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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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.

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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.

Improving Teaching and Learning in Nepal (Partnerships Series No. 8)

Many developing countries have made substantial progress towards improving education attainment (the level of education attained by students) over the last two decades. At the same time, the instruction provided by teachers to students often remains of limited quality. This results in less than stellar education achievement (how much students actually learn). While students may do well enough on portions of examinations that rely for the most part on memorization, they tend to do less well when asked to think creatively or solve complex problems. This post, which is part of a series on partnerships, innovation, and evaluation in Rotary, tells the story of an innovative teacher training program in Nepal that has the potential of improving student learning substantially.

NTTI

Importance of Teacher Training

Outstanding in-service teacher training programs can make a major difference in how teachers teach, how much students learn, and how much they learn, especially among disadvantaged groups. Many factors influence student achievement, including factors that are beyond the control of schools such as a student’s socio-economic context. But teachers are the most important factor under the control of education systems to improve learning. Teachers also account for the bulk of public spending for education in developed and developing countries alike. For these reasons, there is increasing interest in finding ways to attract, retain, develop, and motivate great teachers.

The tasks of attracting, retaining, and motivating teachers fall squarely within the scope of the mission of Ministries of Education. Developing teachers is also a key responsibility and priority for the Ministries, but in this area there is also scope for nonprofits and organizations such as Rotary to play a role by helping to create great in-service training programs for teachers. The importance of in-service training and professional development to improve instruction is recognized by practitioners and policy makers. Three lessons emerge from the literature.

First, opportunities for teacher training and professional development should be made available. But not all programs achieve the same results. When in-service programs focus on changing pedagogy, the evidence suggests that they can improve teaching and as a result student achievement. By contrast, programs that merely provide additional teaching materials for teachers do not generate substantial gains.

Second, the contents of training programs aiming to change pedagogy matter as well. In-service training programs that expose teachers to best practices in instruction and actually show teachers how to implement these practices are more likely to generate positive change. Promoting collaboration between teachers, among others through teacher networks where teachers can exchange ideas is useful. Mentoring programs whereby junior teachers benefit from the guidance of experience teachers also tend to be effective. Other approaches tend to be less successful.

Third, it is important that in-service training and professional development programs target in priority the teachers who need help the most. Teachers who are struggling may benefit more than already great teachers from various programs. Similarly, students from disadvantaged backgrounds or living in poor areas also tend to benefit more from a higher quality instruction than better off students who have more help from their family at home. Identifying priority pockets of needs is most beneficial when implementing and teacher training programs.

Innovative Program in Nepal

Traditional instruction in Nepal relies on lecturing by teachers and memorization by students. Together with the Nepali NGO PHASE, NTTI (Nepal Teacher Training Innovations) has implemented innovative teacher training programs in Nepal for several years.  NTTI aims to train public schools teachers to make the classroom more interactive by coaching them on how to lead classroom discussions, facilitate group work, and ask questions to students to encourage individual thought. Instead of relying on punishment and at times shaming in the classroom to control student behavior, teachers are trained to use dynamic inquiry-based instruction methods and provide positive encouragement to motivate the students to learn. As the classroom becomes more participatory, students engage in their own learning.

The PHASE-NTTI model does not rely on one-off training. Instead it involves a cumulative cycle of trainings and intensive follow-up support to individual teachers. The aim is to help teachers move from an awareness of effective teaching practices to actual implementation of the practices in their own classrooms. The training model includes a series of teacher development courses: Introduction to Best Teaching Practices; Girls’ Sensitivity Training; and a Training of Trainers for those selected as Mentor Teachers.

The model includes pre- and post-training classroom observations, individual feedback received by teachers from Master Trainers, and follow up individual teacher support by Mentor Overall, the program is implemented over a two-year period in each school.

While no impact evaluation is yet available to measure the impact of the program, quantitative data obtained through pre- and post-training classroom observation are encouraging. In contrast to teacher-driven and student-silent classrooms, classrooms with trained teachers seem to be closer to functioning as hubs of learning.

