“Should I Start an NGO?”

This post is by Kirk Dearden. For more about Dr. Dearden, see here.

Are you starting your own NGO? Before you do, ask yourself these questions. If you answer “no” to most questions, maybe it would be better to work with an NGO whose programs do address these issues…
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The broader health and development context
• Do efforts to promote health and well-being focus on a range of illnesses rather than specific diseases (e.g., HIV/AIDS, malaria)? NOTE: in many instances it is appropriate to focus on a single disease but a disease-specific focus shouldn’t be the norm
o What specifically does the NGO do to examine and address other (often larger) causes of sickness and death?
• Do program interventions focus on broad, long-term development or are they limited to a single cause (e.g., disaster relief after the Asian tsunami)?
• What models of development do NGO staff use as a means of framing their work? Are they largely Western in their orientation? NOTE: in some circumstances this may be appropriate

Program strategies including Information, Education and Communication (IEC) materials
• Has the NGO reviewed the “grey” literature for successful training manuals, counseling cards, job aids and any additional, relevant materials that others have already developed?
• Have project staff documented program successes and actively shared reports, training manuals and other materials with NGOs, cooperating agencies and donors?
• Has the project gone beyond “educating” (sharing information) to help individuals and institutions change their behaviors?
• To what extent are individuals and institutions allowed to “practice the practice” rather than simply hearing what they are supposed to do? NOTE: individuals must be given the opportunity to practice the optimal behavior over and over again before successfully adopting it
• Is the project tailored to the special needs of different groups or do staff adopt a one-size-fits-all strategy?
• Have successful local practices (i.e., “positive deviant behaviors”) been identified in every community—thus helping individuals gain ownership of their own development—or are successes in one community simply disseminated to other areas?
• Are interventions evidence-based? For example, the most effective child survival interventions include immunizations, exclusive breastfeeding, insecticide treated nets and so on. Do NGO staff identify and promote behaviors that are known to make a difference?
• Do interventions over-emphasize technology?
• Have NGO staff identified which social forces encourage/discourage individuals from practicing optimal behaviors? If so, how specifically do program activities address these facilitators and barriers?

Staffing and other institutional matters
• Does the NGO rely mostly on local talent or are staff “imported” from the US and elsewhere?
o Do US-based staff replace local staff?
o If staff aren’t local, how long have they been in-country? Long enough to appreciate customs, culture and program successes?
• Have staff from “northern” and “southern” countries received professional training in:
o development?
o public health?
o cultural sensitivity?
o cross-cultural communication?
o policy or other relevant topics?
• Have staff from “northern” countries brushed up on local politics and history?
• Do staff from northern and southern countries have job descriptions?
• Do staff have training and experience that is relevant to their job descriptions?
• Does the NGO foster “south-to-south” dialogue and learning? For example, are field staff from Haiti encouraged to travel to Mali to share program successes and vice versa? NOTE: too often, technical assistance is “north-to-south”
• If the NGO is working in industrialized and less-industrialized settings, are successful programs from “southern” countries (e.g., the use of oral rehydration salts and microcredit—both from Bangladesh) considered for use in “northern” countries?
• Does the NGO have adequate logistic and technical backstopping in-country as well as from a home office (if applicable) to truly offer state-of-the-art programming?
• Does the NGO have a strategic plan for 1, 3, 5 and 10 years?
• Is there broad agency buy-in for the strategic plan?

Local capacity building
• What long-term training is available to develop in-country talent and build institutional capacity?
• Do such training efforts capitalize on local knowledge? If so, is there an explicit effort to train “non-indigenous” staff (e.g., from the US) in locally identified best practices?
• What is the NGO’s exit strategy? (shorter isn’t always better but staying in a country 15 to 20 years or more suggests that the NGO might not have done enough local capacity building)
• How will program efforts be sustained once the NGO leaves?
• Is the NGO sufficiently committed long-term (in a given country or globally) to making a difference or are most activities short-term (i.e., weeks or months)?

