Save the Children Voices from the Field

Building government health systems in Bangladesh

Areba Panni, Advisor-Strategic Communications, MCHIP/Save the Children

Dhaka, Bangladesh

March 28, 2013

Bangladesh is a low-income nation in South Asia and one of the most densely populated countries in the world.  Despite this, maternal mortality rates have decreased by 40 percent since 2001 and the country is on track to achieve the Millennium Development Goals (MDGs) on reducing maternal and child deaths by 2015. In fact, only eight other countries out of the 74 that account for most of the maternal and child deaths can claim this achievement. Maternal deaths remain concentrated in Sub-Saharan Africa and South Asia, an indication of global disparities in women’s access to much needed care during pregnancy, delivery, and the postpartum period as well as family planning services.  Bangladesh’s astonishing progress in the health sector can be credited in part to the government and communities working together at the district level to deliver lifesaving assistance to mothers and babies in need.

An innovative safe motherhood project “MaMoni,” meaning “mother-child,” has been supporting health systems coordination and service delivery in fifteen sub-districts of rural Bangladesh since 2009.  Funded by the U.S. Agency for International Development (USAID), the MaMoni project is run by Save the Children in Bangladesh and two local NGOs, Shimantik and FIVDB, in partnership with Bangladesh’s Ministry of Health and Family Welfare. The project aims to integrate household, community, and governmental efforts to achieve improved health outcomes from the district level down to the grassroots.  

As part of its reform agenda called “USAID Forward,” USAID is focused on delivering results in an efficient and sustainable way, by building the capacity of country governments and by providing more funds to country governments directly. In Bangladesh, USAID is boosting the capacity of the government to deliver health services to rural areas. The agency has aligned its approach with the government’s health sector strategy and for the first time is investing $40 million over five years in the Bangladesh government through the World Bank’s “Single Donor Trust Fund” to support health care and other sectors. 

The investment by the United States and other donors to improve the government’s health service delivery systems is making a big difference for women facing birth emergencies. Last year, Mariam Begum, who was living in a small village, was experiencing pain and heavy bleeding following the birth of her child. A local community volunteer, trained by MaMoni staff to recognize severe conditions like Mariam’s, helped arrange her transport by a water ambulance to the nearest government-owned health center where she was further evaluated. When the health center was unable to deal with the severity of her condition, she was transferred to the district hospital.  Mariam’s life was saved due to the quick assessment of her condition by a community volunteer and the linkages between the community and government health workers. 

In addition to facilitating delivery of emergency services, MaMoni focuses on institution building and community engagement and will assist the management of 11,000 community clinics set up by the government in the country to roll out trainings for community health care providers. MaMoni trains government health workers to offer women pre- and post- pregnancy counseling, birth assistance, vaccinations, and counseling on exclusive breastfeeding.

A network of more than 13,000 community volunteers set up and trained by MaMoni respond to the needs of mothers and newborns, spot cases that require treatment in health facilities, and help organize local health planning meetings. The community volunteers collect health information from the community and meet with frontline government health workers at the end of every month to update registers. Large wall charts in the government’s family welfare centers track where pregnant women live, their due dates, and whether they are experiencing complications that should be monitored.   MaMoni staff are in regular dialogue with the government to help improve their information systems and service delivery.

Based on these best practices from MaMoni, USAID is working with other districts to introduce health systems strengthening projects. USAID’s ultimate goal is to demonstrate a successful model and enable the government of Bangladesh to take it to scale throughout the country.

USAID’s investments in government capacity building help to ensure the long-term sustainability of health programming in Bangladesh beyond the life of MaMoni and other projects.   With these investments, survival rates of at-risk mothers like Mariam increase and the coordination between communities and the government improves the quality of and the access to women’s health services throughout Bangladesh.

 

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Liberia's Government Takes the Helm to Protect Vulnerable Children

Liberia’s Government Takes the Helm to Protect Vulnerable Children

Geoffrey Oyat, Child Protection Manager

Monrovia, Liberia

February 28, 2013

Mr. Mulbah, a farmer in Gleegbar Town in northwest Liberia, was persuaded by a distant family member to send his four older children to a boarding school in Monrovia in 2007.  This school, Aunt Musu said, would provide a better life for his two sons and two daughters since there was no good school in Gleegbar Town. Four years later, Mr. Mulbah was notified that his children were living in an orphanage, where they had been beaten, starved, and forced to beg for money on the streets. Mr. Mulbah’s children were returned to him in July 2011 and he is now caring for a family of nine and sending all his children to the local school in Gleegbar Town. Although Mr. Mulbah is now reunited with his children, many other parents in the region still face uncertainty about their kids’ whereabouts.

