The Challenge of Protection

If authorities want to violate, marginalise and impoverish people, then humanitarian workers are not particularly well placed to stop them since protection activities will be working against the intentions of the legal or de facto groups perpetrating these abuses. Humanitarian personnel will be seen more as a threat than an ally by such negative authorities. Inevitably, room for manoeuvre will be restricted and the strategies and modes of action will be politically complicated. These situations are more likely to raise difficult programming choices between access, compromise and confrontation.

In some wars, civilian suffering may be an unintended consequence and regretted by one or more of the belligerents, who may then seek to assist the civilians. For example, some parts of the state authorities will be deliberately perpetrating violations while others will be genuinely trying to mitigate extreme state policies and improve people’s conditions. The same range of abusive and protective intent can exist within an armed group. Understanding the range of intentions within a given authority becomes a critical part of protection analysis and response. Who has responsibility for ensuring that atrocity and deprivation do not happen in war?

There are cases that rival political or armed groups are carrying out vicious and indiscriminate attacks on populations in their respective territories since both sides are avoiding attacking each other’s forces, hence, are instead deliberately directing their violence against populations consisting of civilians from the opposing group.

The law, the legal principle of primary state responsibility and the mandates of humanitarian agencies offer civilians important legal protection in war and disaster. However, people are not actually protected just because the law says that they are. Therefore it is not lack of laws that people are exposed to abuse rather the will or power to enforce the law. Often laws are broken and rights are violated most by state authorities with the responsibility. In other situations, states that are willing to abide by these laws lack the power or means to do so.

Securing people’s protection, with impartiality, when abusive groups familiar with local machineries, are set to wipe them out or to discriminate against them is a highly complicated task. It can verge on the impossible and routinely involves a number of strategic risks for humanitarian organizations, the increased risks to victims that fact-finding, activities and behaviour may present.

Insensitive or unprofessional behaviour and advocacy by humanitarian staff can also expose particular individuals and civilian communities to heightened risk by leading to punitive backlashes or retaliation. More generally, aid assets and sanctuary can be abused by belligerents. Corruption in aid distribution can also render civilian populations vulnerable to extortion, threat and deprivation.

Aid workers unable to see the political intent behind the atrocities run the risk of inadvertently legitimising violations or perpetrators. It is also crucial to avoid extreme measures in protection efforts in order not to politicizing humanitarian action in the eyes of belligerents

Overall protection programme should try to answer the following questions.

• Who are you trying to protect?
• From what are you trying to protect them?
• What capacity do people have to protect themselves?
• How will you help them?
• What resources will you use?
• Who will you do it with?
• How will you know if you have succeeded?

Protection programme meets these challenges by coming up with:
• the best possible response to people’s immediate protection needs
• the best possible long-term reduction of threats and violations
• the best possible reduction of people’s vulnerability to those threats
• the best possible development of people’s own capacities.



Protection Assessment

The importance of information in any type of successful protection work cannot be underestimated. Information can save lives and is very much two way between civilian communities and humanitarian agencies. Information that passes from affected civilian communities to humanitarian workers can help agencies to understand how people are suffering and coping, so informing and guiding the appropriate design of protection and assistance programmes.

The process of collecting information as part of a protection assessment is often much more sensitive and delicate than in other areas of humanitarian work. Many of the techniques of information gathering may be the same but the highly political and dangerous environments in which you are using them makes information gathering highly risky for you and the people you are trying to help.

Information sources are likely to include key informants in government, armed groups, the media, academia, civil society, religious or humanitarian organisations. They will also include secondary sources such as published reports. But it is often the people at risk who know most about their predicament and have the greatest insight into the threats against them.

Many of these activities will require discussion with the victims of violations. Whenever you or your staff are consulting with people, it is vital that you enable them to describe their experience of suffering and threat directly, that you record it accordingly, and that you cross-check it.

Another key part of any protection assessment is to identify who actually, or potentially, has the necessary desire and ability to protect people from the threats they are facing. The ability of a state authority, organisation, community or individual to protect is determined by a mixture of the resources it has available, political attitude and personal conviction.

