Abstinence & Faithfulness vs Condoms & Drugs – which should we be pushing?

Recently I was working on a donor application, which, while not a HIV prevention program, did have a HIV component. The guidelines stipulated an emphasis on abstinence (A) and being faithful (B) but did not mention condoms (C) or drug treatment (D). While A & B promotion dominated the Bush era HIV grants I had thought we had moved on?  Perhaps not, since it continues to amaze me that this particular donor country seeks to impose their own moral code on societies with cultural practices that are worlds apart.  If there is only an emphasis on abstinence and faithfulness, such behaviour change could take many generations to shift, if at all, and it will not move at the pace needed to eradicate or even slow the incidence of HIV.

Here are some stories I’ve heard or witnessed over recent months which convince me that promoting A&B without a wider response, is pointless as it totally overlooks the prevailing cultural practices which contribute to the spread of HIV.

Everyone here will tell you that a certain chief in one part of this country helps himself to the prettiest girls in his chiefdom whenever it suits him. Once, one of our drivers spotted a young girl running madly down the street waving down cars. So he stopped to pick her up and she told him she was running from the men who were going to take her to the chief. And that chief is reportedly HIV+… While most people think this is terrible, no one challenges him. In many countries he would be jailed for rape and paedophilia.

In some remote areas, another more hidden tradition is the initiation ceremony which encourages pubescent boys to
practice their new found skills in the month after they are initiated into manhood. A newly initiated girl can also expect a visit from any man, young or old in the month following her initiation. Added to this traditionally ordained rape, is the prevailing belief that a girl will never have any status until she is a mother. No wonder there are so many 13 and 14 year old pregnant girls, girls who are, by the way, five times more likely to die in childbirth than women over 20.

Cultural practices like these need deep and sustained work with community leaders and young people to bring about their own culturally acceptable change. It takes skilled facilitation and lots of time for communities to work out for themselves what practices they will keep, change or stop. And while very necessary, it will not move fast enough to slow the pace of HIV infections.

Urban young people are no longer exposed to these initiation ceremonies but a different form of wedding initiation has similarly dangerous implications. Some women describe how the initiation ceremony teaches them to never say no to their husbands and never ask questions about where their husbands have been. The real message of this more contemporary initiation is that a woman cannot refuse any man. So while men will protest that women are also promiscuous, saying no is not really an option for many women. No wonder married women of child bearing age are amongst the highest risk groups for contracting HIV.

A friend who works for a large development agency wondered why, whenever her female colleagues attended a workshop with other NGOs, they would always insist on booking their own accommodation. She finally discovered that the women preferred to book a hotel together away from the workshop so they would not have to deal with the constant harassment, nocturnal door knocking and demands for sex from men at the workshop. It seems  the higher the rank, the more expectant the man, that women would succumb to his wishes. And these men often worked in HIV prevention…So I asked my young work colleague if this is common. She described how, at one hotel, someone from  another INGO kept knocking on her door and pleading with her to come have a drink. Protesting that she was married had no impact. Another time, someone from a government authority invited her for drinks and when she declined, he got her room number from reception (!) and rang her constantly until she threatened to complain to the owners. Later when she reported this episode to a friend, they realised the guy was her friend’s sister’s husband! Did she report his behaviour to her sister? No, even despite rejecting him, women generally do not question their husbands but attack the other woman for tempting him! It seems men are rarely held to account for sexual harassment here.

But then I’ve also witnessed this stuff in action. My colleague and I attended a workshop in Maternal Health but after a few hours she asked if we could swap seats. The MP who was sitting next to her, and who represented the parliamentary committee on HIV prevention, kept sending her notes telling her she was beautiful and asking her out. Once again, protestation that she was married did little to deter him.

How do you begin to change these behaviours? Certainly a massive campaign to eradicate sexual harassment is desperately needed. But it has taken 50 years of sustained effort to reduce sexual harassment in the West and HIV prevention can’t wait for that. The quickest way to eradicate HIV would be to stop intergenerational sex but that is a tough call when it is the older men with the power and the money and when girls are taught to submit. And, yes, multiple concurrent partners are the major contributor to the spread of HIV, but so far, regardless of levels of education and HIV awareness, the stats show that not much has changed in the last ten years despite all the intensive messaging on abstinence and faithfulness. (Although, I did hear about a creative prevention program in another African country, which included billboards, radio dramas and ads that discouraged additional relationships with the ‘side-dish’. The women who were ‘side-dishes’ started  complaining to their men that they deserved more respect and a better deal. So much so, that the politicians wanted the campaign stopped as they were getting too much flack from their own ‘side-dishes.’ Hmm – maybe it was working too well.)