Assessing impact
• Have programs been implemented according to plan (for example, according to well-established protocols)?
• What efforts has the NGO made to assess the impact—both positive and negative—of their program?
• Are baseline, mid-term and follow-up assessments carried out…preferably among individuals with access to programs and controls?
• Are most/all other standard procedures for data collection followed? There are many standard procedures which should include the following:
o A careful assessment of target audiences
o The use of quantitative and qualitative data
o Randomization of respondents
o Use of experienced interviewers
o Adequate training for interviewers (usually 3-4 days)
o Expert data analysis
o Usable results
• Do locals participate in data collection and analysis/interpretation?
o To what extent are locals allowed to discuss the implications of findings?
• Does the program have an impact?
o If so, are results plausible (i.e., can we rule out most/all other explanations for impact, for example, simultaneous interventions from the government or other NGOs)?
o If not, why not? What adjustments to programs are needed based on results from the evaluation?
• How cost-effective is the program?
• Some program “failures” result from institutional culture (e.g., bureaucracy and ethnocentrism). To what extent has the NGO assessed how institutional policy and behavior negatively affect development?
• What efforts are in place to ensure program quality on a routine basis?
• Are the NGO’s program findings replicable in other contexts? If yes, what contributes to their replicability? If not, why not?

Large-scale impact
• Are programs reaching just a few individuals or many (perhaps tens of thousands or hundreds of thousands)?
• Has the project been extensively pilot-tested before scaling it up?
• Is the NGO partnering with other organizations to widely disseminate successes?
o With which organizations is the NGO partnering? The Ministry of Health? Other NGOs (both local and international)? NGO networks? UNICEF? The World Health Organization? Other UN organizations?
• Has the NGO identified successful program strategies (both in-country and globally) that other NGOs and cooperating agencies are already carrying out? While there are no program strategies that are universally applicable, the following have been used successfully (and documented). NOTE: There are too many good strategies to list here:
o Community mobilization (for example, the WARMI project in Bolivia that mobilized families aroung maternal health)
o Negotiation (provides individuals several options they can try when adopting optimal behaviors)
o ORPA/FAMA for counseling cards (identifies context-specific facilitators and barriers to behavior change and commits individuals to trying a new practice)
o Positive deviance and other assets-based community development approaches (helps identify local successes then spreads them)
o Doer/Non-doer (similar to positive deviance)
o Support groups (for example, mother-to-mother support around breastfeeding)
o Social marketing to change norms and promote healthy products and ideas
o Pre-service and in-service training for clinicians and other health and development professionals
o Policy reform (for example, PROFILES, REDUCE, and ALIVE to improve national policies regarding complementary feeding and maternal and neonatal mortality)

Funding
• What is the funding source for activities?
o Is it large enough to make a difference (for example, does it allow the NGO and its partners to operate at the family, community, district and national levels)?
o Are there any conflicts of interest (e.g., promoting breastfeeding with funding from Nestlé)
• To what extent have donors been sensitized to health and development issues?
• Does funding come from an array of donors? NOTE: over-reliance on a single donor can unduly influence NGO direction (for example, sponsorship programs for children often lead to curative care for individuals rather than community-based prevention)
• Is funding sustainable?
• Is funding largely designed to address immediate (short-term) needs or is it for building systems (e.g., training development practitioners, improving quality of care, institutional capacity building, “mainstreaming” of program innovations)?
• Is seed funding available to test new ideas and start innovative projects…even if there’s a risk that things won’t work out?

Responding to local and global needs
• How do NGO staff determine what is needed? Do they conduct extensive needs assessments and if so, whose needs do they assess (are the poor, women, children and other marginalized groups given a voice?)
• Do NGO staff conduct a thorough review of the literature (local and otherwise) to determine prevailing problems (for example, acute respiratory infections kill 7 times as many children less than 5 years of age than HIV/AIDS)
• Does health promotion require project staff to better understand individuals’ specific circumstances before attempting to improve well-being?

Gender sensitivity
• As part of program activities, do those with expertise in gender actively involved in planning, implementing and evaluating programs?
• Do NGO staff evaluate both the positive and negative impact of programs women, men, girls and boys?
• As appropriate, are programs sensitive to the special needs of adolescents (for example, offering separate clinic hours for family planning services)?
• As a result of the project, do women’s workloads become more burdensome (new “opportunities” to participate in micro-credit, adult literacy and health promotion may overtax women)
• Is the project largely focused on addressing practical gender needs (short-term activities that help women and men fulfill their already defined gender roles such as installing a pump to make water fetching easier)?
• To what extent does the project address strategic gender needs (helping communities identify unequal relations and changing power and control to benefit both men and women; for example, helping communities think through who should fetch water)?
• Does one sex, age group, race or ethnic group benefit at the expense of others?
• Does the project subject women or men to increased risk (for example, some studies show that offering women microcredit increases domestic violence)?