This process requires examining a range of actors, including the different organs of the relevant state authority; armed forces and armed groups; individual commanders and fighters; war-affected communities and individual victims; other states; multinational companies; and international organisations, humanitarian agencies, and human-rights organisations. The aim is to understand where protective will exist, where it is being blocked and how best it might be mobilised and supported.

People caught up in violent conflict make calculated decisions all the time about the relative risks of the often dangerous options and dilemmas that are open to them: to stay at home or to flee, to plant crops or to hide the seeds, to join the militia or to stay out of the conflict. These decisions are made on the best information available to them – information that is frequently incomplete and inaccurate because of restrictions on their movement or because it is deliberately manipulated for political reasons.

What is waiting for me if I return home, and if I stay here what will happen to the camp? What legal right do I have to compensation for the loss of my land and how do I go about exercising it? Am I entitled to any assistance and who should I contact to get it?


Monitoring

The key question to shape the monitoring might be: how much is what we are doing, and encouraging others to do, helping to keep people safe, to preserve their personal dignity and integrity and to realise their economic, social and cultural rights?
Answering this question requires that you constantly monitor two main variables:

1 the changing nature of the threats and violations ranged against the particular population (the situation)

2 people’s experience of your strategy and activities (the results of your agency’s actions).

This means taking the collection and analysis of protection indicators seriously, regularly reporting on what you find, and, wherever possible, involving protected persons in the process. While every effort needs to be made to involve people in need of protection in any monitoring process, wherever possible you should also try to involve the responsible authorities or abusing parties as well. Actively engaging them in protection monitoring, or at least being able to meet them to discuss your findings, is a vital way of holding them accountable.

Agency personnel are also a valuable source of monitoring information. Staff can be vital for informal monitoring and adapting particular strategies in accordance with certain key questions about improvement. More qualitative indicators which require real listening and empathy to capture the subtleties of people’s experience and their sense of security must be collected by highly sensitive staff members.

It may be useful to return to the basic protection equation:
risk = threat + vulnerability × time
and to select indicators which relate to each part of the equation in the given context.

Protection focused policies can often sound very state-centric but wherever access and contact permits, humanitarian protection work is also about working directly with affected communities to identify and develop ways in which they can protect themselves and realise their rights to assistance, recovery, and safety. It is vitally important that people in need of protection are not seen just as the objects of state power but also as the subjects of their own protective capabilities. In many wars and disasters, people survive despite the state.




Sources:
Protection, An ALNAP guide for humanitarian agencies, H. Slim, A. Bonwick, ODI. 2005

Bonwick, A. (2006) Who Really Protects Civilians? Oxford: Development in Practice, Oxfam

Roche, C (1999) Impact Assessment for Development Agencies: Learning to Value
Change. Oxford: Oxfam

Protection

People inclreasingly need protection in the many conflicts, natural disasters or protracted social conflicts that come to dominate their lives. There is much that humanitarian agencies can do to help them and to mobilize authorities to be held accountable in implementing politics of exclusion to create a vacuum for robbing people of their possessions. There need to be a new determination to develop truly practical programming that protects people from all forms of violation, exploitation and abuse. Initiations to spread democracy also needs a new determination to develop policies that protects people if we are serious about freedom and dignity of people. Aid workers are expected to know about protection and be able to train others to do so too. This involves an active concern for people’s personal dignity as well as for their safety and material needs. A person’s ability to maintain a strong sense of personal identity and self-respect can hold them through extreme physical suffering.

Ensuring people’s protection is the legal responsibility of de jure or de facto authorities in a given situation. These authorities are usually governments, international peacekeeping forces or armed groups. Humanitarian agencies are rarely in a position to protect anyone directly from the violent assaults, terror tactics, displacement and dispossession that cause so much suffering and destitution to the victims of war and disaster. As a result, and particularly in war, humanitarian agency personnel have often felt like bystanders to atrocity.

