Tag Archives: MDGs

Donor-funded structures in Al-Farisiya village destroyed by Israeli occupation forces.

Starting from scratch: a response to Paul Farmer

By Nora Lester Mund

Perhaps I am skeptical because I live in Palestine among a people whose rights to self-determination have been denied for 65 years and who experience daily violence, theft of natural resources, impoverishment, inaccessibility of services – all while being among the largest per capita beneficiaries of international humanitarian and development aid.

But from where I sit, I don’t see too much hope for post-2015 development, which is driven by a deceptively benign-sounding ideology that manages only to alleviate symptoms of disease that it simultaneously perpetuates.

I call the ideology “starting from scratch,” and it is especially disappointing to hear this ideology expressed by highly-regarded aid reformers like Paul Farmer. His recent article re-thinking foreign aid says that aid is needed to alleviate human suffering, and he calls for more aid to be delivered through local public systems. It’s a worthy-sounding argument, but it starts from scratch, ignoring the causes of continued vulnerability of children, of non-literacy, of inaccessibility of basic infrastructure and services.

Donor-funded structures in Al-Farisiya village destroyed by Israeli occupation forces.
Donor-funded structures in Al-Farisiya village destroyed by Israeli occupation forces.

Can we know how aid affects problems without also understanding what is causing the problems? Without analysis, not only of the historical roots of current problems, but also of the ways that need is recreated and perpetuated in the very fabric of today’s global society, we end up with an unexamined assumption that poverty just “is.” This implies that poverty is somehow innate or genetic to those who experience it. With that worldview, any effort to address poverty is going from nothing to something, from stasis to action, because we are “starting from scratch.”

But there is an alternative ideology. More and more aid critics and development justice activists espouse the view that development is an ordinary, instinctual, human process that, if allowed, will proceed naturally with the momentum of gravity and humanity. We are not “starting from scratch” but rather joining ongoing processes driven by inherent strengths and utilizing historically-nurtured assets and capacities.

Working from this ideology, the task of the international development community should be first and foremost to get out of the way. The second task should be to stop others from getting in the way. Only then should the international development community embark upon the third task—to humbly inquire if there is any way they can help. I call this ideology “supporting responsibly,” and if taken to heart, this would require a fundamentally different approach to international “development” work.

Development actors would need to find the existing developmental energy–which means recognizing its value–analyze and confront the obstacles that impede those natural forces, and remove the obstacles (which will likely require them to give up privileges). This is political work, systemic work, and self-work. It is not comprised of conducting assessments, running workshops and producing reports. Working from the “supporting responsibly” ideology would require development actors to be self-reflective, power-aware, and sensitive listeners, never competing with, ignoring or looking down on “locals” and certainly not trying to transform them.

Sadly, Paul Farmer, like so many other well-intentioned development actors, seems to be caught in a trap of oblivious self-righteousness that I consider part of the problem. He says the phrase “Local solutions for local problems” is “a commonly encountered liberal piety of development work.” He explains: “Many problems originate outside of people’s own communities: most trade regimes, all epidemics, and just about anything to do with climate change.”

This is true! But he goes on to argue that vaccines, pedagogic materials and shoes should not be manufactured locally. To me, this is a non sequitur. If Farmer admits the problems originate outside, then they should be solved outside (in other words, fix the trade regimes!) rather than alleviating the symptoms with externally imposed, short-term fixes, that enable the perpetrators to keep on causing damage.

Moreover, Farmer’s wrong-headed “starting from scratch” ideology leads him to say, “If we are able to strengthen in-country capacity so recipients can manage their own affairs, one day we will eliminate the need for anything other than partnerships.”

But if he spoke from the “supporting responsibly” ideology, he would say, “If we stop actively and intentionally destroying in-country capacity, then surely recipients, like all human beings, can manage their own affairs, and until then, anything we do except in full partnership with locals will be contradictory to that goal.”

Without understanding aid-givers’ role in creating the problems they seek to address, then it’s impossible to assess if and how aid may be “helping.” To use a harsh analogy: Should home invaders pat themselves on the back and take credit for letting hostages eat from their own refrigerator?

The expiration of the Millennium Development Goals provides an opportunity for those who claim to care about development to think about what’s next. I suggest we think first about how we got to the state of inequality, unnecessary suffering, and climate devastation that we find ourselves in now.

Nora Lester Murad is a writer and activist in Jerusalem, Palestine. Her blog, “The View from My Window in Palestine” at covers issues of aid, development and life under Israeli military occupation. She is a dedicated volunteer with Dalia Association, the first Palestinian community foundation, where she works on aid reform, philanthropy promotion, and civil society accountability. 

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How only small NGOs can address unmet needs

Whether it is Daniel-san in Karate Kid, the Jamaican Bobsled team or Mel Gibson in a kilt, people love to support the underdog. Here’s a feel good story with a simple lesson – in international development, we should often do much of the same.

In Cambodia, it is estimated over 600,000 people with disabilities lack access to basic Speech Therapy services. These are people who have disabilities related to communication and swallowing. They may have had a stroke and cannot swallow food independently. They may have been born with cleft palate, and require surgery and therapy to eat and communicate. They may have Autism Spectrum Disorder, and require communication strategies to interact with their family, friends and community.

Despite this great need, there is a huge lack of services that exist for this population. There is a multitude of reasons for this, but this lack of services can be explained through this (grossly oversimplified) diagram.

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At the top of the diagram, there is no explicit mention of disability in the Millennium Development Goals, nor does the UN Convention on the Rights of People with Disabilities mention Speech Therapy services, or the needs of people with communication and swallowing disabilities.

When conventions, laws and policies are not inclusive, this creates the same problems in funding. This affects programs, which in turn affects services. As a result, although no disability organisations in Cambodia could claim to be flush with funding, some of the best funded focus on hearing and visual impairments.

One organization, however, was unable to ignore the needs of 600,000 people needing Speech Therapy services in Cambodia.