Poor services and poverty in rural areas compel parents to send their children to the capital city Monrovia with hopes for a better life for their children. Parents enroll their kids in orphanages with false promises of funding for their education. An assessment done by Liberia’s Ministry of Health and Social Welfare in 2008 found that a majority of the 5,000 children living in orphanages in Liberia are not orphaned but wrongly placed.    

The Government of Liberia is faced with the daunting task of supervising orphanages and ensuring the protection of Liberia’s two million children. Moreover, the country is still recovering from a 16-year civil war and its institutional capacity remains weak.

Over the past decade, Save the Children has been assisting Liberia’s Department of Social Welfare, the government ministry responsible for child protection on measures and structures to prevent and respond to abuse, neglect, exploitation and violence affecting children. 

With funding from the United States Agency for International Development (USAID)’s Displaced Children and Orphan’s Fund, and administered by World Learning, Save the Children Liberia has been removing children from the streets, unsafe orphanages, and other risky circumstances, and reintegrating them with their parents when possible. We have also helped parents to improve their skills and economic opportunities to prevent family separations in the first place.  

With its latest package of reforms called “USAID Forward”, USAID is investing more resources in building the capacity of Liberia’s institutions to take over essential functions such as child protection and health services that were primarily led by international NGOs and private contractors in the years immediately following the war. By shifting these responsibilities –from US entities to the Liberian public sector – USAID is fostering sustainable development and reducing the need for U.S. development assistance over time.

Over the past several years, Save the Children's role has expanded beyond providing child protection services alongside Liberia’s Department of Social Welfare. We are now working to help improve the government’s tracking and protection system for vulnerable children. In the USAID-funded project called, “Educating and Protecting Vulnerable Children in Family Settings” project, we are setting up a case management system for the Department of Social Welfare, in partnership with World Learning, to enhance the government’s ability to prevent vulnerable children from being separated from their families and reintegrate those that have been separated. World Learning has also been working to build the capacity of the Department of Social Welfare in child protection and other priority areas. Since the project began, we have prevented 457 separations and returned 221 children, ages 4 to 18, to safe homes.

Once the project is over in 2014, the Department of Social Welfare will take leadership over the protection and unification of children in Liberia. They will have quality baseline information on vulnerable families in six counties and an active county-level database of families linked to the national record. Moreover, members of Liberia’s judiciary and police will be able to work with 36 community groups and local leaders trained by Save the Children to identify child protection risks, relevant laws, and local services provided by the Department of Social Welfare.   

Building stronger and more responsive government institutions is a challenging task, particularly in a country like Liberia that has been so deeply impacted by war. Efforts by Save the Children, however, help to ensure that U.S. development assistance not only improves the lives of vulnerable children in Liberia now but also strengthens the country’s public institutions to lead and drive effective service delivery for at-risk kids in Liberia in the future.  

Public, Private, and Civil Society Partnerships in Action

Yasmina Padilla, Food Security Project Coordinator

Managua, Nicaragua

January 11, 2013

We like to think of development as a team sport requiring all players to work together toward the same goal. The game gets particularly exciting when you add new players to the team at half time. 

Save the Children has served children and families in Nicaragua for almost 80 years. Three years ago, we began partnering with Green Mountain Coffee Roasters Inc. (GMCR), based in Vermont, on a project to increasethe income and food security for families of workers on coffee farms. By helping families to diversify their crops, improve storage techniques, and bring crops to market, they can better withstand periods of food scarcity during the months between coffee harvests.

The United States Agency for International Development (USAID) joined the partnership two years ago, adding an ambitious health component through their regional “4^th Sector Health” project. Implemented by Abt Associates, 4^th Sector Health develops public-private partnerships and supports exchanges between countries to advance development through health in Latin America and the Caribbean. In Nicaragua, 4^th Sector Health is working with Save the Children and GMCR, along with local civil society partners, to boost maternal and child health and nutrition for the same coffee-growing communities.