Some HIV experts now argue that the most effective prevention method is treating the HIV+ person with anti-viral drugs. This keeps the viral load down and is 90% effective in preventing HIV transmission. It might be the expensive option but it is the only one that is going to work in a hurry – and speed is needed. It is also the just option because it provides the double benefit of making sure that all HIV+ people receive the treatment they need.

Born of moralising, promoting abstinence and faithfulness alone, could be said to be morally bereft of itself, as it condemns many who are tempted – gee whiz - to have sex, with a death sentence!

Let’s be realistic and push condoms and drug treatment in the short term, and make sure every single program is linked to longer term, locally driven strategies around gender and power relations.

Donor Driven Fraud

Some large Donors have been getting a lot of press lately – and for all the wrong reasons. A number of African countries have had their donor funds frozen due to some serious misappropriation of funds. However, as far as I can tell, every effort to tighten controls and prevent fraud actually just makes things worse.  Case in point:

A two year grant program was put on hold while the Donor did a forensic audit of the whole grants program.  Finally, after a six month delay, the Main Grant Manager– a local NGO charged with coordinating the grants – was given the go-ahead to select another group of NGOs to become Middle Grant Managers to manage and distribute the funds to yet smaller Community Based Organisations (CBOs). It took another four months to sign agreements with the Middle Grant NGOs leaving just three months to select the CBOs and implement programs for the first year of the grant.

You’d think the sensible thing to do would be for the Donor to extend the dates of the program and slow everything down so that the funds could be well managed… but no, the timelines held fast and everyone had just 2-3 months to recruit groups, assess their capacity, orient them to the program, assign them funds, get them to implement and then submit reports.

Some Middle Grant NGOs pulled out of the deal, declaring it all too difficult, so the remaining Middle Grant NGOs  took on more of the work. At least one Middle Grant NGO took off at speed, selected CBOs they already knew and trusted, quickly did the desk and field appraisals and worked hard to monitor the activities and keep all the documentation in order. Meanwhile they pressured the CBOs to provide monthly (very detailed) financial and narrative reports despite the meagre grant the CBOs finally received. Noting too, that after the top two levels of NGO management creamed off their costs, the implementing CBOs were advised there was no money for their administration – they just had to build it into their program costs.

So they did…

Then the monitoring teams were sent out, and what did they find?  False receipts, false goods received notices, bogus retailers and suspect beneficiary lists with lots of cost shifting hidden in large taxi fares and fat workshop and training bills. Was it deliberate fraud or just a survival mechanism forced on groups because of the lack of funds for administration?

What forced this situation?  Well my theory is that, to prevent fraud, the Donor became so very prescriptive and micro managing that they made it impossible for the groups to operate honestly and survive.  The Main Grant NGO had to provide a very detailed budget to the Donor, and then required the Middle Grant NGOs to provide an even more detailed budget of how the CBOs should use their funds – all well before the CBOs were even selected.

So when the CBOs submitted their applications complete with budgets, their budgets were virtually ignored, and a budget was imposed on the groups to which they had to adhere. When the Monitors later asked about things like the large taxi fares, some admitted that because they had excess funds in the transport budget they falsified the taxi receipts to cover other purchases, or to pay their staff allowances to make up for the lack of administration funds.

Some of the fraud was minor to shift costs around, but some appeared much larger and perhaps evident of a sustained and deliberate effort to defraud funds over many years. The police were sent in but only the little players got caught. Some CBOs slipped through the net, possibly due to good reporting or perhaps good connections…

Meanwhile, the funds are on hold again as the Donor tightens requirements even further. The next tranche is nine months behind schedule and counting. CBOs that had established programs and recruited staff on the basis of their signed MOU are starved of funds. In the end, a grant program designed to build capacity in CBOs, has instead, set them up to fail and driven some groups to the wall.