CABDICO, a small organisation with 11 Cambodian staff and an annual budget smaller than many UN salaries, went searching for funds to support a program that helped initiate sustainable in-country Speech Therapy services and education.*

Despite the huge need, almost a year of searching provided fruitless. The most common response was “I can see that you’ve raised something very important (for over 600,000 people), yet this area of disability is not our focus and we cannot help.”

When needs are unrecognised at the international level, but felt at the local level, what could CABDICO do?

Larger NGOs often pursue funds that are in the order of millions of dollars. These funds exist because they are in internationally recognised areas of need – education, HIV/AIDs, maternal health, for example. Yet, smaller NGOs like CABDICO, pursuing funds that were closer to $30,000, face tremendous challenges in finding resources.

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The little guy often displays more flexibility, which can be beneficial as demonstrated in this photo.

How do most NGOs respond when then cannot find funding? A good example can be seen through a large and relatively well-funded disability organisation in Cambodia, who, like CADBICO, also recognised the need for Speech Therapy a few years ago. However, due primarily to lack of motivation from funding bodies, they were unable to take steps towards addressing it. Concurrently, they started to develop programs in mother and child health. Why? Due to the availability of funds this area, as a focus of the Millenium Development Goals.

I am by no means suggesting that a focus in mother and child health is unwarranted, nor that this NGO’s work in this area is ineffective. However, the choice this organisation made to pursue available funding affected its ability to be flexible and responsive to the population it serves.

CABDICO, on the other hand, decided to start a funding campaign through the online platform StartSomeGood to offer community-based Speech Therapy services. With these funds, and later, having successfully secured funds through the Australian Embassy, CABDICO began to take steps to address this huge problem.

The first task was to gather everyone who had been doing bits and pieces of Speech Therapy, and those who should know about it, together in the one room. As simple as this sounds, CABDICO had never organised a workshop on a large scale before. It was a daunting task, yet with their can-do attitude, something that they embraced. They partnered with a government coordination body, the Disability Action Council, to help  get access to people from Ministries of Health, Education, Social Affairs and Labor, whom they would otherwise have difficulty reaching.

As a result, for the first time ever in Cambodia, people, international and national, governmental and non-governmental, came together to discuss the future of Speech Therapy in Cambodia.

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Secretary General of the Disability Action Council, HE Em Chan Makara, speaking about Speech Therapy on national news. Unprecedented.

Working groups were set up to address the problem. Buy in from government, so crucial towards success, has begun. Speech Therapy was explicitly mentioned in the strategic plan of the Disability Action Council, but as importantly, in the National Strategic Disability Plan. A Cambodian university that teaches Medicine, Nursing and other Allied Health disciplines has agreed to initiate a Speech Therapy course.

Although there is so much more to be done, the change that has already occurred has happened at breakneck speed, and CADBICO has shown that things can happen like this:

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Identifying an unmet need requires going to one place, listening and observing. Anybody can do that. But, often, only small organisations have the agility and capability to do something about what they hear.

In this underdog story, ordinary people generously helped to create change, because those in positions of power wouldn’t. CADBICO’s efforts, and those of countless other effective, small NGOs demonstrates that it doesn’t take millions of dollars to create change, just the belief of the little guy to dare think that things can change for the better.

 

Addendum: There is still a long, long way to go in this journey. If you would be interested in supporting, in any way, please contact CABDICO.

*I have worked as an external advisor to CABDICO since July 2012.

Cambodian Geo Savy, who had his leg amputated because of diabetes. Photo courtesy of IRIN news.

How to value over one billion people

Over 15% of the world’s population lives with some form of a disability. Yet, in the year 2000, when the Millennium Development Goals (MDGs) were formulated, there was not one explicit mention of disability within it. Since then, progress towards recognition for the over one billion people across the world living with a disability is slow.

In the United Nations 2013 MDG report, disability is mentioned but once within the 59-page document. At this rate of progress, by 2026, we may be lucky enough to see the word “disability” mentioned twice.

On September 23 this year, a UN high-level meeting was held in New York, to discuss the under-representation of people with disabilities within the development agenda, through the MDGs and other internationally agreed conventions. Preceding this, a high-level breakfast, presumably involving pancakes and croissants placed on unreachably high buffet tiers, was held with UNICEF and the Permanent Missions of Mexico and Australia to the United Nations.

The outcome document from the UN meeting makes for good reading, urgently asking development actors to promote the inclusion of people with disabilities, as well as advocating for disability-specific services. There is nothing surprising in there, particularly for people familiar with disability trends worldwide, but that isn’t to say that it isn’t chock-full of common sense.

Speaking of which, a recent Inter Press Service article, which I would highly recommend reading, highlights some of the reasons why those with disabilities have been continuously ignored at an international level. For example, in health-related interventions, we tend to focus on lack of productivity as a reason to intervene. But that doesn’t help everyone of course – especially those with moderate to severe disabilities.

Another interesting point raised by this article is that of perception. In my mind, this is the fundamental reason why disability is not high on the international agenda. If we want to know why those with disabilities are being ignored, we simply have to look at our own perception of the situation.

After the Boston Marathon of April 15, 2013, runners who lost limbs from bombs exploding during the event were flooded with millions of dollars in donations for medical care for the public. As of September this year, $69.8 million had been received by the One Fund Boston, a foundation established to administer funds to the 294 victims of the bombings and their families. Of these, 14 people required amputations.

Yet, in the US alone, approximately 65,000 diabetic patients require lower limb amputations yearly. Resources for the latter group are scarce, and even more scarce in poorer countries like Cambodia.

Cambodian Geo Savy, who had his leg amputated because of diabetes. Photo courtesy of IRIN news.
Cambodian Geo Savy, who had his leg amputated because of diabetes. Photo courtesy of IRIN news.

Similarly, organisations in Cambodia that care for victims of land mines are relatively well resourced in comparison to those that deal with more complex disabilities, such as Autism or Cerebral Palsy. In 2012, there were 185 land mine casualties, down 12% from the year before.