Agencies work hard to ensure that the humanitarian assistance programmes they design and deliver do not thoughtlessly expose civilian populations to yet more dangers from raiding, exploitation, rape, isolation, permanent displacement or corruption, and so inadvertently supporting those pursuing war or personal enrichment.

Politically, humanitarian agencies can also work to influence the responsible authorities, and so play their part in important local, national and international efforts to ensure respect for the norms, rights and duties set out in international law. Holding the appropriate authorities responsible and accountable is critical in protection work. A great part of this involves putting pressure on and working with those with legal responsibility for protection – state authorities, international peacekeeping forces and de facto authorities like armed groups. Perpetrators must be made aware that there will be consequences to their abusive acts of violence. Much of it also involves liaising closely with other international organisations with protection mandates.

Finally, humanitarian organisations can work long-term to influence the deeper values of violent prone societies so that the principles of human dignity and protection are more broadly embraced by the hearts, minds and institutions of a society. Protection needs arise in situation such as in armed conflicts, post conflicted areas, protracted social conflicts and natural disasters which in all these main contexts of humanitarian action, people are exposed to extreme levels of risk and can be forced to engage in equally perilous and exploitative coping or survival strategies.

Violations and deprivations that cause protection needs

• Deliberate killing, wounding, displacement, destitution and disappearance.
• Sexual violence and rape.
• Torture and inhuman or degrading treatment.
• Dispossession of assets by theft and destruction.
• The misappropriation of land and violations of land rights.
• Deliberate discrimination and deprivation in health, education, property rights, access to water and economic opportunity.
• Violence and exploitation within the affected community.
• Forced recruitment of children, prostitution, sexual exploitation and trafficking, abduction and slavery.
• Forced or accidental family separation.
• Arbitrary restrictions on movement, including forced return, punitive curfews or roadblocks which prevent access to fields, markets, jobs, family, friends and social services.
• Thirst, hunger, disease and reproductive health crises caused by the deliberate destruction of services or the denial of livelihoods.
• Restrictions on political participation, freedom of association and religious freedom.
• The loss or theft of personal documentation that gives proof of identity, ownership and citizen’s rights.

Direct personal violence in conflicts or protracted social conflict is a common cause of suffering and death. The deliberate murder, abduction, disappearances of civilians – women, men and children – has been central to the policies of belligerents in most situations.

The vicious use of sexual violence against civilians has also been central to the policies and practices of many of those pursuing war. Beyond the immediate humiliation, outrage and social impact of sexual violence, the spread of the human immunodeficiency virus (HIV) is an increasing and frequently deliberate result of such strategies of personal violence.

Children have been murdered routinely in recent wars just as they have been throughout history. They have also been brutally coerced into becoming child soldiers and prostitutes or forced into circumstances so terrible that taking on such roles emerges as the best choice open to them.

In addition to killings and sexual violence, hundreds of thousands of people have experienced the most vicious personal injuries which ended up to disability. Families have been coerced to give up their belongings to the belligerents. Millions of women, men and children have been left emotionally wounded and economically and socially vulnerable as widows, widowers or orphans.

The extent of these atrocities means that humanitarian action focused primarily on assistance can fall well short of protecting people’s dignity and integrity or meeting their urgent need for safety. People obviously require personal protection as well as food aid and healthcare if they are not to become the ‘well-fed dead’

it is most of all impoverishment, dispossession, destitution, disease and sheer exhaustion that are responsible for people’s suffering . Throughout the 1990s, most civilians died from war rather than violently in war. This is true of most wars that do not involve the mass slaughter of civilians.

The deprivations caused by war – what people have taken away from them –often become the determinant factor in people’s suffering. Deliberate assaults on economic assets and livelihoods plunge people into poverty and threaten them with destitution and disease. In cities, fear can force people into siege conditions. Maintaining or recovering people’s access to key social and economic services is one of the biggest challenges in protection work.

In many cases, force and fear may impel people not to restrict their movement but to extend it dramatically by becoming refugees or internally displaced persons (IDPs). Extreme movement of this kind creates similar problems of access, as people are usually forced to flee to areas where services are limited, congested or non-existent. In such situations, ensuring safe access to basic services becomes a major protection challenge.

