A Surprise on Our Field Visit

After my group’s first day in the field, we stayed in the Mariampahar Catholic mission near the village of Baharwa. My husband Dave and I had stayed there on our first visit to India in 2008. The father remembered us and provided us with rooms to spend the night. The accommodations were well, Spartan and like 4 years ago the electricity was unreliable; we prayed for a slight breeze to come in through our mosquito nets. The mission sits atop a hill along with a church. On the other side of the

The Mariampahur Mission Stands in the Background

hill from the main mission building is a mission-run school that houses 500 boys and 400 girls, nearly all of them from the Santhali tribe, one of the tribal groups with which the project works.
In the evening the children walked around the outside of the church reciting and singing vespers. We stood at the edge of the church grounds and watched; when they were finished they charged at us to say hello. Interestingly, they have last names that indicate their tribe; the Regional Advisor working on the project who is familiar with the tribes asked them to identify themselves by last name, many of which she knew.

Vespers at the Church

In the morning, after breakfast of boiled eggs and garbanzo beans, another father took Dave and I on a tour of the school grounds. To our amazement, there stood all 900 students in perfect rows waiting to greet us. The father had organized a ceremony, complete with us sitting on chairs on the steps to the

School children greet us before school

school. We were greeted with a song sung by a small choir and the entire school reciting greetings in English called out by the father. At the end of the ceremony, the students placed wreaths around our necks; they waved good-bye in unison as we went to our waiting vehicle. What a surprising way to start our second day of field visits.Watch the signing children.

Grace Kreulen

Field Visits

Field visits are used to gather information from stakeholders and give life to the data collected for the final evaluation. For example, the final survey found that the percentage of children born in clinics or hospitals (institutional deliveries), one of the objectives of the project, more than doubled in the 5 years since the baseline survey. We went to the field to find out from staff, government officials and mothers what interventions of the project were most important for achieving results like this.

Interviewing a Village Health Committee

First, we have to get to the villages and institutions where the work was done. Now, like roads in most developing countries, the roads in rural India are a challenge to navigate. One challenge is presented by the conditions of the road, especially during the monsoon season: every pothole is a lake. At one point we did see a boy pulling tiny little fish from a large, muddy hole. The roads are also multi-use:

Sharing the Road

pedestrians, animals and people moving at all rates of speed on every imaginable kind of vehicle share them. We don’t watch the clock or the speedometer while we travel, we just stare in amazement at the life that is India unfolding at the side of the road. At this time of year the landscape is dominated by men and water buffaloes plowing and rows of women in colorful saris bent over stalks of rice that they are transplanting.

Transplanting Rice

We divided into three groups with 5-6 people per group. Each group visited different villages and toured facilities. Equipped with questions we developed and translated into Hindi, we fanned out across the district of Sahibganj; equivalent to an American county and home to about 1 million people. Each encounter was designed to have one questioner and two reporters. When we gather again at the main office, we will report our findings to the group.

Interviewing Anganwadi Workers in a Health Subcenter

Grace Kreulen

Review of the Final Data Evokes Strong Emotions

In the second workshop our job was to help the staff identify the most important activities of the project. These “gems” would focus our thinking on what could be generalized from this project to other maternal and newborn health projects. I used the acronym “ACES” to guide our thinking: Accomplishments, Challenges, Exports and Sustainability. Because there was significant improvement in 22 of 29 indicators it was difficult to choose one or two interventions that were the most important, so after discussion it became clear that the cross-cutting strategies were the ones most likely to rise to the top as being most effective.

The A-C-E-S Framework

As we reviewed the indicators one-by-one, everyone was touched by the success of the project. From the Directors point of view those many hours spent training, supervising and evaluating had paid off with remarkable improvements in newborn and maternal health as well as the capacity of the district to continue the activities. A consensus emerged that the partnership between the project staff and government agencies was crucial for success. Both groups were pulling in the same direction and as the project progressed, the government workers began to incorporate the strategies developed for the project into government programs. Grass-roots timed counseling was an important activity that led to significant improvements in indicators such as community-based antenatal care and post-natal visits with trained health workers. The health workers on the ground, called “Sahiyas,” came from the communities that they worked in and could deliver timed counseling to families in their homes. We plan to meet with Sahiya groups in our field visits.

A Group of Sahiyas

Grace Kreulen

The On-Site Portion of the Process Begins in Sahibganj

In the offices of EFICOR, in Sahibganj, the on-site project manager, directors and coordinators met to develop the process of gathering information that would support and amplify the data in the final KPC report. In the first day and a half I started with what I called workshops. Because there had been baseline and mid-term reports, many of the people were familiar with the general objectives of gathering qualitative information from the field. Nonetheless, we would spend the first half-day reviewing the objectives of the final evaluation and report. The second workshop was devoted to a final review of the data, determining stakeholder groups and developing field questions.

