Talk to the Emir to save new-born chilrden

If you want to protect new-born babies from dying of preventable cause, who do you talk to? The Ministry of Health, right? Because it is their mandate. And their expertise. And they get the funding to do it. Well, do they?

Nigeria has the highest number of maternal and newborn deaths of all African countries, with 33,000 women dying during pregnancy and childbirth every year and 251,000 babies dying in their first month of life – often due to preventable and treatable causes. Katsina State in the North is one of the states where the situation is especially dire, because on average people are poorer and because the state is mainly rural, so hospitals and health centers are few and far between.

My colleagues at Save the Children wondered: Is it really enough to speak to the Ministry of Health? In the past they had observed that making a good plan, submitting a solid budget is one thing, whether or not the funding actually gets released to the agencies is a completely different story. So they asked me to map out: “Who influences the budgeting and the release of funds for newborn survival activities in Katsina state?” I am lucky to have well trained Net-Mappers on the ground, Amina Yauri Mustapha and Haj. Amina Lawan interviewed a whole range of people in Katsina, and this is what we found out:

 

Katsina Save Children DisbursingKatsina Save Children Planning Budgeting

Links: Black - Hierarchy, Red - Funding, Actors: Yellow - Government, Red - Donors, NGOs, Projects, Grey - Others, size of actor - influence

Two completely different sets of actors influence making the plan on the one hand and disbursing the money on the other. The size of the dots indicates the influence of actors on the specific issue (on planning/budgeting in map 1 and on disbursing in map 2). As you can see on the second map, the governor, executive council and political associates of the governor have a stronger influence than the Ministry of Health. And the Ministrie’s influence is on par with that of the governor’s wife. And even the Emir (here called “religious leaders”) has far more influence on the disbursement of funds than the front line health providers – the people who do the job (State Primary Health Care Development Agency – SPHealthDevA and Health Services Management Board – HealthSMBoard).

What does this mean for a successful advocacy strategy aimed at getting the money to implementing agencies? Read the full case study here (1845 KB).

Advocacy Judo vs. Advocacy Weightlifting

Image

Advocate, don’t break your back (picture copyright by Mr. Moss on flickr)

Whether you are promoting new-born survivial in Nigeria, gay rights in a US church or agricultural policy reform in Bangladesh, you will always encounter people with a lot of influence on the outcome who couldn’t care less about your cause. How do you deal with a very powerful actor who doesn’t share your passion? The typical advocate’s approach is:

Make them passionate about your cause! Convince them of the importance of [fill in the blank].

That’s the weightlifter’s approach to advocacy. You carry the whole weight on your shoulders. And making someone care about something they don’t care about can be very heavy lifting. Advocates tend to be so passionate about their cause that they often don’t see how any good person could not care about their cause. How could anyone be against newborn survival or against stopping the spread of HIV? So if the governor, ministry of finance, parliament, media only knew about the problem, if we gave them enough information they would have to act and support us, right?

Well, no.

Unfortunately that rarely happens. Because there is a big difference between accepting that something is a legitimate concern and actively doing something about it. And to do something about it, you have to either become very passionate about it. And everybody who ever had their love rejected, knows: I can not make you passionate. I can not control someone elses passions. Or, and that’s where advocacy judo comes in: You have to use the power of their existing passions, goals and incentives to move them in your direction.

The most elegant throws and moves in Judo require very little energy from the one who is throwing, you just take the energy that is directed toward you and redirect it. You don’t ask: “Does my opponent really want to land on the mat, is flying through the air their passion?” You just look for the energy, no matter what it is directed toward, and channel it for your purpose.

If you want more funding for state level maternal health projects and the governor holds the purse strings, just stand there and watch him for a while, before you even start talking about mommies and babies, the suffering of the people and his moral obligation. Figure out his passion, what he puts his energy in, where his incentives lie. Then, with your ultimate goal in mind, redirect his energies. How do you do that? By reframing your goals and connecting them to his passions.

I don’t know your governor, but his energy could be directed toward

  • being re-elected
  • balancing the budget
  • his state looking good in competition with others
  • having great connections to international donors
  • being personally recognized and in the media all the time etc.

Now your task as a judo advocate is to develop a throw (storyline) where your goal (money for maternal health activities) achieves these things for the governor. If re-election is the issue, he needs to understand how much his constituents care about the issue. And that maternal health is not just a women’s issue but a family issue. If it’s balancing the budget, show how little investments lead to great impacts – also as compared to spending the same money on something else. If he is competitive with other states, statistics are your friend, set different governors up for a race: Who improves maternal and newborn mortality the quickest? You might even be able to give the winner a price. And you’ll definitely be able to get them a lot of face-time on the media. Developing great connections to donors and other international actors is something that is especially easy for you if you are funded by or work for an international organization. If this is one of your governors desires, help him out there, introduce him.

The indifferent influencer in your field might be a different one and with different drivers. But whatever their drivers are (as long as they don’t go against your conscience), use their energy to achieve your goals: Your sport should be judo, not weightlifting.