USAID’s 4^th Sector Health also recently funded an experience sharing trip for Save the Children staff from five Latin American countries, who were involved in implementing GMCR-funded projects. The participants learned from each other’s experiences and are replicating best practices in their own programs, serving to increase their impact and sustainability.

The alliance between USAID, Save the Children, and GMCR is intended to maximize the use of resources and help identify new solutions to challenges affecting these communities. Sometimes the alliance organizations face challenges of their own -- coordinating work plans, reporting on technical outcomes, and carrying out their separate missions. 

Public-private partnerships, otherwise known as the “Golden Triangle,”are a hot topic in the field of international development. Donors like USAID have invested millions of dollars in partnerships with the private sector, yet some development experts have questioned the development impact of such partnerships in achieving real benefits for the poor and marginalized in developing countries.

As part of its recent reform efforts, USAID has put more attention towards improving its public-private partnership model. For one, USAID is including technical experts in health and nutrition such as Save the Children in some partnerships, recognizing that U.S. civil society groups lend valuable expertise in maternal-child health and other technical areas. Moreover, USAID is steering the private sector towards achievement of concrete development targets through their partnerships, as well as ensuring that companies are held to certain standards, such as respect for workers and environmental stewardship.

From my perspective, this alliance between Save the Children Nicaragua, USAID, and GMCR, is having a transformative impact on the communities in which it operates.

Photo Credit: Gerardo Aráuz

Martha Lorena Diaz is one of many enterprising women working with us,whose partner, Jose Manuel Benavidez, is a coffee farmer on a cooperative that sells to GMCR. Martha was initially given five hens and now keeps 40 in her small business, earning about one dollar a day from selling the eggs and chickens. Save the Children project training sessions have helped Martha to identify nutritious sources of food for her three children, particularly during the lean months when she struggles to provide enough food for them. Martha now makes a corn flour drink to boost her childrens’ daily vitamin intake. Moreover, health promoters, trained by Save the Children, visit her neighborhood and others to monitor child health and nutrition and treat sick children in their communities, which are often far from the closest health center.

Successful partnerships, such as the one between USAID, GMCR, and Save the Children Nicaragua, are critical to achieving lasting results in the communities that we all serve. With an increase in USAID’s partnerships with private sector and NGO players, who are committed to making a real difference in the lives of families in Nicaragua and elsewhere, I believe our team will prevail.

Building resilience in the Horn of Africa

Abomsa Kebede, Technical Advisor, Save the Children Ethiopia

Addis Ababa, Ethiopia

December 3, 2012

Two-year-old Lokko Godana drinks cow’s milk every morning. The milk is rich in proteins and vitamins, providing Lokko the nutrition she needs to supplement a daily diet of maize porridge. Lack of access to animal milk was the primary cause of her malnutrition last year when the drought slowed cow milk production in the southern pastoral areas of Ethiopia. With supplementary feeding for the cattle, milk production increased and Lokko’s health improved.  

Malnutrition accounts for 53 percent of infant and child deaths in Ethiopia and children in pastoralist communities are among the most nutritionally vulnerable in the country due to recurrent and prolonged periods of drought. The lack of rainfall devastates fodder and water sources for cattle and other animals, decreasing milk production and putting children under five at risk of severe malnutrition.  

For decades, Save the Children Ethiopia has been working with pastoralist families in Ethiopia to help them plan for, manage, and recover from drought emergencies. While we cannot stop droughts, there are successful strategies to lessen their impact.

One significant challenge in responding early to a severe drought is getting needed resources to communities fast. Speed is critical to preventing malnutrition. In the past, to receive disaster-related funding, Save the Children and other groups had to make new applications for funding to the U.S. Agency for International Development (USAID) and other donors, which often takes weeks or even months to process. This has been necessary because USAID and other donors historically have run emergency and development programs on separate tracks with separate funding sources, application processes, and program objectives. This has meant that even when we see a drought coming, we don’t typically have the flexibility to reprogram resources or receive new resources quickly in order to avert severe hunger and lack of nourishment, despite having existing relationships and funding mechanisms in place.

USAID is changing this way of working. Today USAID will unveil a new resilience strategy to support chronically risk-prone communities in between, before and after the repeat cycles of disaster. Furthermore, the agency will begin to broadly apply instruments, such as the “crisis modifier”, to quicken the pace of disaster response in the Horn of Africa and in other regions. The crisis modifier is a program component written into a cooperative agreement targeting drought-prone areas. USAID has integrated this option into development programs to reduce the processing and approval for emergency funding, even before a disaster strikes.

