Promises Without Action: Closing the Implementation Gap

“What the social world has made,” writes Pierre Bourdieu, “the social world, armed with knowledge, can undo.” Recent years have brought about tremendous advancements and increased resources for global health in resource-poor settings. Never before have public health practitioners had a toolbox so rich and ever expanding with evidence-based interventions. Yet the reality on the ground, reveals a grimmer truth, with few of these new resources made available to those who need them most. Why is it that the schism between theoretical knowledge and on-the-ground implementation is so profound, so acute? Moreover – why is it that we - well equipped with knowledge yet in a complacent stupor - are so unwilling to act? Why aren’t we outraged? Indeed the Haitian Creole saying - promet san bay, promises without action - is instructive, if not tragic in its predictive accuracy.

Why aren’t we acting?

To answer this question, we must engage in honest reflection on the true utility of our models. Our social construction of humanitarian knowledge. We must critically inspect our glossy frameworks authored by expatriate experts and written in air-conditioned offices in high-rises in New York and Washington that never make it to those on the ground who are implementing programmatic interventions. Our weeklong conferences. Our empty declarations. What percentage of frameworks written in the name of the sick, the displaced, the poor, are actually used on the ground? Do the principles and benefits of UN declarations actually reach those in whose name they were written? Who benefits and who pays?

Embedded in these exported documents is an explicit condescension. That ‘we’ (read: the rich white ‘civilized’ world) frame our models, frameworks and inventions within the discourse of ‘saving,’ ‘protecting,’ ‘empowering’ ‘them’ (read: the sick, black, exoticized ‘helpless’ poor) should be a call for soul-seeking within the realm of international organizations and agencies. This power imbalance should be a source of embarrassment and concern for the humanitarian and development communities in its clear perpetuation of existing social and economic inequalities from within which the needs of poor or displaced communities originate.

How much money is spent on external contractors, consultants and ‘technical experts’ when compared to direct service provision, implementation, local capacity building and local staff salaries? It is this very polarized climate that disproportionately directs funding toward rare outbreaks that ‘emerge’ from developing regions, to threaten Western economic interests - threats to “us” - rather than endemic the unsexy killers of diarrhea, pneumonia and malnutrition - the silent diseases of ‘them.”

As victims of the humanitarian panopticon, the poor hold no access to resources, nor to the data necessary to manipulate power and advocate for policy change. They are not armed - in Bourdieu’s terms - with knowledge to undo the structural violence that has been inflicted upon them. Indeed the 3.5 million people who die each year due to diarrheal illness are not present to assemble at the Lincoln Memorial to demand reforms, nor can they lobby Washington.

Given that humanitarian assistance is driven by supply rather than by demand, and the voices of those in need are inaudible - the question beckons, what true hope do the poor and refugees alike hold in setting humanitarian priorities? Can the subaltern speak?

More importantly, if the humanitarian and development sectors were to listen - and listen well - what would we learn? If the vain discourse of ‘saving’ were to be transformed toward one of genuine solidarity and making common cause, how would interventions change? How many deaths would be averted? How much money would be put to better use? Would most expatriates be able to legitimize their own jobs? It is staggering to consider how the approximately $730 million dollars spent in 2007 on salaries for top-level staff within the NGO community could be better spent. Employment of over 400,000 community health workers serving in regions of rural poverty. 146 million bed nets distributed in malaria stricken zones. One year of lifesaving antiretroviral drugs at newly negotiated pricing for 5.7 million HIV positive patients.

The World Bank thought themselves profoundly radical in 2000, after sixty years of working toward so-called poverty reduction, to finally solicit the opinions and lived experiences of the poor, in their much-celebrated collection Voices of Poor. But is this concept so revolutionary? Isn’t it more plain common sense? Indeed, from up in our institutional towers – be they academic, governmental, or medical - it is difficult to hear, much less care, about the priorities of the poor.

What exactly - if indeed we take the time to venture out of our administrative skyscrapers, white SUVs and expatriate saturated hotels - are the poor saying?

First, that resources and programmatic activities should fortify rather than compromise local health infrastructure and public health systems. This is true in both stable situations and within the context of complex emergencies, and yields tremendous benefits along the crisis to development continuum. As a more highly developed health infrastructure can more capably absorb the destructive effects of a disaster, gluttonous donor support for complex emergencies should be directed toward substantial investments in strengthening local capacity once the immediate acute phase of the response effort has been addressed. Often international NGOs and agencies seem make the terrible error of rejecting the national and district level system completely by establishing their own private clinics that run parallel to existing, although admittedly decrepit, health service programs.