We’re all just half-angels

Angle, Devil or what? (copyright by kcmckell on flickr)

Researching public health politics in Africa in the daytime and re-reading Tortilla Flats by Steinbeck at night. And both point from different directions toward my most difficult challenge in trying to understand the world: We are all just half-angels. Most of us want to be good people, or to at least think of ourselves as good people. And we have selfish needs and wants and evil impulses as well. The characters in Tortilla Flats are all charming drinkers who come up with the most twisted arguments for making their selfish behavior sound like they are doing the other person a favor: Everybody knows that money doesn’t make you happy and separates you from your poorer friends, so by not paying rent to their friend Danny they actually save him from this sad and lonely fate…

Now what do these guys have in common with health workers and advocates in Africa? Not much from the first look of it, because the outside observer can easily come to the conclusion that Danny’s friends are the bad people while people who dedicate their lives to health care in Africa must be angels. Steinbeck writes most of his novel from the perspective inside different people’s heads, so you can see how they negotiate their different impulses and how much thought they put into getting what they want AND feeling like good people at the same time. Obviously, it is written in a humorous and exaggerated way. But is it so far from what we all do every day?

When I look back at my first hand experience in and research about health systems in different African countries, I realize that people enter the health professions for a broad mix of reasons, ranging from “saving babies’ lives” to “income”, “power” and “status”. And while most professions carry mixed motivations, in a field like health they are especially obvious, because what you can achieve is so large. Imagine, you can save someone’s live! What a large and gloriously good thing to do. But also: How powerful it makes you, when everyone knows you are the one who can save lives – how tempting to use this power for your own benefit (e.g. by demanding excessive charges or favors). And where there are temptations (call them incentives, if you are an economist), people will give in to them. Not all will give in to the same extent, but very few will completely resist, especially if they know that their behavior will not be sanctioned. At the same time, they will try to keep the self-image of being an ultimately good person. And for many, the result will not be too far from what Danny’s friends do…

But why is this my biggest challenge in understanding the world? Because I love a clear and simple story. I want to be able to have clear feelings and unambiguous answers. My clients like them too, by the way. So I want to be able to say: This system or person is corrupt and not working. And this system or person is not corrupt and working very well. These are the good and these are the bad people, the angels and the devils. But if I delay putting things in boxes labeled “good” and “bad” and instead just allow them to tell me their story and observe what they do, I realize that we are all just half-angels. Yes, I have seen some people with a much larger leaning towards selfless or selfish behavior than others. But another typical character I have met a lot in my research is the powerful person who wears both wings and horns in XXL, the very charismatic, well connected guy (or lady) who achieves far more for “his people” than others in his position would, and, at the same time, lines his pockets with more bribes and favors than anyone else could extract from this position. How am I to think and write about him? What do I recommend? Do we want a smaller person in his position, who achieves less for his people and his own pockets? May we find a full angel, or let’s say a three-quarter one to replace this guy and tilt the scale a bit towards public benefit? Can we change the system, it’s incentives and opportunities in a way that reigns in the selfish behavior better? Or do I just decide, depending on whether I am a cynic or romantic, to close one eye and only see either the wings or the horns and praise or condemn wholeheartedly?

The politics of implementation

Tetanus vaccination - cost effective... but still, who's gonna pay for it? (copyright hdptcar on flickr)

Last week I went to an interesting event by the Society of International Development (SID) about innovative approaches in health system financing in developing countries. The speakers told us about new and more market oriented approaches, local experiences and international trends etc. But what I found most interesting happened in the discussion, when one of the audience members got up and said: “In the end, it’s all about the politics of implementation”. The whole room full of international health and finance expert nodded so vigorously that I felt like the ground was shaking. Yes, everyone who has been in the field and tried to reform pretty much anything, knows that it is great to have sexy innovations or reliable tried and tested approaches to offer. And it is important to push the envelope in trying out new things and also continuing to do (and fund) the approaches that have worked in the past. But that is not at all enough to achieve project success and change the world for better. If you get stuck in the politics of implementation, your best concept will just remain that, a concept. Or, a “plan” as a Ghanaian colleague once defined it for me: “It doesn’t have to be realistic, it’s just a plan.”

Now after I left this room where everyone seemed to agree that you won’t get anywhere without taking politics (in the broadest sense) into account, the question I had was: Why then is it always treated as an afterthought, a surprise, something you have to muddle through once you (Surprise! Surprise!) encounter it? Why is: “How we’re gonna deal with the inevitable politics of implementation” rarely a chapter in project proposals? And why are there few better, more formal or teachable methods than  “muddle through” and “use your intuition/experience/inherent status”? I find this especially surprising as this insight is not limited to public health financing: You could say “In the end it’s all about the politics of implementation” in just about any room of development practitioners and people would agree.

It’s say: If that is one of the main things holding you back, look it in the face, anticipate it, make a plan (I’m being German here, as always, I mean a plan with concrete actions, money and deadlines attached to it), learn and teach methods that help you deal with politics and go ahead, deal with them.

