Thoughts from the Last Mile Welcome to the VillageReach Blog
09.07 2011

Remember the days when you had to go to a library to look something up? What if you had to walk there?  And it took three hours.  And the book you wanted was checked out.  Technology has brought so much to our lives that we sometimes forget the value of information.

In my work, I’ve realized that information can be a hard commodity to sell or even to give away. Even when we try to make information available, when living under constrained circumstances, we often have bigger fish to fry (like trying to get the actual fish!). The focus is on tangible resources. And in developed countries we may treat our technology and especially its outer manifestations—phones, computers, televisions—as the end in itself.  We value the package as much as what it brings us.

This year, VillageReach launched a new project in the Balaka District of Malawi to provide women and caregivers of young children new ways to access information and advice about pregnancy and child health through mobile phones.  This project reminds me that information is another valuable missing resource in the most rural communities. We have heard from health providers that women often attempt to “wait out” their own or their child’s medical problems, rather than seeking care quickly when local resources may be of use because the often arduous journey to seek health care may represent a risk or a cost in and of itself.  It can be a difficult decision to make. The simple practice of informing people of when something is serious and when it can be managed at home can both save lives and ensure the strategic use of existing resources.

Of course information isn’t enough, and a pregnant woman may still have to walk for three hours to reach the health center. We can’t afford to forget that, even while we are helping women and caretakers make informed decisions about seeking care. For me, this means remembering the context for the advice and information we are providing.  I keep this picture on my desktop. I took it as we were traveling to a rural clinic. It’s a reminder of what rural really means, but it’s also a reminder that there are life-changing resources that go beyond the tangible.Blog_Stacey

Stacey Cunningham

Stacey Cunningham is the Maternal, Newborn, and Child Health Project Manager for VillageReach, based in rural Malawi.

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08.29 2011

“The pure and simple truth is rarely pure and never simple”
Oscar Wilde

I’m an MPH graduate student and a recent addition to the VillageReach team as a summer Health Systems Group intern. When I was asked to come up with some ideas for how to evaluate active case finding for VillageReach’s new tuberculosis (TB) program in Kwitanda, Malawi, I was ecstatic.

Step one: figure out what active case finding is (preferably before anyone realizes I have no idea). Once I did the research, I realized it’s a pretty simple concept: the more people who have TB, the more people they can spread it to. If we can actively find people with TB and treat them (rather than waiting for them to come to the health center which may only happen after they become very sick or may not happen at all), then we can reduce TB. Easy!DSC00130

Step two, how do we decide if our active case finding program worked? The health centers keep track of new TB cases so we can use those numbers to evaluate our program. If the numbers of TB cases seen at the health center goes up, then we were successful in finding more cases of TB. If the number of TB cases goes down, then we were successful in reducing the number of people who have TB. So no matter what the numbers say, we can say we were successful? While I was tempted to bring back a no-fail assessment plan to my supervisors, I had a sneaking suspicion that it wasn’t going to fly in an organization that highly values evaluation.

Step three, more research. Turns out lots of people are interested in evaluating TB programs and the Millennium Development Goals have set the goal of increasing the “case detection rate” to 70%. That means for every 10 people who actually have TB we want to find 7 of them. Ok, that could work. We already know how many people we’ve found with TB because of the health center data but how do we find out how many people actually have TB, assuming that many of them are undiagnosed? We would need to go door-to-door in Kwitanda and test everyone for TB (or at least test a large sample of people). That would be expensive. And frankly, if we had that kind of resources we WOULD just go door-to-door and test everyone. Not for evaluation purposes but because it would be the right thing to do!

So back to square one. After driving myself crazy with statistics and indicators for at least several days, I came up with an idea. We already do an annual house-to-house survey of questions – what if we asked every person if they have a cough and if they’ve been tested for TB? That way, we can know the percent of people with TB symptoms who’ve been tested and that number should always go up. If TB incidence in Kwitanda goes down (which we hope it will) the number of people with symptoms should go down too. But, with any luck, the percent of people with symptoms who have been tested will continue to increase until 100% of people who need to be tested can get tested.