The reality is that these two examples illustrate a fundamental difference in the way different groups with disabilities are perceived. We support one over the other because of our own perception of people with disabilities.

The identifiable victim bias states that we are much more likely to help a victim that we know and understand. It explains why so many people opened their wallets to assist those who were victims of Boston Marathon bombings. The more we understand and can identify with a victim, the more likely we are to want to support them.

Similarly, land mine victims in Cambodia and runners injured during the Boston Marathon share a few key common attributes. They are all victims. They are blameless. It could happen to any of us. The cause of the problem (and perhaps the solution too) is simple and obvious.

Our desire to keep things simple, and not overwork our brains means that we naturally have a bias to support these sorts of projects. Compare that with the mental energy (and education) needed to understand how diabetes can lead to lower limb amputations, or how unsafe birth practices or poor maternal health can lead to a child being born with Cerebral Palsy. These concepts are more difficult to grasp and therefore less likely to receive support. This explains why projects that could potentially assist over 600,000 people in Cambodia struggle to get support from traditional sources.

Yet, research suggests that people who use a more analytical style of processing information are less likely to default to the identifiable victim bias. They are more likely to support the greatest need, rather than the victim that is easier to identify with. What this suggests in practice is that potential donors need to take the time to analyse the situation more, and not donate purely on the basis of impulse or emotion. This might not seem like anything remarkably ground-breaking, but it is something to keep in mind.

Unfortunately, as long as NGO marketing continues to follow the lowest common denominator approach, it is unlikely that we’re going to see a major shift in the way appeals are made sector-wide.

How then do we ensure that people with disabilities are no longer forgotten worldwide? We encourage people to look at the facts and figures on the need that exists, and discourage them to support based upon their ability to identify with the victim alone. Pushing back on these instincts might just mean a brighter future for over one billion people in the world.

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The roadmap to ending extreme poverty by 2030: a street directory or GPS?

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To much fanfare, the roadmap to end extreme poverty by 2030 was released Thursday. The high-level panel (HLP, one letter short of HELP) is co-chaired by David Cameron with the Susilo Bambang Yudhoyono, the Indonesian president, and Ellen Johnson Sirleaf, the Liberian president. The forceful and well-oiled verb ‘eradicate’ was used to describe how extreme poverty would be ended. It would be eradicated. It is an interesting choice of verb and one which we never tire of using. Eradicate. The original Latin meaning to ‘uproot’. So, we want to ‘uproot’ poverty and do what with it? How are we going to uproot extreme poverty?

12 goals. 54 targets. 15 years.

‘Sustainability’ is mentioned a lot  (in fact, 25 times). ‘Sustainable’ is mentioned a whooping 186 times. The phrase ‘sustainable development’, 99 times. Ok, so once extreme poverty is uprooted, the seeds that fall back to the ground will not find root. They will not grow again. This time, it’s sustainable.

And yes, this time it is different. I am sure much more qualified and knowledgeable people will comment, troll and discuss this report (indeed, some already have such as Andy Sumner and Alex Cobham here, and Claire Melamed here). And yes, there are plenty of eye-rolling statements and narratives, such as when you read that the panel discussed “the daily reality of life on the margins of survival” (p.15). In London. Or, the new and oft-repeated catchphrase of the report to “leave no one behind”. And, speaking about a “global ethic”, which apparently is financial in philosophy as the panel proceed to list off a cost-benefit analysis of development interventions.

I just want to touch on a few features and then speak more specifically about the education sub-directory in the roadmap.

The X factor

Although the goals are universal, the targets are not all universal. “Almost all targets should be set at the national level or even local level, to account for different starting points and contexts” (p.41). Rather than stating that there should be universal access and completion of pre-primary education, Goal 3(a) states that there should be an “Increase by x% the proportion of children able to access and complete pre-primary education”. According to the panel, they have gone to great lengths not to be prescriptive but to illustrate examples.

Furthermore, indicators will be disaggregated by income, gender, location, age, people living with disabilities and relevant social group. This is landmark. But, it is also a huge ask of the current and future state of data collection, validation, analysing and synthesising capacities of many national governments, both in terms of district, regional and national-level data.

SMART?

The basic framework for the goals is the old acronym that we all learn: SMART. Specific, measurable, attainable, relevant and time-bound. They are SMART goals. Or are they? The panel acknowledge the risks of a single agenda, ranging from “unworkably utopian” to “overloaded” to “business as usual”. Despite the acknowledgement, the panel does not satisfactorily address these risks in the report.

Much like the ‘risks and assumptions’ written for a LogFrame, they are just there because they have to be. The panel states that the “best way of managing these risks is to make sure that the post-2015 development agenda includes clear priorities for action that the international community can rally behind” (p.26). This just sounds like business as usual (aka MDGs) and doesn’t actually address the risks identified.

Goal 3

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There are three ideas that standout in the education sub-directory of the roadmap, otherwise known as Goal 3:

  • Pre-primary schooling. After much evidence clearly demonstrating the impact, pre-primary schooling gets a look in. Also known as ‘early childhood education’ or ‘early childhood development (ECD)’, this is a cross-cutting issue of the roadmap and will begin to feature prominently in development initiatives and interventions. However, there is a lot to be learned from the MDGs in regards to ensuring equitable and effective access to schooling. It will be more than a matter of just building pre-primary schools, recruiting teachers and producing textbooks. The inclusion of secondary schooling in this goal was a preordained due to the MDGs focus on primary schooling.
  • Standards. The move towards standards is one already being played out in OECD countries both at the secondary and tertiary levels of education. Here, both B and C look to promote and achieve ‘quality’ by measuring students against standards and outcomes. While it focuses on accountability and measuring students’ performance and learning outcomes, a standards agenda can often come into contest with inclusion-driven agendas.
  • Get a job! In another boost to the life-long learning agenda and concept, D recognises the need for vocational and technical education for ALL, and not just education for children. Also known as vocational and educational training (VET), it has a long, storied and debated history in regards to its role in public education, the national economy and political and educational discourse and agendas. It is often framed around the notion of providing alternative, low-skilled career and workforce pathways to young adults who do not succeed in the traditional education system. Its inclusion here is perhaps in response to rising youth unemployment rates and the lack of alternatives for young people who are unable to ‘succeed’ in the traditional education system.