USAID already has implemented the crisis modifier successfully in my country for years. For example, in a project that I help manage, called “Pastoral Livelihoods Initiative,” or PLI, funded by USAID, the crisis modifier can make the difference between life and death for livestock – and malnutrition for kids. When the drought hits, the crisis modifier allows emergency programs to begin immediately by adding funds provided by USAID’s “Office of U.S. Foreign Disaster Assistance” (OFDA), to our existing PLI grant enabling Save the Children and our project partners to address the crisis early and limit its effects. The emergency funds help to prevent livestock loss through activities such as supplementary livestock feeding and commercial destocking to help families sell livestock ahead of a drought and then replace them after the drought. In response to the emergency in 2011, USAID programmed approximately $1.6 million through the crisis modifier to the consortium led by Save the Children under the second phase of the PLI project. As a result, this project was able to lessen the impact of the drought for more than 180,000 people. 

USAID is not planning to create a new bureau to implement their resilience agenda, but instead will bring all bureaus together- OFDA, Food for Peace, Global Health, Food Security, Climate Change and others -- to do more joint problem solving and planning. Instead of sending multiple teams out to target countries to complete separate analyses and action plans, USAID has launched “joint planning cells” from these bureaus to connect staff in the field and in Washington. These joint planning cells set objectives, design projects, and develop procurements around the same problems of community vulnerability, looking at both immediate and long term needs. This joint approach appears to be paying dividends.

While recognizing that the resilience approach, crisis modifier, and joint planning cells are not yet standard practice across USAID programs, I believe they show good progress in the right direction. While developed initially for the case of Ethiopia, USAID is looking for ways to introduce the crisis modifier to other disaster-prone countries around the world. Just in the Horn of Africa, USAID is seeking to directly benefit 10 million people and reduce the numbers of people that need emergency assistance by one million over five years through resilience-focused programming.

We as Ethiopians feel that our government and local institutions should increasingly lead, manage, and apply these disaster risk management techniques in a way that is most appropriate for our communities. Moreover, we need to create early warning systems for livestock crises and community-based resilience funds that are coordinated with the Ethiopian government’s emergency response. Already the Ethiopian government has adopted some PLI best practices in its national emergency livestock guidelines.  

USAID must play a strong leadership role with the Ethiopian government and other donors to ensure that resilience is not just another fad but a meaningful and sustainable step forward in changing how all national and global institutions address recurrent crises. Kids like Lokko are counting on it. 

Fighting global poverty with locally led strategies

Mathew Pickard, Malawi Country Director 

September 25, 2012

Lilongwe, Malawi

In 2008 Malita Chimwemwe was six-years-old living in the remote village of Mayaka. Her family was hit by chronic poverty and HIV/AIDs. Malita was in first grade at the local primary school but was speech-impaired. She was lucky; her village was part of Save the Children’s early childhood development (ECD) sponsorship program and through this program, Malita attended a community-based center where she was given speech training. Government-supported community health workers provided Malita’s family with medical assistance.  

In Malawi needs such as Malita’s are widespread.  One child in eight dies before reaching five years due to poor health or nutrition. Most Malawian mothers have to carry their children on their backs for long distances to seek health care. Free primary education is offered in Malawi but face declining standards and high drop-out rates. Malawi’s government needs and welcomes donor support, but U.S. government-funded programs, including those aimed at reducing poverty, have not always aligned with Malawi’s needs at the community level.

Requirements set in Washington– such as congressional earmarks and global targets --have at times constrained the ability of the U.S. government, the national government and partners in country to address Malawi’s community health and education needs. Over 80 percent of U.S. foreign assistance funds are directed to specific programs before they hit the country level. Pre-determined funding allocations often undermine the ability of the U.S. government and partners to provide assistance when, where and how it is most needed.

Save the Children Malawi has been involved in a new USAID initiative that is trying to change this and better connect U.S. foreign aid decisions to local needs and priorities. As part of its “Forward Initiative,” the U.S. Agency for International Development (USAID) is creating a five-year Country Development Cooperation Strategy (CDCS) in Malawi to increase country-driven programming. Working closely with host country governments and citizens, civil society organizations, other donors and U.S. government agencies, CDCSs are being developed at the majority of USAID’s country and regional missions worldwide. A goal of the CDCS process is to actively take into account the rights and interests of the country’s citizens.  In Malawi, this means a greater sensitivity to the development needs of citizens at the community level, positively impacting more vulnerable children like Malita.  Seventeen CDCSs have been approved so far, with a total of 73 expected to be completed by the end of 2013.  