When we are cut we bleed and when we cannot drink we thirst; but beyond our material needs, we also feel and care – about ourselves and others. This sense of self-worth, and the deep value of being together in family and community of some kind, are as important to protect and assist as are our physical needs. We live emotionally, socially and spiritually as well as physically, and so we suffer emotionally, socially and spiritually too. So for those who are excluded and detached there is additional sense of insecurity since there seem to be no one to turn to. Many violations, deprivations and restrictions degrade a person and are often designed to do so. They make people feel less than human by shaming them, tormenting them, disregarding them, dispossessing them or reducing them to inhuman conditions.

This most basic insight of humanitarian action makes clear that preserving a person’s dignity and integrity as a human being is as much a goal in humanitarian work as ensuring their physical safety and providing for their material needs. The principle of humanity recognises human beings as much more than physical organisms in need of the means of survival. As such, humanitarian work extends beyond physical assistance to the protection of a human being in their fullness. This means a concern for a person’s safety, dignity and integrity as a human being. These deprivations are all deliberate violations and abuses of a person’s right to property, livelihood, education and health, as well as to free association, freedom of religion and cultural autonomy. Ultimately, they can prove socially devastating and individually fatal, which is frequently the intention.

Protection: An ALNAP guide for humanitarian agencies, ODI, 2005

Website: www.alnap.org

Safety and Security of Aid Workers

While few statistics are available, there is an abundance of evidence indicating that aid workers are victims of hostage taking, assassination, mine explosions and robbery in addition to the ongoing exposure to vehicular and health threats. An important factor is the perception that aid workers are now more at risk of being deliberately targeted, either for political reasons or because they are easy prey for criminals, and this drastically alters the perception of risk.

Official harassment is typical in situations where an NGO is assisting a group persecuted by the host government, or where NGOs are operating across lines of confrontation. Bribery is not a good strategy here, as it only exacerbates the problem for all concerned over time.

Opening primary health care programmes and a winter heating programme
in Republika Srpska greatly enhanced the ability to negotiate passage, while not compromising the mandate in the region. Similarly, singling out refugee or returnee groups from a larger community which might also be in desperate need can also undermine security. Health programmes in northern Sudan have sought to provide assistance in a balanced way to Northerners as well as Southerners.

Threat assessment should accompany any initial programme assessment, and be carried on continually during programme operations. Like programme assessments, security threat assessments should include a wide variety of inputs from the United Nations, the embassies and national government, through to other NGOs, local government and community leaders and finally individuals in the community. In the simplest terms, it is a matter of identifying what security threats are of the highest probability and greatest consequence to an NGO’s operations and prioritizing resources to these threats accordingly.

The Security Triangle:
Acceptance-Protection-Deterrence
Security is often conceptualized in terms of military or police models which emphasise equipment and tactics. While there is much that we can learn from these models, NGO security is far more complex. Fancy communications gear, logistics capabilities and compound security have their place, but are only a small part of what constitutes security for aid workers. Field offices must adapt a local security protocol which includes each of the three elements of the security triangle: acceptance, protection and deterrence. An effective local security protocol must balance all three elements. A strong acceptance strategy with supportive protection and deterrence elements is ideal. However, where local conditions limit the effectiveness of the acceptance strategies, it is necessary to build stronger protection and deterrence capabilities.

Acceptance is the cornerstone of security for NGOs with a development mandate, but is often challenged under the timeframes and political circumstances in which NGO relief efforts take place. In war-time relief operations, acceptance by the beneficiary community may seem to be grossly overshadowed by the hostility of one or more of the combatants.

Protection strategies can mitigate against official harassment. Training of staff in methods of conflict diffusion is helpful. Staff need to be well oriented in the agency’s mandate and mission and be able to represent the NGO in a mature and non-threatening way. Finally, the deterrence strategies centre on the relationship between the NGO and the larger political actors who may be able to cajole a hostile government when all else fails.