Second, that increased support for existing MOH clinics and hospitals are key, but are meaningless without aggressive investment in paid community health workers engaged in community-based care. Current funding allocations for international public health continue to prioritize projects that fund and provide contracts to agencies based in wealth nations. Funding to develop indigenous capacity and a skilled health work force remains sadly neglected and under funded. Community health workers, already amongst the world’s ‘bottom billion,’ are told that funds are limited and that they must work as volunteers. Meanwhile, the $90 million annual budget of the International AIDS Vaccine Initiative (IAVI) supports a staff of only 200 people. If redirected, the same funds would employ an estimated army of 60,000 community health workers.

Throughout the developing world, deflated national budgets and severe limitations on government spending imposed by international financial institutions have prompted an exodus of healthcare professionals and the collapse of health care delivery systems. Improving salaries and working conditions for doctors and nurses is one key to closing this infrastructure gap. By delivering services to patients in their homes, community health workers improve treatment adherence and reduce the burden of time, transport and service fees.

Third, and lastly, those in the developing world are arguing that global health funding pipeline should be guided by global disease burdens, with specific emphasis on diseases of the poor – diarrhea, respiratory infections and malnutrition - replacing the current pre-occupation with more trendy, exotic, yet significantly less prevalent killers.

If Bourdieu is correct, which I indeed hope he is, there is reason for optimism in the quest to close the global service delivery gap. The modern technologically advanced age has armed us with the tools to treat the major plagues of our time, it is only our apathy - promet san bay – that kills, and kills in multitudes.

stakeholder analysis

QUESTIONS TO CONSIDER BEFORE STARTING PROJECT: 

I. What are the stakeholder groups?

II. What is the stake of each group in the program?

III. What does the program want the role of each group to be?

IV. Will the group have concerns about the program or the role desired of them? If so, what are they?

V. How will you approach/engage each group?

global health statistics

child health statistics: 

globally 10 million children die per year

42% of these children are in africa

29% are in southeast asia

high income countries: 6 per 1,000 children under 5 yrs. die per year 

low income countries: 88 per 1,000 children under 5 yrs. die per year

poorest countries: 120 per 1,000 children under 5 yrs. die per year

(Victoria CG et al., Lancet 2003)

under 5 mortality (disaggregated by cause of death)

neonatal = 37% of all deaths

acute respiratory infection (ari) = 19% of deaths

diarrhea = 17% of deaths

malaria = 8% of deaths

measles = 4% of deaths

malnutrition: contributes to over half of all under 5 deaths

7 out of 10 under 5 deaths are preventable!

maternal health statistics: 

500,000 women die each year die to pregnancy or child birth

post-partum bleeding = 25% of deaths

unsafe abortions = 13% of deaths

eclampsia = 12% of deaths

obstructed labor = 8% of deaths

830 maternal deaths per 100,000 in africa 

*risk of death is 1 in 16 pregnancies

24 maternal deaths per 100,000 in high income countries

*risk of death is 1 in 2800 pregnancies

therefore, african women are 175 times more likely to due due to pregnancy

general statistics: 

life expectancy in africa: less than 50 years

life expectancy in high income nations: over 70 years

88% of all drug sales go to north america/europe/japan

1 in 6 people live on less than $1 per day

9.8 million refugees 

24 million internally displaced persons (IDPs)

(UNHCR, 2005)

TB prevalence in prisons is 100 times higher than in the civilian population

the earth's human population doubled from 1950 to 1990

naomi klein: the shock doctrine

books + articles + theories + people

• Inclusive Aid: Changing Power and Relationships in International Development by Leslie Groves, Rachel Hinton
• Health and Human Rights: A Reader by Jonathan Mann