Street Scene in Sahibganj

My first step was to spend some time getting acquainted and re-acquainted with each other. The most popular personal item from my past was a wedding picture of my husband and me. Once the laughter died down, members of the team shared what working in the project has meant to them. Then we began our work.
One of the objectives of the final evaluation is for the staff to relate activities that had the greatest impact on outcomes. This was actually made more difficult by the fact that nearly all of the indicators had significant improvement compared to the baseline study that was performed 5 years ago before the project began. I had to work hard to get the staff to tease out the “gems” from all the interventions that they were involved in over 5 years. By using a combination of approaches including my role-playing an interviewer, we finally developed a set of questions that would be first translated into Hindi and then used to interview stakeholders in the field.

Role Playing an Interview

Grace Kreulen

The First Step: Meeting with Project Directors and Consultants

Project Directors

I met with the project directors from CRWRC and EFICOR as well as the consultant who wrote the final Knowledge, Practice and Coverage report. We analyzed the final data and discussed possible interpretations. Because nearly all of the objectives of the project were met, it was a pleasant meeting. What a joy it is to be the evaluator on a successful project that I have followed since its inception.

After the meeting we boarded the train in Kolkata for the 5 hour trip north to Sahibganj, the “district seat” of Sahibganj district where the project was carried out. We enjoyed 5 hours of “restful” sleep on the train before we arrived at 4 a.m. Our next step will be to begin meetings with project staff–the troops on the ground. Now i can begin to tease out the significant accomplishments of the project.

Grace in her sleeper on the train

Grace Kreulen

Final Evaluation of Child Survival Grant in Jharkhand

I am leading the final evaluation of a Christian Reformed World Relief Committee (CRWRC) child survival grant. I have arrived in Kolkata, India for review meetings with some of the project staff from Evangelical Fellowship of India Commission on Relief (EFICOR), CRWRC and an Indian consultant. After that initial step we will board the train to travel 5 hours north to Sahibganj, Jharkhand the district where the project is taking place. In addition to the work of an evaluation, we are planning a time of celebration with all the workers who made this project a success. Here in Kolkata, a large city on the border with Bangladesh, there are already reminders of the impact of poverty on peoples’ nutritional needs. The photo was taken across the street from my hotel.

Feeding the poor in Kolkata, India

Grace Kreulen

A Shift Towards NCDs?

Last week I had the privilege of attending the Global Health Council’s 38th Annual Conference in Washington, D.C. The conference focused on global demographic changes, which naturally result in a shift in the burden of disease as populations grow older. The key acronym of the week was “NCD,” or non-communicable diseases. As someone who has spent most of his professional life exploring ways to scale up proven interventions to fight infectious diseases in children (some of which are known as “NTDs,” or neglected tropical diseases), my first reaction was that the focus on NCDs would polarize the conference participants – NCDs vs. NTDs. One of my primary concerns was related to the scarce resources for global health and the concern that a focus on NCDs would divert resources – both human and financial – away from infectious diseases. In addition, I assumed that resources for NCDs would go to those who were living longer and more financially secure, which would overlook the poorest and most marginalized populations.

Recognizing the tension between the NCDs and NTDs, one of the conference co-chairs, Dr. Felicia Knaul (Director of the Harvard Global Equity Initiative), redefined the “NCD” acronym to represent the changing burden of disease by referring to “new challenge diseases.” Instead of focusing on the difference between communicable and non-communicable diseases, Dr. Knaul and the other co-chairs urged us to consider common obstacles and solutions that we all face. In particular, one problem that everyone encounters, regardless of the disease, is equitable access to healthcare. Those who are most marginalized have limited access to life-saving treatment and often die from preventable causes. This is true for both communicable and non-communicable diseases. For example, a child who is suffering from acute lymphoblastic leukemia has the same right to healthcare as a child who is suffering from acute diarrhea. Although the type of treatment may be very different, we should not evaluate a child’s right to quality healthcare based on the type illness. There is a need to strengthen health systems to provide quality, affordable, accessible healthcare that benefits all people who are suffering from all types of diseases. However, this will not happen by chance. Equity must be intentional. This is especially true when there are limited resources to address these new challenge diseases without neglecting the existing diseases that cause thousands of preventable deaths every day. We live in a world where the burden of disease is constantly changing and health systems are expected to adapt to these changes. In order to move towards a comprehensive, adaptable approach to health systems strengthening, we need to consider all health system components, processes, and relationships simultaneously and not as disaggregated parts. Although the solutions will be complex, they cannot be ignored.

