria, South Africa, and Uganda. Family Health Days provide comprehensive, free health care services to underprivileged communities. The services include lifelong immunizations to children, such as polio and measles vaccines, and comprehensive life-saving annual screens such as HIV, TB, Malaria, Diabetes, Hypertension and more, including information about HIV-AIDS.
The program was initiated in 2011 when Past District Governor (PDG) Stephen Mwanje from Uganda asked Marion Bunch, the founder of RFHA, for partnership support in obtaining funding and other resources for this program. PDG Mwanje’s vision was to have all Rotary clubs in his district work together towards a common cause, focusing on HIV/AIDS but also including other disease prevention measures.
Family Health Days is a Rotary-led program, but it leverages partnerships with others including the Coca-Cola Africa Foundation, the U.S. Mission – including the Centers for Disease Control, USAID and the health service delivery expertise of their Implementing Partners – as well as each of the four countries’ Ministries of Health that provide services and supplies at the sites.
Equally important in each country are the primary media partners that include the SABC and Caxton in South Africa, and other media centers in each of the other countries. The Family Health Days program has grown from serving 38,000 citizens in one day in 2011 to serving 343,622 citizens in 2014 in 402 sites with the help of more than 8,000 Rotary volunteers. RFHA hopes to expand the program in more African countries in 2015 and is planning a pilot in India. Importantly, it is also thinking about the measurement and evaluation of the impact and sustainability of the program.
In the fight against AIDS, community-based organizations play an important role because of their proximity to the population, their knowledge of the issues on the ground, and the trust that the population has in them. Rotary could be considered as a large NGO given the amounts of funding managed by The Rotary Foundation of Rotary International. But it can also be considered as a small local-based quasi-community group given that many Rotary clubs are indeed small and working at the local level collaboratively with other NGOs.
A key question for Rotary is how to leverage effectively the resources provided by its network of clubs and members around the world. The Family Health Days, the signature program of the RFHA Rotarian Action Group, is a very interesting case of a successful mechanism to leverage the energy of many local Rotary clubs into programs that reach at least some level of scale and make a difference in the fight against AIDS and the improvement of broader health indicators.