• APHA's Control Of Communicable Diseases Manual
• World Health Organization's Communicable Disease Control in Emergencies - A Field Manual
• WHO's Communicable Diseases
• Judith Bruce's Quality of Care Framework
• Susser American Journal of Public Health, op-ed
• Susan Jacoby, The Age of American Unreason
• Heat Wave
• The Bottom Billion
• Larry Brilliant speech on TED.com
• The Ghost Map by Steven Johnson
• COLLABORATIVE LEARNING PROJECTS: The Do No Harm Handbook
  (The Framework for Analyzing the Impact of Assistance on Conflict)
• MSF Nutritional Survey
• WHO Nutritional Survey
• Globalization & Its Discontents by Joe Stiglitz
• Human Development Scale
• Human Poverty Index (HPI)
• Rick Brennan, International Rescue Committee
• Christopher Murray, Institute for Health Metrics and Evaluation
• Dr. Julio José Frenk Mora, Minister of Health, Mexico
• MENTOR (malaria control) http://www.thementorinitiative.org/internationaltraining.html
• Public Health Engineering, by MSF France
• Engineering in Emergencies by Davis and Lambert
• International Union Against Tuberculosis and Lung Disease , Karl Stiblo http://www.iuatld.org/index_en.phtml
• Michael Golden, WHO Manual on Nutrition, medical management, F75/F100
• Bob Black, Lancet
  

piped water systems

when water is piped, quantity is not the issue anymore, focus on quality!

in piped systems ensure that:

1) there is chlorine residual in pipes, and that
2) the pipe pressure is kept very high via tapping and water conservation to prevent cross-contaimination with seewage pipes should there be a line break/leak

ventilated improved pit latrine (vip)

The VIP latrine is free from smell and flies. It consists of a normal pit latrine with a screened vent-pipe fitted to the pit. Smells from the pit are carried up the pipe and escape from the top. No window. Takes about 3 to 5 years for a latrine to fill up.

Flies from outside are attracted to the pipe by the smell, but cannot get in through the netting and flies hatching in the pit are attracted by light at the top of the vent and fly upwards, assisted by air movement, but cannot get out through the netting. Adding ash decreases amount of flies and can also add lyme to decrease odor and flied but this will make the pit fill up much more quickly. The ventpipe should be placed straight over the pit to a height of 60cm (2 feet) above the roof.

This is one form of VIP. A vent-pipe provides ventilation with flyproof netting at the top.

Construction

A slab should be cast in concrete and placed on a foundation, or a complete lining, approximately 30cm (one foot) above the level of the surrounding ground, to prevent rainwater from penetrating under it.

Start by casting the slab and allow it to cure while you make the foundation and dig the pit. Dig down until you reach stable soil and make a foundation to fit the slab. Lay the foundation up to 30cm (one foot) above the surrounding ground in brickwork and cement mortar. Allow the mortar to cure for two days before continuing to excavate the pit inside the foundation.

Use the excavated soil to fill in around the foundation and compact it well to prevent puddles forming close to the pit. After the slab has been paced over the pit, the walls, vent-pipe and roof can be erected. Semi-darkness may be achieved by making an L-shaped entrance with or without a door. The vent-pipe must be fitted with fly proof gauze made of stainless steel or aluminium.

Location

Build on an incline to avoid ponding. VIP latrines should be situated in a place where the wind will blow over the top of the vent-pipe, as this is necessary for it to function properly. It should also be sited on the downwind side of a house as some smell will always emerge from the vent-pipe, and preferably 10 metres away from dwelling and down the slope from groundwater sources.

Cost

A normal VIP latrine uses five to six bags of cement per latrine and around 1000-1200 bricks, plus a gauzed vent-pipe of ultraviolet-protected PVC or asbestos cement. A low-cost version would use about three bags of cement but the same number of bricks. If latrines are built to last it becomes more economical. (estiamted @ $80 including local labor)

Source: Latrine Building – A Handbook for Implementation of the SanPlat System

* * *

ADDITIONAL ADVICE: Before the decision to build a latrine is made, there are many things to consider. Get some expert advice if you can.

The type of latrine

We will look at three types of hygienic latrine…

• a pour-flush latrine – suitable where people use water or soft toilet tissue for cleaning themselves
• a sealed-lid latrine
• a ventilated improved pit latrine (VIP).

Where to build it

It is convenient to build it near to the home but it should not be within 15m of a well or a spring source or it may pollute the water.

One or two pits?

You can dig a single pit about 3m deep (or deeper if you want it to last longer). If you cannot dig so deeply, then you can dig two shallower pits. With a pour-flush latrine these pits can be outside the shelter, connected to it by pipework. With the sealed-lid latrine or the VIP latrine the shelter has to be partly over both pits.