Within this goal, there are also a number of glaring issues and questions that only academia will probably address, think about and write on. The issues mainly reflect broader and deeper issues of power and Discourse.

  • Who decides what standards and which standards? A few key phrases stand out: “completes primary education able to read, write and count well enough to meet minimum standards”. What constitutes ‘well enough’? Well enough for what, for whom? To do what? Who will decide what the minimum standards are? How will these standards be monitored, appraised and renewed? Will all children be tested against the same standards, regardless of circumstance? Where does creativity, music, art, drama and other non-science subjects fit into the curriculum and standards? How will a standards agenda co-exist with a focus on inclusion?
  • Who decides what skills and which skills? With jobs and skills featuring prominently, it is stated that we need to “Increase the number of young and adult women and men with the skills…needed for work by x%”. What skills are those? Are they the skills needed to work jobs that do not currently exist but will exist in the future economy? Who will decide what skills to address? Are they traditional skills?
  • “regardless of circumstance”. This is a nice, convenient phrase, expressed as a means to addressing (or at least referencing) inequality and inequity. It captures a child in northern Ghana who has a disability, lives with his grandfather in a rural area and is not attending school. It also captures a young girl in northern Vietnam, who was married at the age of 12 and no longer attends school. Or a young refugee from Burma still living in a refugee camp on the Thai-Burma border. It is a clumsy phrase and perhaps dismissive of the role circumstance (read: inequality) plays. It is not just a matter of regarding circumstance as regardless. This phrase does not capture inequality and inequity. Remember, it is mostly the political, social, economic and cultural circumstances of children and their families that keep them from accessing, attending and completing schooling. Throw in the broader circumstances at community, national, regional and global levels, and more needs to be said and addressed than just ‘regardless of circumstance’.

There are many things to admire about this report and the roadmap is describes. Its scope. Its ambition. It is just down-right tenacious in the vision it puts forward. At the same time, it raises a lot of questions and does not put to bed many prior concerns with a single, global agenda formed by an elite few. While the panel’s roadmap is not a GPS for ending extreme poverty, it does offer the vision and the conditions for doing so. In effect, it is a street directory, which individuals, communities, organisations and governments can use to find the best path forward towards meeting many of the goals and ending extreme poverty.

Good Ol' Gurban Berdimuhamedov aka Berdy aka Big Berdy aka Big Bird

The MDGs: human rights in small doses?

Recently, I’ve had the pleasure of editing the previous two posts (here and here) regarding the Millennium Development Goals (MDGs). It’s clear now that not many if any will be met. Those that have been or are being met are not being welcomed with the cheers of a rousing success, but the pursed lips and raised eyebrows of concern. And rightly so – there is much still yet to be done.

A little late to the game but relevant to this matter nonetheless is a podcast I was listening to. The Guardian Global Development podcast episode from March 27, 2012. On it the panel members were discussing the MDGs and what was to be done next, whether they are a success and what needs to change for the next go round. It was at roughly at the 32:30 mark that an audience member asked about human rights and human development.

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The audience member asks about human rights in regards to the MDGs, which have no explicit element to them. Rather, they focus on more tangible and ‘acceptable’ development goals that any government can accept. Listening in, the panel sounds like they’ve immediately dismissed the question, never harkening back to it or specifically speaking about human rights. Rather, they address the MDGs relevant to their particular area of expertise.

The big one mentioned was maternal health and the right to it, which Mike Miesen discussed in his post ‘MDG 5a: An Update On Maternal Mortality‘. Mike writes about the need for the world to re-evaluate and ramp up its work on reducing the mateernal mortality rate, as at the moment we’re failing to reach that 75% reduction rate. Scott Weathers also contributed a post about the MDGs, ‘Goals are good, but do the MDGs need to be simplified?‘ Soctt asks the equal vital question of how to make the goals manageable and understandable. This though may have an adverse effect on any human rights aspects, if they exists, included in the MDGs as they could be left out entirely or watered down to such a degree that few would recongise them as human rights.

In discussion with a friend, who initially told me about this very episode, we came to wonder – have human rights in fact been included in the MDGs? She like me, not so much waffles between opinions, but remains unsure – and for the following reasons.

1. One argument is that the MDGs been broken down into their relevant sectors reflected and thus made manageable for governments, without the obvious tropes commonly associated with human rights – no direct calls for votes, democracy, representation or judiciary measures. Supporting evidence would be the focus on women’s health, equality and education for all, both implicitly grounded in human rights.

Good Ol' Gurban Berdimuhamedov aka Berdy aka Big Berdy aka Big Bird
Good Ol’ Gurban Berdimuhamedov doesn’t want to swallow something so difficult as human rights.

Those human rights that certain countries, like Turkmenistan, argue as a right such as ‘the right to food’ are included – even as the debate, albeit small, remains as to whether this in fact a right. The argument here often falls on the definition of ‘the right to life’, given that food is a necessity for life but there is no guarantee that anyone should have access to/receive it. Hence, countries such as Turkmenistan will provide bread, rice, salt and other rations as part of the state’s ensuring the ‘right to life’ of its citizens, while arguing that the US does not as they do not provide such staples.

2. The contrary argument being the fact that there is no clear language in any of the MDGs calling for human rights as a whole, especially those that extend to housing, governance and rule of law. Instead there is talk of trade, debt relief and aid coordination – all worthy in their own rights and not to be dismissed, but not directly connected to human rights either. Many of the matters associated with everyone, not just women, are not included in the MDGs.