Treating others with respect
• Are locals seen as equal partners in development or simply the objects of pity? NOTE: programs that are meant to “serve” and “help” others are often patronizing
• To what extent has the NGO mobilized locals around issues they feel are important?
• Do NGO staff see current poor conditions as largely the fault of individuals (for example, because of laziness) or do staff account for the broader forces that keep people from reaching their full potential (i.e., corrupt governments)?
• Does the project focus on bringing about change at all levels (government, institutions, families, individuals)? NOTE: projects that address multiple levels are often more successful than activities focusing only on individual behavior change
• Are program staff largely driven by charity, justice or both? NOTE: William Sloane Coffin once said “Charity seeks to alleviate the effects of injustice; justice seeks to eliminate the causes of it. Charity in no way affects the status quo, while justice leads inevitably to political confrontation.”
• What “strings” are attached to programs? For example, do staff require that locals adopt certain beliefs (e.g., Christianity) in exchange for access to programs?
• Are community members encouraged to make a contribution to collective well-being or does the NGO provide handouts? NOTE: in Mali, Save the Children enters partnerships with the community. Community members build latrines, pay the salaries of local teachers, and provide rooves for village schools. Save the Children constructs schools, recruits students, helps communities develop school curricula and trains teachers
• Is training based on principles of adult learning theory (capitalizing on the life experiences of those participating in training; allowing individuals to see, hear and do, etc.)
• Does the NGO offer praise to individuals who change their behaviors?
• Do NGO staff adopt the same behaviors they promote (e.g., correct and consistent condom use)?
• Some staff members’ attitudes may have a negative impact on the program’s success. What staff member beliefs might jeopardize impact?
• Who ultimately is responsible for the success of the project? If not locals, why not?

Welcome, Kirk!

I am very pleased to announce that Dr. Kirk Dearden, a public health professor at BYU, will be posting on this site occasionally. Kirk has given me valuable advice based on his extensive global health experience (while also playing a mean game of racquetball). His online bio reads:

For 12 years, Dr. Dearden worked as senior research and evaluation specialist at the Academy for Educational Development, Johns Hopkins University (JHPIEGO), Save the Children Federation/US, and the International Center for Diarrheal Disease Research, Bangladesh. He also carried out post-doctoral research with Johns Hopkins University’s Bloomberg School of Public Health. Dr. Dearden has consulted on applied research with the Academy for Educational Development, Save the Children Federation/US, Freedom from Hunger, the BASICS Project, USAID (including projects to assess the impact of microenterprise services), and the World Health Organization. He has worked short- and long-term on development projects in more than 20 countries in Africa, Asia and Latin America.

Welcome, Kirk, and thanks for joining me!

Top 5 Global Health Stories of 2006

Good post summarizing important global health stories of 2006 here.

HELP WANTED! update

A “HELP WANTED!” update can be found here.

Packards’ Experience with the Measles Initiative

NOTE: This is the final of a series of posts on measles. I have already posted a brief summary of the global measles problem, an introduction to the LDS church and the Measles Initiative, and an evidence-based answer to the question “How effective are mass measles vaccination campaigns?”

There are a handful of people that I have either heard about or met that leave such an impression on me that I am left with no other choice than to evaluate my life and make changes. The Packards fit into that category. They were kind enough to answer I few questions I had about their involvement in the Measles Initiative.

Last summer, Blair and Cindy Packard served a 3-month mission for the Church of Jesus Christ of Latter-Day Saints in Mozambique working with the Measles Initiative. Prior to that service, they travelled to to southern Africa multiple times to found and organize Care for Life. Blair’s professional background is as a physical therapist, and Cindy worked as a midwife. They currently serve as in a volunteer 3-year capacity as mission presidents in Mozambique. You can learn more about the Packards here, here, and here. Thanks for joining us, President and Sister Packard!