Digging two pits means that first one pit is used until it is nearly full. Then it is sealed while the second pit is used. After at least a year the material in the first pit can be safely emptied and used to improve the soil in a garden. The emptied pit is then ready for use again.

Digging and lining the pit

At least 0.5m depth of lining is recommended at the top of a pit in all types of soil. This supports the squatting slab and may also support part of the shelter. For the rest of the pit the need for lining will vary depending on the soil strength…

Hard firm soil – may not need lining below the top 0.5m.

Rocky ground You can build some of the pit above ground surrounded with a mound of earth and steps leading up to the latrine.

Soft loose soil You will need to line the pit to prevent the sides falling in.

The lower part of a lining should have small holes so that liquid can seep through the holes and out of the pit. Circular pits are stronger than other shapes.

If you have firm soil and do not need to line the whole pit, first dig only to the depth of the lining and then build up the lining wall. When the lining wall has hardened you can continue to dig a slightly smaller pit inside the wall. A guide frame and a plumb bob (eg: a stone on a piece of string) are useful aids for obtaining the right size of hole with vertical walls.

An octagon (8 sides) is a good guide for a round hole.

The covering slab

For sealed-lid and VIP latrines, the best material for the squat slab is concrete, since this is strong, rot-proof and easily cleaned. Flat slabs will need to be at least 80mm thick with 6mm diameter bars every 150mm in both directions. (See page 15 for thinner kinds of slabs.)

The size of the slab can be the same size as the outer lining if this is built of brick. If the lining is made from an oil drum or basketwork it needs to be slightly larger so that at least 200mm of the slab rests on the ground all round the pit. There should not be any gaps under the slab to let flies or smells leave the pit. You can also build a floor out of traditional materials like wood covered with mud – but add a sanplat so that the area around the squat hole can be washed clean.

Pour-flush pans can be placed directly above a pit in which case the floor needs to be strong. If two pits are used the pan and shelter floor do not need to be directly over the pits and can be unreinforced. Concrete slabs will still be needed to cover the pits.

Size of squat hole

The hole should not be too large, or small children can fall into the pit. A keyhole shape 100mm wide and 400mm long with a 200mm diameter circular hole at one end is a good size.

Squat hole cover

A squat hole cover should only be used with the sealed-lid type of latrine (it would stop proper ventilation of a VIP latrine). This cover (lid) needs to be tightly fitting to control smells and flies.

The shelter

The shelter can be built from any available local material. For a VIP it needs to be fairly dark inside but this is not necessary for the other two types of latrine. If people are unlikely to close a door after using a VIP, a better design is to build a spiral shaped shelter. This does not need a door but still provides privacy.

VIP latrines

VIP latrines must have a vertical pipe, ideally at least 150mm diameter, or brick chimney connected to the pit. The top of the pipe should be covered with mesh to stop flies using the vent to enter or leave the pit. To prevent the mesh deteriorating due to the sunlight or corrosive gases from the latrine it should be of glass fibres or stainless steel and not plastic or normal steel mesh. The holes should be about 1.2–1.5mm square.

Wind blowing across the top of the vent pipe sucks air out of the pit while fresh air flows into the pit through the squat hole. This flow of air is helped if the door faces the direction from which the wind normally blows.

The VIP shelter needs to be fairly dark to discourage any flies that enter the pit from leaving it through the squat hole, carrying disease-causing organisms with them. This works on the principle that flies are attracted to light. To a fly in the pit, the squat hole will not be brightly illuminated so it will try to leave by going up the vent towards the sunlight shining down into the pit. The mesh will stop it escaping and it will eventually die.

Children’s latrines

Young children are often afraid to use a latrine, or find it difficult to manage. An alternative idea for very young children is to dig a shallow pit (0.5m deep) with a small slab with a cover (just like the sealed-lid latrine but smaller). No shelter is needed. Encourage children to use this and always to replace the lid. If you find that this shallow latrine becomes smelly, you may find that adding some ashes will help. Move the slab to a new hole when the bottom 200mm is used and fill the used hole with soil.

Keep the latrine clean!

Wash the latrine slab regularly with a brush and soapy water. (Rinsing water left from washing clothes is ideal.) Make sure that hands are washed each time the latrine is used.

Take pride in your latrine. The benefits to your family’s health are enormous! Encourage all your neighbours to follow your example.