Leaving certain rights out, one can argue that human rights are being dismissed entirely – as its a one for all and all for one deal. Piecemeal implementation allows for privileged application, creating the inequality that the MDGs seek to eradicate. But, given the UN’s perennial inability to implement anything beyond its obligation to annual pay raises for its employees, how are they are expected provide for and guarantee rights for all?

The line between human rights and development, in my opinion, is never an easy one to walk. It’s why there are so many organisations with a range of operating procedures. It’s the impetus for MSF’s creation. To say their entirely separate is if anything to deny the very reason that we’re in this business to begin with – to help people – because not everyone needs the same sort of help.

My questions for the readers of WhyDev are these:

  • Are human rights included in the MDGs? If not should they be?
  • If they are, then have they been blunted or reframed to be more acceptable?
  • Do human rights have a place in development, particularly on the global scale?

 

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MDG 5a: An update on maternal mortality

With two years left, it is highly unlikely that Millennium Development Goal (MDG) 5a – in the clunky verbiage of the UN: “Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio” – will be met worldwide.

But, substantial progress has been made, which in human terms, means that hundreds of thousands of maternal deaths have been prevented. It’s worth taking a step back to understand the scope and scale of the problem, and to think through the interventions that have been successful in myriad developing and developed countries.

The Maternal Mortality Ratio (MMR) is calculated as the number of pregnancy-related deaths (from any point in the pregnancy to 42 days post-birth/termination) per 100,000 live births. In 2010, an estimated 287,000 mothers died from pregnancy-related causes, or 210 deaths per 100,000 live births; it’s an almost 50 percent reduction from 1990, when an estimated 543,000 mothers died, or 400 per 100,000 live births.

These roll-up figures mask a wide variation in the distribution of maternal mortality. In 2010, an astounding 99% of deaths occurred in the ‘developing world’ (56% in sub-Saharan Africa alone), and the MMR in developing countries is, on average, 15 times higher than in developed countries. According to the World Bank, the country with the highest MMR in 2010 was Chad, the lowest Estonia, at 1,100 and 2 per 100,000 live births respectively. A chart showing the 40 countries with the highest MMR is below, with the United States – at 21 – added for reference:

Bar Graph

 

Scan the list of countries and it becomes clear that the MMR problem is clustered in Africa, with few exceptions. There’s wide variation among these countries too. The question is: why?

Worldwide, the leading direct causes of maternal mortality are: Post-Partum Haemorrhage (PPH); Pre-eclampsia and eclampsia; and sepsis (see the Figure 2 below). Together, these three conditions account for 60% of maternal deaths.

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Figure 1

At the patient-level, interventions to prevent or treat all three are well-understood, cheap, and straightforward:

  • Prevention of PPH is facilitated by following a protocol known as Active Management of the Third Stage of Labor (AMTSL), which involves the administration of an uterotonic (e.g., oxytocin, ergometrine, misoprostol) and massaging/monitoring for two hours post-birth. A Randomized Controlled Trial (RCT) found that women who received AMTSL experienced PPH 6.8% of the time vs. 16.5% with passive/conservative management; almost a 60% decrease
  • Treatment of pre-eclampsia and eclampsia involves the injection of magnesium sulphate, a cheap compound (in the West, the non-pharmaceutical preparation is known as Epsom salt). A highly-regarded RCT found that magnesium sulphate halves the risk of eclampsia in pregnant women
  • Prevention of puerperal fever*, or sepsis more generally, is a matter of maintaining proper sanitation before, during, and after a birth. If a mother develops sepsis, a full course of antibiotics can be administered as treatment.

Here’s what’s clear: the devil isn’t in the details. It’s in the diffusion of pharmaceuticals, health care workers, and knowledge through health systems, and in improving those systems holistically. It goes deeper than the health system of course; to administer AMTSL, for example, requires the drug being available (partially a supply chain/regulation issue), a health care worker who is trained to administer the drug (an education issue), and a health care worker who has the time to administer the massage every 15 minutes for two hours (a financing issue). And keep in mind, that’s only if the mother has a trained health care worker by her side, which in sub-Saharan Africa puts her in the minority, with only about 46% of births attended by skilled health personnel in 2008.

The complex task of reducing maternal mortality demands a multifactorial solution that draws on a wide coalition of government departments and private organizations; and each country has to find a solution that meshes with its own cultural and structural realities. Nevertheless, there are broad themes that transcend these inter-country differences and show up in the success stories of many positive deviants:

  • Increase access to family planning and contraception
  • Strengthen demand for antenatal check-ins through education campaigns, conditional cash transfer programmes, or easier access to skilled professionals
  • Increase the percentage of births attended to by a skilled professional; ensure skilled professional is able to provide necessary care (e.g., equipment, pharmaceuticals, knowledge) for non-complicated birth and is able to refer complicated cases
  • Ensure Emergency Obstetric and Neonatal Care (EmONC) services are comprehensive and of high quality, and that health centres are staffed with skilled workers; stocked with maternal medicines, antibiotics, and proper equipment; and accessible to remote populations
  • Establish or strengthen monitoring systems to highlight successes and areas of opportunity.

All of which goes a long way towards our understanding of why some countries have already reached MDG 5a and others are unlikely to do so; the interventions require sustained political will, ‘soft’ infrastructure (e.g., regulations, communication), consistent funding, and a systems approach to process improvement. Unfortunately, it may take more than 20 or 25 years to build out this basic scaffolding on which to build sustainable change.

The imminent failure to reach the goal of reducing the MMR by 75% by 2015 shouldn’t obscure the fact that there are hundreds of thousands of mothers alive who, without the focus on maternal mortality, may not be otherwise. Much more can – and will – be done in the next two years, and in the next two decades.

In many ways, 2015 is just the start.

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Figure 2

 

*If you’re a public health or history of medicine wonk, you may recall that puerperal fever (or childbed fever, as it was known) was the disease that led Ignaz Semmelweis to call for basic hygiene measures in his Viennese hospital pre-Germ Theory of Disease – and was promptly rejected from the establishment for his heresy. As one contemporary doctor put it, “Doctors are gentlemen, and gentlemen’s hands are clean.”