Solutions? I would say – give the money to an agency that has the track record and experience in grants management and instruct them to fund CBOs directly. This would mean just one layer between the donor and the CBO, instead of two. Establish systems to assess, build capacity and monitor CBOs carefully, before grants are awarded, and based on long-term programs, not short-term projects. Always let the CBO implement the program for the full time period, setting the start date from when the funds are transferred to the CBO. Work with the CBOs to develop budgets together and make sure the funds do adequately cover staffing and administrative costs in a responsible and cost effective way.

Oh and maybe the donors should invite the CBOs to design and dictate what the program activities should be – given that the CBOs may actually have some local knowledge of what works and what doesn’t… AND, most importantly, make sure that the local communities and local networks are all consulted and involved in the grant process so they know about the project and can hold the grant recipients accountable for the funds they receive. This is by far the most effective monitoring tool!

Any other suggestions?  For more reading on this issue see Rosalind Eyben’ s great reflection at http://www.oxfamblogs.org/fp2p/?p=4743

Babies with Babies

When I first arrived here I would often see young girls with babies strung on their backs with a colourful wrap. I would think – ah they must be helping out their mums. But I quickly learnt that pretty much all of them were carrying their own babies. Babies carrying babies… Not just in the districts and remote villages but often in the main city too. Why – because this is a society where the onset of puberty is equated with being ‘ready for marriage’ or R4M as it is popularly known among young people. Poverty is another major factor as parents pass their daughters on to older men who can pay a small dowry. The parents earn some money and hope that their daughters will live with someone with more resources than them. The poor little girl has no say, is condemned to early pregnancies and a higher risk of contracting HIV.  

Some stats – girls who become pregnant under 15 are five times more likely to die in childbirth than a 20 year old, and between 15-20, twice as likely to die… Any girl under 18 should immediately be referred to a hospital for delivery as the chances that she will need a caesarian section are very high. At the major teaching hospital in this capital, 400 women a month, present to the hospital for post abortion care! All of those girls exposed to unsafe sex and to the risk of terrible complications including death. Unsafe abortions represent about 14% of maternal deaths in the developing world. I recently heard one very sad story of a 13 year old girl who had to have a hysterectomy as the injuries from her abortion were so severe.

My work includes helping rural women to access obstetric fistula repair surgery. Virtually unheard of in the developed world, thousands of women across Africa are living in isolation and shame because their obstructed labour left them with such serious injuries that they leak urine or faeces uncontrollably from the birth passage. Why the shame? Apart from the smell, traditions here suggest that an obstructed labour means that the husband or wife was unfaithful during the pregnancy… Further compounding this tradition, is the one that suggests that you are ‘not enough of a woman’ if you need a caesarian section to give birth. And, you are not ‘enough of a man’ unless you have a very large family. The odds are stacked against little girls in many parts of rural Africa.

Thanks to a great partnership with a little organization that provides specialist doctors around the country, we have managed to support over 280 women to receive repair to their injuries – life changing stuff and very rewarding – but the real work needs to go into prevention.  Many of the women are really girls, often a 13 or 15 year old and sometimes with a baby on the breast as well as going through the surgery…

How does this story relate to my theme of good and bad development? Well we arranged for a short prevention film to be made at one of the Catholic mission hospitals where we hold the fistula repair programs. The film includes lots of prevention information including family planning. When I requested permission to film at the hospital, the medical director was happy for us to film but stated the hospital’s unwillingness to endorse anything other than natural family planning messages. He wrote: I don’t see the relevance of family planning to fistula  - it is all about good antenatal care…

Really? I know the Catholic church only promotes what they call ‘scientific family planning’ which I call ‘misogynist family planning’ because it means women can only have sex when they least feel like it and need to abstain when their hormones put them in the mood. It is beyond my comprehension that the church refuses to provide information for these little girls, to prevent them from becoming pregnant before they are physically ready.

We are also working with traditional leaders and the government to ban early marriages but it takes time. I recently heard a great story of a Chief from another African country who is threatening to expel families from his chiefdom if they force an early marriage on their children. The same Chief is passionate about child protection and promoting the rights of women and children. If only all leaders, including our Catholic friends, would make the same commitment to the well-being of young girls…

You will become the problem

These last few months have been the hardest of my rather long working life, as I come to grips with a few stark realities about working here - which I’ve never dealt with before.