All of this got me wondering the same thing non-profits have been wondering for years: how much money do we spend running our programs versus how much money do we spend finding out if we’ve actually run them well? While our indicators for the TB program may not be perfect, they’ll give us enough information about whether or not our approach is working while still leaving lots of time and resources to actually do the work.

Erin-Larsen Cooper

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08.23 2011

I joined VillageReach Mozambique in June of this year as the Monitoring and Evaluation Officer. With previous experience working with other nongovernmental organizations and government in the area of health information, I was excited to work with VillageReach to strengthen the health system with evidence-based decision making. Since I joined, I have had the opportunity to make several visits to the provincial offices and health centers, and I’ve seen first-hand the role of information in the health system.  Read more on VillageReachFocus.

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08.05 2011

I’ll admit that before I started working for the HSG Team as a summer intern, I would not have considered myself a “systems” person.  Systems are boring, right? But now, only 6 weeks later, I find myself a full convert. It turns out everything is about the system.

When I began delving in to what it might take to improve access to emergency transportation in Kwitanda, Malawi, I thought I was going to learn about bicycle ambulances.  Or lack of bicycle ambulances. Or broken ones.  Or maybe even full-on motor vehicle ambulances with sirens and flashing red lights.  But alas, I learned about systems.

It’s true that one of the major barriers to successfully accessing emergency medical services in resource-limited environments is the lack of reliable and affordable transportation between the location of the emergency and the nearest hospital.  And in Kwitanda, bicycle ambulances are filling that gap. But when people need to get to a hospital in a hurry, the vehicle that takes them there is only one piece of the puzzle.  First, someone needs to recognize the need to get to a hospital.  Sure that may be obvious in the case of a serious accident, but it might not be in the case of a woman, giving birth at home, whose labor is taking a turn for the worse.  Next, there has to be a way to notify the ambulance that there is an emergency and in a place with limited access to electricity and cell phones, this can be tricky.  Once the bicycle ambulance is located, someone needs to drive it to the hospital, and equally importantly, bring it back so it’s available for the next emergency.  In the best-case scenario, there would be a way to notify the hospital that a seriously injured or ill person is on the way, so that the hospital can be ready when s/he arrives.  In short, there needs to be a system.

Luckily, the communities we work with in Kwitanda understand the importance of systems (and understood it much more quickly than I did, I might add).  Currently, there are village committees in place to oversee the use and maintenance of the ambulances.  In fact, the number of households that have “ever used” a bicycle ambulance saw a three-fold increase between 2010 and 2011.  To keep seeing these kinds of results, we need to ensure that the systems, not just the ambulances, are working.

Erin Larsen-Cooper

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06.01 2011

A few months ago at the start of my medical treatment, I contrasted the Fortunate Last Mile with the Not-So-Fortunate Last Mile. Now that I am nearing the end of what I jokingly refer to as my “Swedish spa treatments,” I would like to add a few additional thoughts. The second part of my treatment has involved chemotherapy and radiation treatment. The mapping_visualization3 picture shows me receiving radiation through a device called an Electra Linear Accelerator at the Swedish Cancer Institute Swedish Cancer Institute in Seattle. The device costs approximately $6 million to install and I am fortunate it is available at my health center. With this level of medical resources available to me, my doctors expect a full recovery.

In contrast, Stacey Cunningham, VillageReach’s Project Manager for our Malawi Maternal, Newborn, and Child Health Project Malawi Maternal, Newborn, and Child Health Project recently sent pictures of a village clinic operated by VillageReach and the Malawi Ministry of Health. These mothers are seeking medical treatment for their young children to prevent them mapping_visualization3 from dying from afflictions common to their area: malaria, pneumonia and diarrhea. The village clinics are rudimentary but effective in treating medical challenges that are barely given a second thought in the United States. Unfortunately, medical resources are still very limited and far too many children die of easily preventable diseases.