Instead of only lecturing trained teachers lead classroom discussions, facilitate group work, and ask questions to encourage individual thought. Students learn how to make their own novel connections and think critically about what they hear and read. Qualitative data suggest that the program is appreciated by teachers and students.

Remaining Challenges and Conclusion

There have been challenges to which the program has had to adapt. The program did not work as well in secondary schools, so it now focuses on primary schools. Support from principals for teachers changing their pedagogical approach is needed, but not guaranteed. Distances to schools in rural areas make it hard to maintain regular contact after initial trainings. Lack of time for teachers to prepare lessons as advocated by the program is also a constraint. The structure of classroom time may limit creativity and inquiry-based teaching. The persistence of traditions harmful to girls in parts of the country is a major challenge to keep girls in school.

The PHASE-NTTI program does not have all the answers to these challenges, but it does have the key features that tend to be associated with successful in-service training programs. The program is also a great example of partnership (with the Ministry of Education and public schools), innovation (in teacher training), and evaluation (at least through monitoring of teacher pedagogy). A Rotary global grant proposal has been submitted to help develop the PHASE-NTTI program further and implement it in additional areas.

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.

Investing in Disadvantaged Youth in the United States (Partnerships Series No. 6)

Growing local economies requires many different ingredients, but one of the most important ones is a skilled workforce, especially among youth. Skills tend to be acquired through the education system. As part of a series on increasing Rotary’s impact through partnerships, innovation, and evaluation, this brief tells the story of an innovative program in Washington, DC that is improving writing skills for high school seniors in public schools and preparing them for college in part with support from Rotary.

A student presents his papers at One World Education's Fair
A student presents his papers at One World Education’s Fair

The United States benefitted for decades from one of the most skilled workforce in the world, but there are concerns that this is not the case anymore. Within the US, the District of Columbia has been struggling and often ranks at the bottom of the National Assessment of Educational Progress league tables. There are many reasons for the poor performance of the District. In spite of major improvements in economic development in the last decade, a substantial share of its population remains poor, and poverty is one of the main drivers of poor performance in school. But some programs are helping.

One World Education

One World Education (OWEd) trains teachers and helps students improve their writing skills, and think about their college options at the same time. OWEd was created in 2006 by two teachers, Eric Goldstein and Emily Chiariello, who taught at one of the charter schools in Washington, DC. Their idea was to use students’ reflective writing as the foundation for what was discussed in the classroom. The model proved successful as students became more engaged and, in turn, started to develop better research, writing, and analytical thinking skills. The non-profit was launched in 2007 and has been growing.  OWEd recently signed an agreement with DCPS (District of Columbia Public Schools) to expand its programs in all public high schools in the city. As a result, OWEd has become the largest nonprofit program operating in the District’s public schools.

The program focuses on writing skills and is adapted to various grades. For example, the Grade 12 program helps students analyze, research, write argumentative essays, and lead presentations about the college and career issues that await them after graduation. It includes a comprehensive seven week coaching period. Essays written by students can serve as their Senior Project. Selected student essays are published on OWEd’s website, providing recognition for students and creating a cycle of peer-to-peer learning.

More generally, for all grades where the program is implemented (Grades 8, 10, and 12), students and teachers can access a number of resources provided by OWED, including the following:

  1. Common Core Aligned Lesson Plans: All lesson plans are created by teachers, for teachers, and are aligned to multiple research, writing, and presentation Common Core State Standards. Lessons are accompanied by rubrics for teacher evaluations and peer-to-peer reviews;
  2. Student Writer’s Notebook: the notebook leads students to analyze exemplary, peer-authored essays before guiding them through researching, outlining, drafting, and revising their own argumentative essays.
  3. Student and Educator Portals: Students and teachers will have access to easy-to-access lesson plans, rubrics, research sources, and related resources for teachers and students are available online.