What drives a nation of otherwise very smart, friendly and godly people to be so unwilling to be up front and straightforward about things? Why is there so much corruption in this country? Why do political leaders, and people of significance, keep getting away with it? And how is it that the expat community feeds into it, succumbs to paying bribes and seemingly props up behaviour that would be unacceptable at home?

Maybe I am stumbling onto something of an explanation. A meagre and uninformed one, that may only reflect the culture of the workplace rather than the culture of this nation – but I have recently learnt a new phrase:

If you identify a problem YOU become the problem…

So – better to keep your mouth shut…no matter what you see.

Small example:  Brand new car with a broken cup holder which could be repaired under warranty: “Have you reported the breakage?” “Oh no, they’ll think I did it!”

Slightly bigger example: A friend organised a mobile phone deal which provided leadership staff in his organisation with a telephone. It was a company brand phone – a cheap copy of a blackberry. After a while, he noticed that some people were not using their phones. So he decided to ask around. He discovered that: they switch off in the middle of the call; are unreachable despite being on and within range; freeze during an sms; the screen scratches and becomes unreadable; the internet drops out… No one raised the problems, because no one expected it would be fixed – and besides, they might be blamed for misusing their phones…

As a life long, passionate, change agent, who just can’t help herself, I find this attitude hard to understand. You find problems and you work together as a team to solve them… It’s that simple, surely.

Ahhh but I am learning fast. I quickly became popular in my workplace as the first person to stand up and ask ‘but why’ and isn’t there a better way? Especially when it came to the levels of bureacracy and blockages around accessing funds for my project. And I thought I was making a difference. My African work colleagues urged me on. I was shifting the culture of blame and negativity into one of encouragement and appreciation. My team were full of enthusiasm and achieving great things. Even so, we kept hitting blockages from finance and administration. Clearly my desire for change, while welcomed by the minions of the organisation, was not so welcome at some management levels.

The finance manager, almost burst with glee every time he found something wrong with our paperwork. And too often, when there was an issue, it languished in his in-tray for days. He made an art form out of making sure our project did NOT have its funds ready to do its activities. I keep trying to encourage us all to be solution focused and to remember that we are all part of the team which needed to deliver outcomes…

The other story I heard recently was of a team building retreat that went reasonably well until the last session when the CEO of the organisation decided to give a final pep talk. It became like a political speech, with a repeated chorus, “Are you with me? If you are not – then there’s the door!” The CEO proceeded to name individual staff members,  outlining their weaknesses, and declaring: “Will you improve? If not – then there’s the door!”   Public reprimand is popular here. How do people cope? Work to rule, keep your head down, don’t report any problems or you will be next…

If it were my workplace, I think I would be getting up and walking out that door by choice! But then, that is the other possible cause for turning a blind eye to other people’s cover ups. Most people cannot afford this option.

A much larger example: On one of its routine monitoring and evaluation (M&E) visits, an organisation that sub-grant funds to smaller community groups, discovered that groups were forging receipts and misappropriating funds. The project officer was involved, receiving cash on the side, and he rightly got the sack and the police were called in.  But the integrity of the M&E team was also questioned. From all accounts, some of these community groups were in collusion and corrupt for years. The M&E team were the first to stumble onto the problem and expose it but then they were reprimanded and blamed for letting it happen…

So they experienced something of what most people here seem to try to avoid because: if you uncover a problem YOU become the problem… To avoid getting into trouble, and to avoid the wrath, I see people telling little white lies, hiding information, overlooking things, making deals on the side, all to stay under the radar and avoid conflict. I see it driving, even the most honest people, to twist the truth a little to avoid attracting blame and wrath.

I wonder if this is what allows corrupt people to go unhindered as others avert their eyes in fear.

And for me, well I am learning that I question far too many things and it is time I pulled back… but not sure I can do that.

pillowcase dresses?

So you have been wondering what to do with those old pillowcases piling up in the linen press…ah – let’s send them to Africa! Then we will all feel so much better… http://www.littledressesforafrica.org/blog/.

But wait a minute…there are amazing fabrics in Africa, gorgeous designs and vivid colours and often, they are very cheap. And there are amazing tailors in Africa who can measure you and make you a three piece outfit overnight for as little as $10.  And that is at the top end of town. There are many people who can make and remake even cheaper clothes with treadle machines and handsewing.  And, if you cannot afford that, there are huge bundles of secondhand clothes that arrive in the markets and sell very cheaply indeed. (I know, the secondhand clothing dumped into Africa and Asia is destroying local manufacturing too.)