When faced with a serious medical challenge, it’s mapping_visualization3 common to be overwhelmed with a rush of thoughts and emotions. In the midst of that swirl, the picture of this young boy caught my eye. With a simple twist of fate our birth places could have been reversed. I can’t say I have sorted out the bigger picture, but I do know there is a serious problem with lack of access to quality healthcare and it’s time to act. And for me, it’s personal.

Allen Wilcox

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05.17 2011

In his last blog, John noted VillageReach places a high value on transparency, and that has attracted a crowd of supporters who are challenging non-profit sector paradigms about transparency. This is a force for change to improve on donor-NGO relationships, and ultimately to create better impact. But what does it mean to be transparent? In international development, being transparent has impact on two distinct relationships: those between NGOs and donors, and those between NGOs and partners on the ground. Today I’m writing about the latter.

VillageReach’s work is often conducted in close partnership with governments. We’re not in the practice of creating or running health systems. Instead, our role is to strengthen what exists – typically the public health system. For example, in Mozambique we work with the provinces to implement a vaccine logistics system, and the work only starts when both partners are ready. For our own purposes, we must plan our work and forecast what needs we will have. Naturally, we base our plans on what we know about the provinces: eg. financial, personnel and transportation resources, and broader scheduling plans for various other health program initiatives.

But situations often change for government agencies and communities in low-income countries with limited resources. As a result we may publish plans that don’t coincide with the unique scheduling and resource planning priorities of the government.

When government representatives see our plans, they may naturally jump to the question, “whose health system is it anyway?” and wonder why VillageReach is making plans for them.

Planning is best done by talking with government partners about when they will be ready to work on a program. Their assumption will be that we have identified the resources before we begin discussions with them. Of course that is not always the case – we will want to present a case to donors that indicates prior government commitment. If our response to the provinces is that we haven’t [yet] identified the resources, then they may question our ability to make a long-term commitment.

In a similar vein, being transparent raises questions of data ownership. We strongly believe that it is critical to have data for monitoring and evaluating the impact of our work, and our donors and partners agree. The extent to which we share that data publicly is not always agreed upon with our partners. For example, when we carry out a baseline study with household surveys about vaccination coverage rates, that data and decisions about sharing it don’t belong to us – they rest with the government who factors in the various reporting obligations it has to other constituents, including other government and private donors. An important fact to consider in understanding government decision-making in low resource countries can be seen in what dependencies these governments have on external parties – as an example, as much as 70% of the public health budget may be supplied by donors.

We want to report on our program data, yet at the same time, the government needs to report on national indicators to other donors. The story the national data supports and the story for a province might be very different. The more NGOs, the more complicated this becomes for the government.

So balancing transparency for our donor partner needs and our government partner needs is a challenge. We’re committed to the principle of transparency – without it we might alienate donors, or at least limit their ability to make informed decisions about investing in our expertise and contributing to our programs. We’re similarly committed to being a trusted partner to governments we work with in order to ensure we’re valued and our expertise is applied at the greatest scale for maximum benefit.

Leah Hasselback

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04.25 2011

Kevin Starr at the Mulago Foundation has an interesting piece in the Stanford Social Innovation Review this month about the future of philanthropy and social entrepreneurship (note the Mulago Foundation supports VillageReach). Kevin’s blog has a number of perspectives in it that are each worthy of comment, but I’ll focus on one issue today.

Kevin is concerned about evaluations of impact, or the lack thereof, in the social sector. He expresses frustration about the sector “…operating in a dysfunctional market for impact.” Kevin had just returned from the annual Skoll World Forum, as I had. He was struck with what he heard: that highly evaluated organizations with demonstrated impact can’t always attract the capital they require. Whereas “… zombie NGOs can operate for years …” This in comparison with the private sector, where capital tends to follow the most appealing investment cases. The lack of an established social sector marketplace, where entrepreneurs – the Doers – and investors/donors find each other efficiently through common standards of evaluation, is a source of frustration for Doer and funding organizations alike.