 

MDG

Goals are good, but do the MDGs need to be simplified?


MDG
If the recent US presidential campaign felt more acrimonious and hard-fought than ever before, remember, there’s probably good news for global development. According to the UN, the world has met two critical Millennium Development Goals (MDGs), including halving extreme poverty and doubling access to clean water. Although success is not evenly spread and some of the MDGs will probably not be met, we have considerable reason to celebrate the most significant gains we have seen in our lifetime.

In order to ensure that this progress is equitable and accelerating, our goals for the post-2015 framework must take a different shape. Simplifying the MDGs to just four goals encompassing global well-being, extreme poverty, health and climate change will make the MDGs more memorable and reportable.

Although global well-being may not seem to fit in the context of the MDGs, it makes sense to measure what we’re actually trying to impact by examining the degree to which we’re improving lives. This will require new resources and thought around what is an acceptable measure of well-being, as Bhutan’s interpretation of “Gross National Happiness” illustrates, but these are details that deserve to be debated in the full light of greater research and commentary. Importantly, creating an MDG that aims to raise overall global well-being will not only spur research and aid funding to more accurately assess whether our anti-poverty efforts are achieving this goal, but also receive attention from some who may not otherwise pay attention to global development.

But in this respect, attracting attention to the MDGs, simplifying our broader aims to just four will give us more freedom to make the MDGs a cause to advocate for in and of themselves. Currently, activists advocate for the end of AIDS or the capture of Kony, but few clamour for the achievement of MDG five, if anyone can even name what it actually is (improving maternal health). But by consolidating our aims to a distinct four, MDG progress can be sped along by activists advocating for the end of climate change, for example. Making the MDGs marketable for the purpose of activist involvement isn’t about reaching for inclusion where it doesn’t exist, but finding alternatives to waiting for governments to chip in.

And though I’ve earlier called the MDG gains the most significant of our lifetime, exaggerating successes and drowning in failures is probably an unhelpful trait of development writing. Although it’s wonderful that extreme poverty has been halved since 1990, China’s recent growth has much to do with this, which is largely not a product of humanitarian development dollars. If our post-2015 MDGs are destined to merely measure our overall progress against poverty, then there is nothing wrong with claiming success when we succeed as a result of a factor we didn’t expect. But this isn’t the goal of the MDGs. The MDGs should seek to compel individuals and nations to up their contributions to development. This is only possible if we judge success by the amount we increase our commitments every year—in dollars, contraceptives, bed nets, medicines, and anything that improves lives.

Certainly, this approach will encourage help of all kinds, but it’s crucial that we aren’t misled to believe that charity given regardless of context or need is a victory. The MDGs should not just be a reflection of where we wish to see the world in the near future, but how we should prioritise our spending. For example, the Copenhagen Consensus, an organisation that attempts to gauge which development interventions are the most cost-effective, ranked providing malaria treatment as one of the best ways to save lives and improve health in 2012. Although HIV/AIDS is arguably a more pressing issue than malaria if judged by a simple number of deaths, money spent treating malaria will have a greater impact than treating HIV/AIDS according to their research. Many people are understandably uncomfortable with the premise of determining who lives and dies on the basis of cost-effectiveness, but compassion does not justify ineffective approaches.

While the MDGs may not contain the adrenaline and energy of a costly election, activist engagement may allow us to achieve success where government funding hasn’t. Four MDGs, encompassing most of the interests of the current MDGs, will pull us through every MDG success, every failure and every unsatisfying outcome in between.

 

improve_discipline

How would you make aid and development better?

This post is in response to a call out from AidSpeak, the blog of the Humanitarian Social Network known as AidSource. The guys recently asked writers to talk about how they would improve aid and development. Of course, this is by no means an exhaustive list (that would involve a word limit longer than Tolstoy’s War and Peace), but just a few key areas in which we might move aid and development forward.

Let’s make aid and development truly about “beneficiaries”, once and for all.

Aid and development, as it stands, involves a triangular relationship between the donor, the NGO and, for lack of a better word, beneficiaries. Although the word beneficiary sounds a little too passive for my liking, getting to the core of aid and development is about improving the lives of people in communities that are impoverished or vulnerable. However, too often, aid and development does not revolve around them.

The donor often determines what programs get funded and therefore what kind of development work gets done. The Millennium Development Goals (MDGs) announced in 2000, contain no specific mention of disability. Since then, there has been anecdotal evidence that some programs developed by disability NGOs, in consultation with communities, have been refused funding.

Some agencies and funding bodies refuse to fund programs that target people with disabilities simply because disability is not explicitly mentioned in the MDGs. For the 15% of the world who live with disabilities at least, rather than foster collective action, the MDGs have promoted inaction.

We need to create an environment where communities determine for themselves what issues need improvement. This in itself is complex, because simply asking communities often ignores those who are not already in positions of power. It is up to NGOs to reach those who are typically the least heard. Women, children, ethnic minorities, LGBT, migrants, and people with disabilities would help. Let’s get NGOs to do the listening, and then spend time and energy talking to donors about what communities really need.

Put more trust in poor people.

In Just Give Money to the Poor: The Development Revolution from the Global South, the authors take a step back from looking at what reduces poverty, and investigate our own attitudes towards poor people. They ask the question: “Who is to blame for poor people being poor: society as a whole, or poor people themselves?” The variation across countries is fascinating.

Who is to blame for poverty – poor people or society? Adapted from Just Give Money to the Poor.

The data shows that the majority of people in the United States tend to blame poor people for their level of poverty, rather than society. At the opposite end of the spectrum, only 13% of people in Germany blame poor people, with 87% blaming an unfair society. Our own attitudes about who is to blame for poverty are crucial in how we attack the problem.

If we continue to see poor people as the architects of their own predicament, then “poverty eradication” will continue to be done for them, not by them. Programs will continue to be paternalistic, and poor people themselves will have little to no agency in creating a better future for themselves.