Small town NetMapping: Can informal relationships be captured within institutional analysis? (guest post by Jody Harris)

My PhD research in Zambia is an evaluation of an NGO program that aims in part to align and coordinate certain activities within the Ministries of Agriculture and Health for improved nutrition outcomes (both food and health being essential elements of good nutritional status, of course!). A key piece of information, then, is how are different players in these sectors interacting right now, and how does that interaction change over the course of the project? Enter NetMap.

The key to the alignment strategy being used in this project is to start at District rather than National level, to create a model of coordination that can be used to advocate for scaling up to other areas or even other countries. Ministry staffing is minimal at District level, so I aimed to interview everybody employed in each District Ministry, from the Directors down to technical officers (around 5 people per ministry), and to snowball out from there to anyone else who came up in the interviews as crucial to the process.

This being the first time I had used NetMap, I was unsure how it would be received- how would people react to being asked to give up an hour or more of their day to draw pictures with an outsider? In anticipation of rejection, I made sure the process looked as professional as possible- putting together a regulation NetMap kit, sending formal letters of invitation to interviews, hiring a highly professional local assistant, and dressing as smartly as I possibly could in sweltering pre-rains temperatures. But the method held true, and just following the steps from actors to links to influence engaged everyone from the moment we started- as I had been promised it would!

Being on a smaller scale than much national-level research I have seen that uses social network analysis, I had wondered if I could use NetMap at the individual level; that is, could I map not only the formal interactions but also the informal interactions between individual players within each Ministry, since it is very likely that personal relationships shape collaboration, particularly in such a small population as in the district capital (a small, one-road town). One of my pre-defined links therefore was informal interactions, and my questions attempted to probe whether person X might have family ties to person Y, or whether person A drinks in the evenings with person B. But it turned out in pre-test that even small-town rural Zambia had too many players in this field for everyone to know everyone; people knew which organizations were doing what with nutrition, but not who was doing it, and the method defaulted pretty quickly back to looking at organizations rather than individuals. Still a very interesting picture, but I wonder if there might be something in this for my future research…

So, now I have a collection of beautifully colorful maps to process and a good idea of local views on the alignment of sectors for nutrition in rural Zambia, so watch this space…

The Network of Europe’s E. Coli (EHEC) Crisis

Does this look like a killer? (picture by yogendra174 on flickr)

Network analysis is great for getting some clarity and a sense of direction in complex, messy, multi-actor situations, and I guess that is a pretty good description of the situation in Europe’s E. Coli outbreak (just how messy? These CNN and Newsweek articles give some insight). It’s a multi-actor situation, the actors involved include different government departments (e.g. for health, agriculture, trade) of different countries (Germany, where the outbreak happened, other countries that may or may not have produced the vegetable responsible) and at the EU level, everyone in the supply chain, from farmers to traders and food businesses to consumers, research organizations, media outlets etc.

But what makes this really messy, is the fact that these actors are linked by very different kinds of connections. There are the material flows of produce (infected or not) from farm to table. There is the movement of the infection through the system, with the bacteria sometimes connected to the produce, but now, further into the outbreak, more likely a person-to-person connection. As if this wasn’t complex and obtuse enough, the way that countries and the EU as a whole deal with this issue is structured by the administrative networks and hierarchies. And because multiple departments or ministries in multiple countries are involved, this is not just one hierarchical pyramid, where the person in the top position can decide what to do, but a number of (internally hierarchical) organizations, which are linked to each other by non-hierarchical links and somehow have to figure out how to collaborate quickly and effectively once new information becomes apparent.

And this leads us to the fourth kind of link we need to look at, to understand how this outbreak works and that is the information link: Where is new knowledge about sources, spread, effects and treatments produced and how does this knowledge reach those who matter, who tells decision-makers what they need to know to make good decisions, who informs (and doesn’t mis-inform) the media, where does the general public get their information?

Now imagine you sat down with a group of researchers, government and farmer representatives to map out the actors, how the produce flows between them, how the infection has spread so far, how they are connected in terms of hierarchy and coordination and where the information flows through the system. The resulting map might be so big and messy that it first blows your mind. But (even without mapping it) that is the reality that the decision makers on the ground have to deal with; under time pressure and with high stakes.

And as we have seen when mapping out the response to bird flu outbreaks, just putting this map together can help those involve discover crucial oversights and structural problems in the system. In Ghana, we were able to point out how the structure of the compensation schemes created corruption hot spots at the border and where structural holes led to a risk of communication breakdowns.

However, when reading about the outbreak, certain network links are in the forefront of everyone’s attention: The big question everyone is asking is: How does the infection travel through the system (did it ride a cucumber or a bean sprout)? And while this is one crucial question, the questions that will have a greater long term impact are: How ready was the system to deal with the outbreak? How did information flow and how are interventions coordinated? Jack Ewing hints at that in a New York Times article, pointing out that the federal decentralized system of disease reporting led to a crucial delay in understanding the scope of the threat. But to increase readiness for the outbreak of any contagious disease (be it the swine flu or bird flu or a new strain of E. coli) it is crucial to improve the information and intervention systems along with discovering the source of a specific outbreak.