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

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

Nigeria saving lives

Project and Partners

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

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

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

Innovative Approach

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

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

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

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

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


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


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

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

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

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

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

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

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

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


Water Projects

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

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

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

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

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

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

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

Community Needs Assessments

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

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

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

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


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

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

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

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

Buying Down Polio (Partnerships Series No. 2)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Partnerships, Innovation, and Evaluation, 1: Introduction

This post is the first in a series on increasing the impact of Rotary. The series will feature case studies of great service projects that have achieved larger impact through partnerships, innovation, and evaluation. The hope is that the case studies will encourage clubs and districts to think bigger in their service work.  The series will cover each of the areas of focus of the Rotary Foundation, as well as polio.

Service work through volunteering or projects is at the heart of what Rotary is all about. Membership surveys suggest that the main reason why members join and remain in Rotary is the opportunity to serve (see my recent book on Rotary). Fellowship and networking are also very important, but service is first.

Rotary is a fairly decentralized organization with at its core the Rotary club. Rotarians come in many shapes and forms, beliefs and passions. There is amazing diversity in the types of service work that Rotarians engage in. This is a strength as members choose to contribute to the causes they are most passionate about.

Most of the service work that Rotarians engage in is done through volunteering, not through service projects that benefit from financial support from the Rotary Foundation (TRF). In adition, many projects implemented with TRF support are small and based on local opportunities identified by clubs. These projects may not rely on partnerships, they may not be especially innovative, and they may not be evaluated in depth. As long as it is clear to clubs and local communities that the projects are helpful, a lack of partnership, innovation or evaluation is not necessarily a major drawback. One straitjacket does not fit all in Rotary.

At the same time however, if Rotary is to have a larger impact globally, there is also a need to put together more and larger projects that do rely on partnerships, are innovative, and are monitored and evaluated properly.

Partnerships help to implement larger projects and benefit from the expertise of organizations that are among the best in their field. Partnerships may also generate visibility and media coverage for Rotary (polio is the best example). Partnerships have a cost since effort is required for collaborations to work. But if partnerships deliver scale, expertise, or visibility, gains outweigh the costs.

Innovation is even more important than partnerships to achieve larger impact and discover better ways to serve communities. Without innovation, the contribution of TRF is a drop in the development assistance bucket. TRF does have a respectable size, but in comparison to development funding, it is very small.

Total annual giving by the foundation represents less than half a percent of what the World Bank provides in development assistance every year, and this is just one of a number of development agencies. But if Rotary experiments and innovates, pilots that prove successful can be scaled up by other organizations with deeper pockets, thereby achieving larger impact.

Without serious monitoring and evaluation, innovation does not help much because impact on the ground must first be demonstrated at the pilot stage for a promising intervention to be scaled up. Innovation and evaluation are like twins: they work best as a pair. Evaluation is also needed for Rotary to learn internally from both successes and mistakes.

All three ingredients ̶ partnerships, innovation, and evaluation, can help increase the impact of Rotary’s service work. In order to encourage clubs and districts to move in that direction, this series will show how partnerships, innovation, and evaluation can be harnessed to serve Rotary’s mission of service above self.

The series will tell the story of projects in each of the areas of focus of TRF: promoting peace, fighting disease, providing clean water, saving mothers and children, supporting education, growing local economies, and eradicating polio.

You will learn about an innovative financing mechanism for polio eradication; an award winning project reducing under five mortality in Mali; a program that is transforming teaching and learning in Nepali classrooms; a project to save the life of mothers and children in Nigeria; a program to invest in the writing skills of disadvantaged youth in the United States; projects and initiatives to improve access to water and sanitation in Uganda; and the work done by Rotary with Peace Centers.

All these projects are in one way or another innovative. They all leverage partnerships. And virtually all build on solid monitoring and evaluation mechanisms. Hopefully, the series will give you additional insights into some of the great projects that clubs and districts are implementing around the world.

Please do not hesitate to send me an email through the Contact Me page of this blog if you believe other projects should be featured (perhaps in another series), and feel free to post comments on the projects that you find particularly inspiring.