Community consultation is not new to USAID, but what’s different about the CDCS process in Malawi has been the depth and reach of these consultations. For example, earlier this year, USAID partnered with the University of Malawi’s Chancellor College to convene citizen groups across the country at the national, district, and village level, in order to capture the voices of a wide range of people. This process is also expected to inform the government of Malawi’s own programs, policies and services, leading to better country-led development over the long-term.

The CDCS process in Malawi is still underway. If the initiative moves ahead as planned, and the people’s voices are listened to, U.S. development budgets and resource allocations in Malawi will be driven more by localized strategies and plans developed by Malawi’s citizens than by a top-down approach out of Washington. This is not just a matter of principle, but of impact. When local communities and governments have a sense of ownership over development, they invest their own energy and resources to make it successful.

For the CDCS process to accomplish its purpose, CDCS consultations should be broad and deep in all countries and involve communities, government, and other development stakeholders. USAID missions in the other countries must create opportunities for genuine engagement at the community level and potential for influencing national government priorities – as in Malawi. 

Aligning the U.S. government’s poverty reduction and community development efforts with the needs and priorities of Malawi’s citizens will lead to better futures for not only thousands of children like Malita, but for the nation as a whole. 

In 2008 a Malawi government official said, “If each country was given a chance to really prioritize what it wants, then we could make a difference in poverty”. With this new U.S. government strategic planning and budgeting approach, Malita Chimwemwe and other citizens in Malawi may have a greater voice in their fight against poverty. Today, as Malita moves to grade four, she can look at her future with more hope and confidence that her voice and that of her community will be heard.

Moving Local Organizations into the Driver’s Seat

Carlos Cardenas, Guatemala Country Director  

Guatemala City, Guatemala

July 18, 2012

Sometimes the best way to serve families over the long haul is to step back. A recent change to U.S. foreign assistance policy is putting more local organizations in the lead on development projects around the world.

In Guatemala, chronic malnutrition keeps half the country’s children from developing properly. That fuels a vicious cycle of poverty that hurts children in rural, indigenous communities the most. U.S. investments to break this cycle have helped countless children and families, but new reforms mean Guatemalans will play a bigger, more sustainable role in fighting the worst rate of chronic malnutrition in the Western hemisphere.

Save the Children has worked in Guatemala for 14 years with a variety of public and private funding to help poor populations overcome the impact of poverty and three decades of civil conflict. As an international nonprofit humanitarian and development agency, we work alongside communities to implement integrated programs that improve health, nutrition, economic opportunities, disaster risk reduction, democracy and governance.

For the last five years, Save the Children was the prime recipient of funding from the U.S. Agency for International Development (USAID) to run a major food security project. In tandem, a local consortium created by Guatemala’s largest export corporations called AGEXPORT was running small scale projects with USAID funds opening up markets for poor rural farmers.  

As a result of USAID’s policy called Implementation and Procurement Reform, AGEXPORT is about to move into the driver’s seat. Under this policy, USAID aims to spend 30 percent of its resources on local institutions by 2015. In Guatemala, USAID has required that a local organization be the prime funding recipient in a new Feed the Future project called “Rural Value Chains.” AGEXPORT has been selected to take the lead and AGEXPORT has asked Save the Children to play a supportive role by providing key technical support and institutional capacity.

We know that improving farmers’ access to markets leads to greater, steadier income through the year and--critically for children--to improved nutrition for their own families. 

If the new project moves ahead as planned, AGEXPORT will bring its expertise with domestic market to the partnership, and Save the Children will bring our experience improving children’s nutrition and food security.

AGEXPORT’s selection as the prime grantee will also give the organization the opportunity to build capacity and institutional expertise to lead increasingly large-scale projects. 

That bodes well for the future.

In the next grant cycle, I suspect that AGEXPORT may not need Save the Children or any other international NGO to improve conditions for Guatemalan farmers and their children. And Save the Children can move on to another area where our technical expertise and services are still truly needed. 

Working ourselves out of a job is a development success.