Will Story

HIV/AIDS – 30 Years Later

AIDS turned 30 the June 5, 2011. At the same time, as if to commemorate it, a press release was issued by the HIV Prevention Trials Network saying that “men and women infected with HIV reduced the risk of transmitting the virus to their sexual partners through initiation of oral antiretroviral therapy (ART).” While this hypothesis has been around for a while (ARVs have already helped make the disease a manageable, chronic condition), this study supports this hypothesis. Due to the statistical significance of the data, the study was cut short. It became obvious that the use of ARVs, even while CD4 counts were low, was preventing infection — to keep it going would have been immoral.

I was not aware of the story until I saw The Economist in our local supermarket (a week late) here in Oman. It caught my eye right away. Their June 4th issue’s cover shouted, “the end of AIDS?“. I came home and looked it up online. Sure enough, it was a line designed to lure you into reading and then give you the real punch-line in the text — how very smart of them. Yes, there was very good news – a simpler way to prevent transmission of HIV. This news indicates that HIV/AIDS can be beaten! For 30 years, the virus has been increasing in number and infecting more people in our world. The study suggests that we can reliably (without the need for people to be faithful to their partners or wear a condom) prevent HIV from replicating in new bodies. The clincher is that, while the end is in sight, more money will need to be donated and spent to put more people on ARVs. In theory, right now, 16 million people who show symptoms or whose immune systems are weak should be on ARVs. In theory, all 34 million people who have it should be put on them if we were to act on the HPTN study findings to stop transmission as quickly as possible. Will the world powers continue to give money to see this to the end, even amidst a financial crisis that doesn’t want to end?

Such investment is crucial especially for the developing world, where not everyone yet has access to ARVs and where the disease is spreading the fastest. The same week that the world recognized the 30th anniversary of the discovery of AIDS, South Africa held its 3rd National AIDS Conference. Health professionals there were talking about the “unprecedented rise in child mortality” that they have seen in the country as a result of the disease. One doctor noted, “in the age group [mothers] 20 to 29, 47% are infected, and in [the offspring of] that population we see a trebling of infant mortality in the past 15 years. It’s catastrophic.” The evidence presented demonstrates how ARVs are not reaching enough of those infected in South Africa; many of those overlooked are children under the age of 5 who got the disease from their mother. So the good news from the study is quickly tempered with a great challenge — can the benefits of research and drugs reach everyone infected or only those lucky enough to live in well off countries?

The New York Magazine also published a story to mark HIV’s big 30th – “The Man Who had HIV and Now Does Not.” The man in question was treated in Germany, where 1 in 100 people have immune systems that control the disease naturally, for leukemia. He got a stem cell transplant from a bone marrow donor who was one such lucky person. And today they can’t find a trace of HIV in his body. It is not necessarily a miracle. It makes sense. But there is no way this treatment can be performed on many people and it is hugely expensive. We can count out the vulnerable populations in South Africa. Though it does open up new waves of thought on a treatment in the future that is more accessible, so the research must continue.

Right to Food

Photo by: Bethany Duffield

The opposition party leader in Uganda, Besigye, has been organizing innovative protests in Kampala opposing high food and fuel prices in the last couple of months. He encouraged people to walk to work to demonstrate their concern to the government, effectively causing some chaos and traffic jams in the streets. He has been quite successful with this endeavor, motivating many Kampala residents to be a part of the protest, annoying President Museveni and getting arrested 5 times (once preventative, once sprayed with pink, yes pink, paint) in the process. Museveni was voted into office for the 4th time in February, extending his reign as President from 25 to 30 years. Most likely he is one of those African presidents who would loathe to leave his office, making sure that he finds ways to continue being President. Besigye has been trying for the last decade to dismantle Museveni’s hold on power. His walk to work scheme has proven the most successful to date, perhaps riding on the coat-tails of the ‘Arab Spring’. His latest idea is for everyone in the city to honk their horns at a certain hour to voice their protest (since I guess he is tired of being arrested).

Besides borrowing momentum from the Arab states of North Africa, Besigye is taking advantage of rising food prices worldwide in order to make his voice heard and discredit Museveni, a smart move. He has received international press for his antics and Museveni’s responses. And he has many followers because Ugandans, especially the city dwellers at this point in time, are feeling the burden of high food and fuel prices. I suppose my question as an observer, and what makes Besigye’s moves seem somehow manipulative of the current state of affairs (though I agree it was time for Museveni to think about leaving power) is: Can President Museveni really do anything about rising food and fuel costs around the world?