1. Describe your daily activities with the Measles Initiative. Who were your partners?

Let me answer the last part of this question first, which will lead to what we actually did for our 3 months in Mozambique. The partners in the global measles and polio campaign are several, depending the nation in which the work is taking place. Worldwide partners include the American and International Red Cross and Red Crescent organizations, the Center for Disease Control, UNICEF and the World Health Organization. The Church of Jesus Christ of Latter-day Saints got involved about 3 years ago in the African phase of the work with an initial contribution of $3 million and the commitment to mobilize its members in each nation to assist primarily in social mobilization. This support from the Church has been renewed and is ongoing.

In each country a major partner is the local ministries of health or other ministries related to the health and social needs of their people. It was with this national ministry in Mozambique that we worked most closely. In fact, we were members of the national micro-planning committee which met weekly to plan and review every detail of the campaign. In these meetings we shared what the Church could do to assist in the campaign. This included donating prepared television and radio spots and purchasing airtime for these spots, developing posters and flyers for the campaign, developing ID badges for our volunteers and other workers, and contributing volunteer time by our Church members in a variety of ways.

Our work involved “social mobilization” which included getting the message out about the campaign and getting the populace to the immunization stations. Specific activities included the following:

• Contacted Olympic Gold Medalist Maria Matola from Mozambique and obtained her willingness to participate in promoting the campaign. While she was in the US for training we worked with her and the Church Media department to film and record TV and radio spots in Portuguese and English. These spots were later modified on site to meet local needs. We negotiated with local TV and radio stations to air the spots.
• Church Media provided two other radio spots that had been used in other campaigns successfully. These were translated to Portuguese and reproduced for use in Mozambique.
• In cooperation with the Ministry of Health we designed and produced 11,000 large campaign posters for use throughout Mozambique. These poster featured Maria Matola and our 6 year old daughter, Lindy, running together to “win the race against Measles and Polio.” The posters contained dates and other information about the campaign. The posters were distributed by the Ministry of Health and were a very visible part of the campaign.
• We organized a training program for all our Church members that was provided to each congregation. The program had two purposes – to educate our own members about these two diseases and their prevention and two encourage their participation as volunteers in encouraging their neighbors and others to have their children immunized.
• We organized over a thousand volunteer members to participate in various ways in the campaign. This included door knocking with campaign literature, distribution of fliers and posters, develop of small skits or theatre to dispel some of the myths of immunization, and organization of members who volunteered or were hired as workers at the immunization posts throughout Mozambique.

2. Describe your successes and why you think those efforts were successful. Are you aware of any data?

The overall success rate of the campaign in Mozambique was nearly 94% of the target population. The target population were children under 15 and these 9 million plus children represented 45% of the total population of Mozambique. Success goes directly to Dr. Mark Grabowsky’s approach. Dr. Grabowsky is from the Center for Disease Control (and was on loan to the American Red Cross during the campaign). It was he who first conceived of the initiative and a strategy that was based on “partial ownership of complete success instead of compete ownership of partial success.” It was an experienced group of global partners all working together with local ministries of health toward a goal of “complete success.” The logistical challenges in each nation are significant, but each group working together, contributed to the campaign success.

Another success that goes to the heart of the Church’s involvement relates to the approach taken. Initially a request came to the Church from the American Red Cross just for a financial contribution. That invitation was accepted. But it was Church president Gordon B. Hinckley’s foresight to involve members and contribute in ways more than just monetarily that made the biggest difference.

3. What were some of your major challenges?

Perhaps the biggest challenge from our perspective was just the coordination of such an effort. Bureaucracy always plays a part in such a large undertaking and did in many instances in the campaign in Mozambique. But, overall, there was a marvelous degree of cooperation and energy. It was particularly rewarding to observe at many of the immunization sites and ask some of the mothers who were bringing children why they were doing so. It was clear there was both an awareness of the diseases and a strong desire to see their children safe or provided with a better life than parents had. We saw one mother with Polio who used a hand crank scooter to pedal several kilometers and bring her small child to get immunized. We saw children carrying younger siblings on their backs and even young children coming by alone to get their immunizations. (See attached photos)

Initially we thought that getting the information out to more rural areas would be the biggest challenge. Contrary to that, the lowest success rates were in the largest metropolitan area in Maputo. Better organization by more rural units and public indifference in the cities were probably contributing factors to the challenge.

Unfortunately, I was not able to attach some of the accompanying photos. I will figure it out soon!