Microcredit, or the giving of small loans to people in poverty has, at best, tenuous evidence in lifting people out of poverty across the board. As economist David Roodman says, “microfinance is rarely transformational”. Yet currently, microcredit is incredibly popular. This is despite strong evidence that suggests that unconditional cash transfers (just “giving money to the poor”) may be more effective in reducing poverty, particularly amongst vulnerable groups.

Why do we favour microcredit? One reason may be that behind all of this is the unspoken belief that poor people cannot be trusted. In fact, advocates of microfinance often point to loan repayment rates as a sign that microcredit is working. One of Grameen Bank’s greatest brags is that 97% of their loans are repaid.

However, this figure is only a distraction. Surely, the success of microcredit should be measured by the effect on reducing poverty, rather than the ability of people to pay loans back. People often baulk at the idea of giving money away with no strings attached, because they feel that poor people cannot be trusted. Yet the overwhelming body of evidence suggests that cash transfers work better than microcredit. In asking why we still prefer microcredit, we have to ask ourselves the simple question: “Do we trust poor people?”

Do more to reach the most vulnerable.

In his book, Due Diligence: An Impertinent Inquiry into Microfinance, David Roodman notes that while microcredit can change the lives of some people who are poor, there is one group that microcredit almost universally does not reach: the poorest of the poor.

To boil a very complex situation down to its simplest form, microcredit is run like a business, and the ability to reach the poorest in any community has a high opportunity cost associated with it. You may be able to reach the one ultra-poor family in the remote hills away from the village, but this will come at the expense of reaching four less poor families within the village.

Similarly, aid and development as it stands today does not do enough for people with disabilities, often the most poor and vulnerable within any community.

Poverty and disability are inextricably linked. The lack of access to decent employment, the higher costs of living, the opportunity costs of caring for those with disabilities – all of these factors combine to make families of people with disabilities multiply disadvantaged. Children with disabilities are far less likely to attend school than their non-disabled peers.

Although this trend is starting to be reversed, too few mainstream development organisations and agencies include people with disabilities into their programs. I have personally met with many development NGOs who do great work across a wide range of areas. However, when asked specifically how they address the needs of people with disabilities (often 15% or more of their target group), I’m faced with blank stares.

How can we truly claim that we are working towards improving the lives of poor and vulnerable people, if we continue to ignore those at the most vulnerable end of the spectrum?

Often, organisations resist including people with disabilities because it is perceived as too difficult or intimidating. Fortunately though, there is a wealth of information available to help mainstream the specific needs of people with disabilities. Here is a fantastic guide, produced by the disability organisation CBM, to get the ball rolling.


Why is volunteerism so widely maligned?

In April, I was fortunate to attend an event organised by VSO. It was the unveiling of their official partnership with United Nations Volunteers (UNV), including the launch of UNV’s first ever State of the World’s Volunteerism Report 2011.

The title of the event, “Framing the future of development:  putting people first”, was intriguing. In essence, it puts volunteerism at the centre of participatory development approaches by both acknowledging the forthcoming focus on creating the next international framework  (post Millennium Development Goals), and winking at the past (via association to Robert Chamber’s seminal 1983 book “Rural Development: Putting the Last First”).

As I sat and listened to Flavia Pansieri, Executive Coordinator of UNV, and Marg Mayne, Chief Executive of VSO, I was struck by the perhaps unsurprising convergence of discourses. They expressed a need for “social development to converge with economic development”, and the importance of “active citizenship” which gives rise to “the voices of people to influence policy-making”. I did have a moment where a cynical voice said “isn’t this what was being said in the 1980s?” Perhaps, but I think there are some fundamental differences, including the emergence of information and communications technologies in development, and the increasing importance of establishing systems for accountability.

As a former volunteer for a range of organisations in different capacities, I began to ask myself the question: well, if volunteering is such a dynamic and (dare I say it, at risk of compounding its overuse) robust approach, then why is it still underestimated and under-used? It is often viewed as an activity either for the young or the retired in the so-called global North. Or it remains invisible amongst the everyday acts of service and community responsibility acted out in collective societies (for example the Guthi system in Nepal).

And so, here are a few reflections as to what I think is holding back the role of volunteerism in development:

1. VSO and UNV espouse that “volunteerism is a universal concept”, which can mean that it becomes a way of doing (and being) that is everything and nothing at the same time.  The UN General Assembly (2001) defines it as: not for financial reward; based on free will; and of benefit to someone else. There are several threads of volunteerism which are informal and perhaps invisible. Indeed volunteers may also not want to be seen or to be recorded/labelled as such, because this very visibility can detract from the value of service. It is in some respects the quintessential “do gooder” label, which is imbued with a series of contextual power relations.

2. In many countries in the so-called Global South, volunteerism is often perceived as something foreigners do. The State of the World’s Volunteerism report sees this as problematic and states that, “in parts of the ‘developing’ world, the term ‘volunteer’ is a recent import from the North and refers essentially to expressions of international volunteering…[it] still flies under the radar, yet many societies would be hard pressed to function without it” (2011:3). Robert Leigh, the lead author of the report noted that there is still a tendency to also write that “national volunteers are written of as providing service in kind, rather than as volunteers”. Again, what does this tell us about the power relations (as Bourdieu would be quick to analyse) and what are the consequences of this?

3. Volunteerism is not inherently good. Just because a person is a volunteer, it doesn’t mean that they are: a) a good person; b) doing a good job. I know this is somewhat of an obvious statement, but there is a lot of naivety out there. Marg Mayne reminded the audience that it’s about getting “the right volunteer into the right (needed) placement, and supported by the right people”. No easy feat!