I was working for the Christian Reformed World Relief Committee as their Regional Disaster Response Coordinator in East & Southern Africa during the last spike in food prices in 2008. Food security decreased throughout the region soon after, and throughout the next year, we started more projects than ever before in the region. Even minor drought conditions caused heightened food insecurity when coupled with high food prices. When I saw the news in last January (2011) that food prices had hit ‘an all time high’, greater than the spike of 2008, warning bells went off in my head as I wondered how the region would fare this year. Uganda’s protest headlines caught my attention first, but to be honest, I had expected more fallout from the price spike in sub-Saharan Africa. (WFP says this is because supplies of major food crops in Africa are more plentiful this year than they were 2 years ago because of better harvests, keeping the white maize price stable.) Now I realize that rather than causing acute food shortages, this latest spike is indicative of future chronic food price problems around the globe, which will especially affect the health and well-being of the most vulnerable.

A few days ago, Oxfam came out with a new report — ‘Growing a better future: Food justice in a resource-constrained world’ — saying that food prices will double by 2030. It claims the world is entering a new era of a ‘permanent food crisis,’ which will see those who spend 80% of their income on food most affected, cause political unrest and ‘require radical reform of the international food system.’ Oxfam calls their prediction an ‘unprecedented reversal in human development.’ This is true because, as I stated earlier, there is enough food in the world to feed our population. What we see when food prices go up is a greater disparity between those who have purchasing power to buy food and those who do not. Some will get fat and others will starve. Oxfam argues that our current global food system is broken:

It leaves the billions of us who consume food lacking sufficient power and knowledge about what we buy and eat, almost a billion of us hungry, and the majority of small food producers disempowered and unable to fulfill their productive potential. The failure of the system flows from failures of government — failures to regulate, to correct, to protect, to resist, to invest — which means that companies, interest groups and elites are able to plunder our resources and to redirect flows of finance, knowledge, and food to suit themselves. Every day, it leaves 925 million people hungry.’

Oxfam does not only state the problem and identify causes of the problem, it also tries to offer solutions, the crux of which is that we should all recognize that everyone on the planet has a universal right to food. While sub-Saharan Africa seems to be disadvantaged in the predicted food security scenario — their farmers at the mercy of climate conditions and if they can’t grow enough staple crops, their citizens at the mercy of expensive imports from other countries that have the technology to overcome climate conditions — they must start thinking about how to build the resilience of their populations. So, there is plenty that President Museveni can start doing right now to help keep food prices stable.

Some ideas for the Ugandan president gleaned from Oxfam good report include: 1) invest in agriculture (improve infrastructure, extend access to productive resources to increase food production and incomes of rural communities where hunger is concentrated); and 2) prioritize climate change adaptation (i.e. improve crop storage, ensure equitable access to land, think of some social protection systems like cash transfer programs or weather-index crop insurance). While all governments must come together to improve the world’s food security, Museveni and other African leaders cannot sit by and wait for directives from somewhere else or for potential self serving opportunities either. For one thing, they know they have a great resource — potentially very productive land. They need to ensure that this resource benefits Africans first and foremost, all Africans.

Incorporating Equity into Health Programs

The focus of the 2011 Spring CORE Group meeting was ‘Equity in Health: Ensuring Access, Increasing Use.’ The topic was approached from conceptual, programmatic, technical, and legal perspectives. One session, led by Jennifer Luna, discussed a guidance document developed collaboratively by USAID, MCHIP, the CORE Group and other technical experts entitled Considerations for incorporating health equity into project designs: A guide for community-oriented maternal, neonatal, and child health project designs, and a related checklist. Achieving health equity involves “both the improvement of a health outcome of a disadvantaged group as well as a narrowing of the difference of this health outcome between advantaged and disadvantaged groups, without losing the gains already achieved for the group with the highest coverage.” Assumptions guiding incorporation of equity into health programming emphasize the importance of reaching and monitoring the most disadvantaged within a project area, understanding and addressing the underlying inequity issues to improve a health outcome or achieve an equity outcome, and critically assessing how to best achieve equity in coverage between the disadvantaged group and others in the population so that differences are narrowed without sacrificing gains for the population as a whole.

Incorporating health equity into project design is a six-step process.

1) Identify inequities in health outcomes between groups in the project area, quantifying the magnitude of the differences, and systematically collecting qualitative information to understand the underlying barriers and issues that lead to the inequity.

2) Delineate the focal disadvantaged group for the project.

3) Decide on a manageable target for feasible change.

4) Formulate equity goals, objectives, and a project-specific definition of equity.

5) Develop equity interventions that target the primary causes for the inequity.

6) Create an equity-focused monitoring and evaluation plan.

Although consideration of inequities ideally starts in the conceptualization stage of a project, these steps can be applied in a non-linear manner and be used to inform design, make adjustments to processes during implementation, facilitate staff-stakeholder communication, and explore how equity was addressed at the end of a project.

Check out this presentation by Jennifer Luna to learn more about incorporating equity into health programs.

Grace Kreulen