But at least in each of these options someone is working and earning some money out of their trade.

So then, why are women in America making little dresses out of pillowcases to ship, at great cost, to Africa?

I am sure there are many needy little girls in the US at the moment who could well do with some new clothes… But perhaps little girls in America would not be prepared to wear a pillowcase.

Do Gooders who Don’t

One thing I struggle with is why we all feel so much better if we give something directly to a ‘poor deserving’ recipient, than if we support a good development agency with years of experience in sustainable community development.

Why do we feel so much better if we give an item direct to someone? We sponsor a child and then want to visit that child and make sure s/he feels grateful and indebted to us because we have helped them from our largesse. Or we donate our old stuff, because we hate to throw it away and it makes us feel so much better if we think our own excess (dedication to fashion) is helping someone else. In the process, huge amounts of money and energy is spent on sending sometimes dirty, broken and out of date equipment and clothes to a country that least wants or needs the goods. Some of it is destined to become unusable rubbish in countries already groaning under the weight of their own badly managed waste systems or lack there of.

I’ve had the awful task of sorting through donated goods, so generously donated and shipped to us for distribution. We threw out stained tea-towels, torn shabby clothes and used underwear. Amongst the clothes were often XXL items – sent to an Asian country where most people stood less than five feet tall. And then we had to find the resources to distribute the remaining goods – not a cheap task.

 Although the Salvation Army won’t accept our old computers, we want to send our dinosaur PCs overseas to communities without access to reliable sources of electricity. There is huge potential for IT to foster health and education in remote areas but what is needed is solar powered, mobile phone or satellite capacity technology. Remote areas need high tech, low cost laptops, not old desktops, way passed their use-by-date that cannot run any of the latest software.

A couple of years ago I stumbled onto one of the worst examples of this need to give  – recycled old bras distributed across the needy world for all those women suffering from lack of support! I was dumbstruck when I heard about ‘Project Uplift’. What would anyone want with a second hand bra! I don’t know about you, but I don’t throw out my bras until they are well past it – and as intimate apparel – can any one of us imagine wearing someone else’s bra! Not me…And bad luck for the local intimate apparel business who is trying to make a living selling affordable, new bras.

Just recently, I heard about a European fundraising group that raised lots of money to send bicycles to Africa. These bikes, no doubt made in Asia, were shipped to Europe and would need shipping onto Africa to be given out through an African NGO. Apart from the unnecessary transport costs via Europe, there are many really good bicycle suppliers within Africa who are trying to make a business, employ locals and inject income into the economy. Every time a group sends a whole stack of donated goods to the country, they simply undermine local business efforts. Surely it is far better to give the cash, so that the NGO, in country, can buy from a local business, employ locals and support local efforts to move the country from a charity case to a thriving economy. We are all about ‘buying local’ in our own countries but we don’t seem to apply that principle to the countries that we want to support with our charity.

A group of women raised $2000 to help build a kindergarten, so three representatives of the group paid thousands more to check on the project. Our organisation then had to spend another $1000 to accompany them to the project site, where they had the pleasure of distributing small gifts to the children. The group also visited a widows’ support project. They had brought second hand clothes to give to them. One woman, whose husband was massacred during a militia attack years earlier, had one remaining son who was born just after that time. Her special son, who had done well at school and who was starting university, had died of an asthma attack just three months earlier. The woman was grieving terribly and became very upset as she recounted her loss again through an interpreter. As they were handing over their gifts, one visitor turned to me and said. “She doesn’t seem very happy about her gifts, do you think she is grateful?’ What more can I say?

Ahh – but then there is the whole debate around those NFL t-shirts…

Getting Started

So I am going to start a blog – this will be personal and possibly of no relevance to anyone.  I am going to write about my experiences of working in international development. I am a bit of a latecomer to the field. As a long time community development worker in the Western World, I got dragged into international development by my partner. So this is now my second posting, to a rather nice, settled, but still very poor part of Africa.

I will not give any more geographic detail than that for the moment because I think I do want to vent my spleen and I do not want to lose my job – or anyone else’s in the process.

So here I go.