Evaluating Program Impacts

Randomized controlled trials have not yet been implemented to assess the impact of the programs run by One World Education, but other data suggests that the program is having an impact. Specifically, evaluations by students and faculty at American University and George Washington University suggest gains in writing quality and self-confidence for students that have participated in OWEd’s programs.

In order to assess gains in the quality of the writing of participants, a sample of students participating in the program take a writing test before the start of the program and at the end of the program. The test is graded by university professors. Results suggest important gains after program participation.

Feedback from teachers – and more importantly students who have participated in the program is positive. For example, in the 2014 DCPS Grade 10 evaluation by students, participants reported improvements in terms of their ability to make a claim (87 percent); Provide research to support a claim (87 percent); Write (85 percent); Research information (84 percent); Analyze research (84 percent); Create an outline (79 percent); Create a draft (78 percent); Establish a research plan (75 percent); and Revise their essay (75 percent).

These and other positive evaluations of the program in partnership with two local universities have been a key factor in the agreement reached by OWEd with DCPS to substantially expand the program in grades 9, 10, and 12. All public high school students in the District in those grades will now have the opportunity to participate in the program.

How Has Rotary Helped?

Rotarians from the Rotary Club of Capitol Hill in Washington, DC, have supported the project in various ways. The club has donated funds to, and volunteered with, OWEd for several years. In 2015-16 the club’s donation will be matched with a district grant using so-called district designated funds from the Rotary Foundation.

Each year student essays are assessed by a panel of judges at a College and Career Writer’s Challenge each year. This enables students to learn how to make an argumentative pitch to a panel.  One student from each school is eligible to earn a college or vocational training scholarship, and every participating school can nominate a number of seniors to participate in the event. Rotary club and district grants will allow OWEd to provide small scholarships for college to 10 students who have written especially good essays thanks to the program.

In addition, Rotarians have participated in OWEd’s programs in a number of volunteering capacities, including as judges for the essay competitions taking place at the College and Career Writer’s Challenge.

Conclusion

In supporting OWEd, Rotary builds on the benefits from partnerships, innovation, and evaluation. OWEd itself has partnered with District of Columbia Public Schools to substantially expand the reach of its program. The program is innovative in the way writing skills for students are being developed using a range of different resources and mechanisms. Evaluations of OWEd’s programs have shown that the programs generate measurable gains in middle and high school students’ writing skills, and in their self-confidence. The program not only improved the student’s writing, but it also helps in preparing them for college and career-level writing.

For Rotarians, OWEd’s programs have also offered unique opportunities to personally support students from disadvantaged backgrounds by contributing in the programs in various ways. This had been done through donations, but also through volunteering.

Promoting Peace with Peace Centers and Fellows (Partnerships Series No. 5)

In terms of global grants, promoting peace is one of the smallest portfolios among the areas of focus of the Rotary Foundation. But this does not mean that examples of partnerships, innovation, and evaluation cannot be found in the peace portfolio of the Foundation. The largest program for promoting peace that Rotary invests in is actually managed outside of the global grant model. Rotary provides funding for six Peace Centers established in universities around the world as well as Peace Fellow scholarships for individuals to obtain Master’s degree or Certificate program at the Peace Centers.

Chulalongkorn University in Thailand
Chulalongkorn University in Thailand

The Peace Fellows program is good an example of partnership (with universities), with components that are innovative (especially the Certificate program for professionals working in the area of peace), and for which at least some monitoring and evaluation data have been collected by Rotary through tracer studies of graduates of the program as well as assessments of the perceived quality of events organized for Rotary’s Peace Community of Practice.

Peace Centers and Peace Fellows

Up to 100 Peace Fellows are provided with a Rotary scholarship each year among a pool of applicants recommended by Rotary clubs and districts. Rotary provides funding for the scholarships given to the Peace Fellows as well as part of the operating costs of six Peace Centers at which the Peace Fellows undertake their training.