Kevin suggests the fault lies with investors/donors for the most part – they don’t always insist on stringent evaluations of the work they fund. That’s cause for concern right there because it suggests more could be achieved with the same resources, but isn’t.

But we can’t place all the blame on the sources of funding. Doers are also charged with evaluating their performance in order to improve results, and of course many already do this. But some Doers may be reluctant to make their results public, out of fear that the challenges they face will not be appreciated. Achieving sustainable results at large scale in international development is just hard, and can be unpredictable.

But I think you have to give the donor more credit. Our supporters want to see tangible evidence of our performance, but also explanations of the challenges. Many are not foundations or organizations – they’re individuals who want to make a difference. I’d make the case for individual donors being a real force for change in wanting to evaluate the impact that financial support provides for social causes.

The smart giving movement encourages measurable, sustainable impact for their donor dollars. There’s a growing number of people eager to track the Social Return on Investment (SROI) of their personal contribution. The movement doesn’t only encourage reporting of results. In fact, it seems investors/donors also respond well to organizations that document their plans. For our donors, results matter. But they gain confidence in us when they see project plans, program metrics and financial plans online. GiveWell, and their positive rating of VillageReach, is further evidence that being more public with plans for effecting change is a natural attraction for investors and donors.

Transparency itself becomes a differentiator. And we can always improve upon that.

On that note we recently published updates to our work in Mozambique, with new details of the project plan and the financials, with an explanation of what has changed. We’ve seen some delays in deploying the model to additional provinces, but we’ve also received support that enables us to plan more effectively for the longer term. See VillageReachFocus for details, including the updated program report.

John Beale

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03.16 2011

After weeks of elaborate tests using very sophisticated health technologies, my diagnosis has been confirmed and I can begin my treatment. The first step in the treatment was surgery last Monday, only a few miles from my house. As part of the procedure, the surgeon made a six-inch long incision from my left ear to the center of my throat. To close it, he gave me zipper of temporary metal staples.
I can now claim to be the first in my family with body piercings, teenagers notwithstanding. The rest of the treatment will keep me from my day-to-day duties at VillageReach for about three months. At the end of which, however, my prognosis is for a full recovery and I will be back at my desk by early summer. That’s because I live in a high-income country where quality healthcare is readily accessible – at the Fortunate Last Mile. But for billions of people living in low-income countries where access to quality healthcare is scarce, my same diagnosis would be a death sentence. As we all know, life isn’t fair. But that’s just one more reason those of us living at the Fortunate Last Mile need to work to address the inequities in access to quality healthcare for those living at the Not-So-Fortunate Last Mile.

Allen Wilcox

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02.01 2011

Join Us for an Evening of Fun & Jeopardy!

Hey gang in Seattle! We hope you can join us for a fun evening of celebration and excitement here in Seattle.

The first-ever man vs. machine Jeopardy! competition will air on February 14, 15 and 16. As noted in the Seattle Times, Ken Jennings, the celebrated Jeopardy! contestant who broke the record for the most consecutive games played by winning 74 games in a row, is a local hero and is competing in mid February with the IBM Watson computing system. Ken has generously named VillageReach as beneficiary for half of his winnings at the competition.

The VillageReach team and friends will be getting together on the evening of February 16 to watch the final show and find out the results. Please join us to watch the fun and cheer on Ken!

Where
Dad Watsons Pub
3601 Fremont Ave. N.
(corner of Fremont Ave. N. & N. 36th St.)
Seattle, WA 98103
(206) 632-6505

When
Wednesday, February 16, 2011
6:30 p.m. – whenever you like.
Jeopardy airs at 7:30 p.m.

RSVP
Please RSVP to make sure we reserve enough space.
Email: john@villagereach.org.
Tel. (206) 925-5203.

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Malawi healthcare worker