4. There should be more emphasis on the processes of volunteering, rather than on the end effect on the individual volunteer. In this way, volunteerism becomes less about the end in itself (i.e. a fulfilled, personally developed volunteer), but rather about the how, and the what (i.e. the evidence of positive/negative outcomes on a community). Volunteers can be amazing channels/tools that bring adaptation and innovation. But there needs to be more evidence of this, and as Danny Burns from Institute for Development Studies said, “if you are not looking for it – you won’t find it!”.

5. A tension that can arise with volunteerism, which essentially is related to the nature of exchange, and that these are clearly articulated by all people involved. Although a volunteer is doing something for no financial gain, is there something else that they are hoping to gain in return? Is it a time bound exchange? Can volunteers voice a change in expectations? Are there opportunities for the relationship/identity to change? Managing expectations is crucial.

6. “Volunteerism is a way to get out of marginalisation”. I was struck by this statement made by Flavia Pansieri. Indeed, there is a whole chapter on this in the report. VSO and UNV are commissioning some research on the impact of volunteerism, which I think is very timely indeed.  I look forward to the evidence generated from this, which will no doubt further the learning from which Flavia’s statement springs. How volunteerism is talked about is very important. It is a similar challenge in the youth development field, in which I work.  The normative role of volunteerism is transitional – volunteering is something you do at a transitional stage (young/old in life) for a given period of time. Yet, as the UNV’s report highlights, this is a limited view of volunteerism; it is an approach for development for all ages.

You no doubt have some of your own reflections/experiences to add and challenge me with – please do so with a comment below.

In the meantime, hats off to the volunteers behind whydev,  Brendan, Weh and Allison – a refreshing example of collaborative volunteerism in action.

The end of aid through trade?

We are undergoing a transformation in the global economy. The financial crisis which has plagued the United States and Europe since 2008 is still holding back growth in those nations. In the meantime many developing countries continue to register positive economic growth. This is partly because developing countries are less dependent than they once were on developed countries as a source of growth. Research carried out by the International Monetary Fund (IMF) in 2008 found that the business cycles of rich and emerging nations were diverging. Further to that, the IMF is forecasting that next year the developing world will out-produce the developed world for the first time. This signifies a key turning point and a monumental opportunity.

At the same time the importance of maintaining aid to developing countries is coming under the spotlight. Recently, the Canadian government made deep cuts to their foreign aid budget. Whilst the foreign aid budget has so far escaped such cuts in the United States, Greece and Spain have also slashed their aid budgets, as have Austria and Belgium.

The debate around the effectiveness of aid also rages on in many forums, including here on whydev (such as in this post). But, in light of the improved economic performance of developing countries, should there be a shift in the debate to be more focused on how the global community achieves the end of aid? And if so, how would we bring about the end of aid?

Although I don’t generally enjoy quoting Tony Blair, I’ll make an exception this time. In a recent op-ed in the Huffington Post, he argued that Africa can be free of dependence on aid in a generation. To achieve such independence he wrote that Africa needs economies that generate wealth and improved living standards for all. Similarly, the Nigerian finance minister, Dr Ngozi Okonjo-Iweala, highlighted that aid to save lives is only part of the story. She explained that, “saving lives turns those people into productive contributors to the economy. Of course the social and humanitarian reasoning makes sense but add to that the economic”. She raised the question, “after lives are saved what is the next step?”

The next step is economic growth through trade. Today’s aid needs to enable tomorrow’s trade. Whilst economic growth figures in developing nations in recent years have been impressive, they can still be improved. Sub-Saharan African growth averaged 5% in the years 2000-2008 and we’re all familiar with the approximately 10% growth rates in emerging Asian nations in the same period. Although the economic turmoil in the US and Europe dented those growth rates, both regions rebounded in 2011. But, a recent World Bank report on the Light Manufacturing Industry in Africa highlighted the impact of poor trade logistics, which increases cost and reduces competitiveness, the holy grail of trade. Improved trade competitiveness is essential for developing countries to continue their growth trajectory and ultimately cut aid dependence.

In order to build a “trade enabling environment” an essential element of foreign aid spending needs to be investment in infrastructure such as roads, railways, ports, and systems. This is especially important on an intra-regional basis. In the African example, transport from landlocked nations to ports in the coastal nations adds significant cost and extends transit times, again reducing competitiveness. Also intra-regional trade is in itself a key component to increasing trade and economic growth. The OECD reported in 2010 that “South–South” linkages had intensified and trade is growing rapidly as part of the global production networks and also to serve the growing middle class in many emerging nations. The World Bank’s report “Connecting to Compete: Trade Logistics in the Global Economy” emphasises that efficient trade logistics is strongly associated with trade expansion, export diversification, the ability to attract foreign direct investment and economic growth. The basis of that report is the Logistics Performance Index, which assessed the reliability and effectiveness of import and export supply chains in 155 countries and ranked countries from best to worst. The countries in the bottom 10 in the rankings are low and lower-middle income countries and eight out of 10 countries are in Sub-Saharan Africa. China has the highest position of any developing country at number 27. It is quite clear that in order for autonomous economic growth to replace aid, investment in and improvement of transport infrastructure is an essential prerequisite.

In countries such as Malaysia, India and China, trade driven growth has been shown to be successful. In order for other developing countries to replicate such growth, rich countries can also ‘aid’ developing countries by allowing access to their markets and indeed providing a more level playing field. I won’t go into all the details of the failings of the Doha round, the so-called ‘Development Round’ of trade talks, but it’s clear that the lack of agreement is a key threat to increased global trade and that it is causing developing countries to lose out on significant opportunities. The current economic environment has also led to an increase in protectionist sentiment and hence creates less potential for a resolution of the round.

In a world where more than a billion people still live in poverty, it’s important to highlight that the end of aid dependence can be the goal only after development foundations have been laid, such as achieving the Millennium Development Goals. Aid is still an essential pillar of the “first step” in development that is to save lives. But Dr Okonjo-Iweala is right to ask, “what is the next step?”

The next step is becoming clear – it is economic growth through trade. Today’s aid needs to better facilitate this next step, by supporting better infrastructure and access to high-income countries’ markets.