Five of the six Peace Centers and associated universities offer Master’s degrees, with up to 50 Peace Fellows selected each year.  These Peace Centers are affiliated with Duke University and the University of North Carolina at Chapel Hill in the United States (joint Center), International Christian University in Japan, the University of Bradford in England, the University of Queensland in Australia, and Uppsala University in Sweden. The fellowships are for Master’s programs that take 15 to 24 months to complete and include a practical internship of two to three months during the summer break.  The sixth Peace Center is affiliated with Chulalongkorn University in Thailand. It offers a three months Certificate program for up to 50 Fellows per year.

A Different Model for Scholarships

Rotary has a long tradition of providing scholarships for graduate students, but the Certificate program at Chulalongkorn University is different. It is cheaper per person than the master’s degree program, and probably better targeted to individuals committed to work on peace and conflict resolution since it serves practicing professionals. The certificate takes eleven weeks to complete including two to three weeks of field study. The program aims to provide Fellows with a comprehensive overview of peace and conflict studies with four modules of study: (1) Concepts and Values of Peace and Conflict Studies (introduction to the field); (2) Diagnosis and Analysis of Conflict (assessment of conflict and peace interventions); (3) Conflict Resolution Skills, Approaches, and Strategies (including negotiation, mediation, facilitation, and communication); and (4) Conflict Transformation and Building a Sustainable Peace (ways to move from conflict to peace with proper stakeholder participation in society). Two practical field studies experiences are included in the program, one after the third module in Thailand, and an international field study at the end of the fourth module. The program relies in part on guest lecturers with governmental, NGO, corporate, and security backgrounds.

Tracer Studies

In-depth evaluation of the Peace Fellows program have not yet been conducted, but results from tracer studies among graduates suggest a high level of satisfaction with the program among graduates. In addition, the tracer studies suggest that most graduates appear to be indeed working on peace and conflict resolution broadly defined.

Since the first class of peace fellows graduated in 2004, a total of 930 living alumni have graduated from the program, 603 with a Master’s degree and 333 with a Certificate (six have completed both). Virtually all Fellows (94 percent) have reported their post-graduation area of employment to Rotary through tracer studies at least once, and nearly two thirds (62 percent) have done so over the last 24 months.

Interesting findings emerge from the tracer studies. At least two thirds of graduates work as practitioners in peace, conflict resolution and development. This includes working for NGOs or other peace-related organizations (36 percent), a government agency or the military (15 percent), a United Nations agency (six percent), police or law enforcement agencies (three percent), and the World Bank (one percent). One fourth of the Fellows engage in research, teaching, or further study (eight percent each as teachers/professors, students, and researchers/academic support staff). The rest are working as lawyers (three percent), journalists (two percent), and as other professionals (seven percent). Four percent are looking for work.

Program alumni work and live all around the world, including in North America (30 percent), Asia (22 percent), Europe (15 percent), Africa (11 percent), Australia and Oceania (nine percent), South America (seven percent), the Middle East (four percent) and Central America and the Caribbean (two percent). This provides a potentially impactful worldwide network or community of practice of individuals committed to peace and conflict resolution. The question, then, is how to mobilize this network, including in collaboration with Rotary and Rotarians.

Building a Community of Practice

Rotary is investing in building a community of practice among Peace Fellows and Rotarians interested in promoting peace. One tool is the Rotarian Action Group (RAG) for Peace. Another is the Rotary Peace Symposia organized every three years. The last and fourth triennial Symposium was held just before the Rotary International convention in São Paulo in June 2015. This was an occasion for Rotarians and Peace Fellows to discuss collaborations and potential service projects together. Oscar Arias at the 2015 Peace Symposium in São Paulo. Photo: Rotary International.

The event was held for two days. It was attended by 354 participants, including 72 Peace Fellows, Rotarians (some of whom are members of the RAG for Peace), representatives of the six Peace Centers, and leaders of NGOs working on peace and conflict resolution. Oscar Arias, the former President of Costa Rica and a Nobel Peace Laureate, was a keynote speaker. Nine in ten attendees surveyed after the Symposium were satisfied or very satisfied with the event, suggesting potential for the community of practice.

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.

Evaluation

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.

Conclusion

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.