Conclusion
There are clearly advantages and disadvantages to any strategy, which must be weighed within the context of each local environment. In Liberia, for example, the poor quality of rented cars and their drivers eventually posed a greater risk than car theft, and the policy was abandoned. Thus, flexibility and local control over security policies are an imperative. When developing security policies, field managers should first identify the key risks in the local environment based upon probability and consequence. Risks of high probability and/or high consequence should be the primary focus of agency attention and resources. Secondly, for each of these key risks, the field manager needs to carefully and creatively consider each of the three strategies - acceptance, protection and deterrence - in devising an appropriate local response. Security for humanitarian staff operations is too often viewed in terms of military models or, worse yet, overlooked as an inevitable and inalterable aspect of working in humanitarian crises. In fact, there is a lot that can be done to enhance security in humanitarian operations. However, security in humanitarian operations calls for a new paradigm that weighs not only the familiar equipment and technology of security but also the dynamics of community support, interagency coordination and diplomatic influence.


source:
Security training: where are we now? Forced migration Review, Oxford University, 2003

NGO Field Security, Forced migration Review, Oxford University, 2003

Public Health Issue: climate change

Climate change related to global warming is the world's most urgent public health problem. Climate change is a major health threat and requires concerted action to mitigate it. Health professionals must set an example and advocate for contraction and convergence both locally and nationally. Around 60% of the ecosystems essential to sustain life are already damaged1 There are initiatives in raising the awareness among the medical community about the climate change and saving the planet.

Climate change poses grave risks to health. It threatens the essentials of life. It brings drought, floods, storms, and extremes of heat and cold that can lead to famine, homelessness, dislocation, destruction of communities, the spread of disease, and even mass migrations and armed conflict as people vie with each other for land, water, food, and energy. And let's not forget the effects on mental health of anxiety, insecurity, and a sense of powerlessness as we watch the grass wither and the ice-caps melt.

There are many ways in which Health community can contribute towards contraction and convergence policy. If medicine is about saving lives, not just by last ditch interventions but by trying to avert illness, then working to alter patterns of behaviour that contribute to climate change could arguably become a priority for clinicians—as an urgent preventive measure. Debating the health implications of climate change may also be the best way to get the general public to take the problem seriously. Concepts such as "sustainable development" and "global warming" can strike the average person as either too daunting to consider or too distant to concern them. But we can all relate to the idea of risks to health that may affect ourselves, our children, and grandchildren. So there are good reasons to put climate change at the heart of the health agenda.

Likewise, the climate change debate belongs at the heart of health service management. The institutions of health care have enormous power to do good or harm to the natural environment and to increase or diminish carbon emissions. This applies particularly to the NHS, with its sheer bulk—still growing year on year. In 2006-7 the annual NHS budget in England is expected to be £83bn ( 121bn, $156bn), with a total UK health expenditure of £97bn.w1 NHS purchasing power is estimated at £17bn a year.w2 It is one of the largest employers in the world, beaten only by the likes of Wal-Mart and the Chinese army. It employs more than 1.3 million peoplew3 and runs 259 NHS trusts.w4

Future development programme in the NHS must be directed toward concerns for unsustainable building. By 2010, about £11bn is expected to have been spent on 100 new hospitals and more than £1bn on new primary care buildings.w5 w6 The new hospitals’ car parks and energy intensive air conditioning, heating, and lighting must use more environmental friendly equipments. They should wary of costly demolitions of buildings and the use of construction materials from unrenewable sources.

The recent suggested policy for tackling global warming is contraction and convergence, developed by Aubrey Meyer of the Global Commons Institute Contraction and convergence is a carbon cap and trade policy designed to stabilise and then reduce carbon dioxide emissions, which are responsible for 70% of greenhouse gases. Industrial methane emissions, responsible for much of the rest, will reduce alongside carbon dioxide. Given the present global population, this amounts to 2 tonnes/person/year, five times less than the present UK average emission. Evidence from Mozambique suggests that this money will help trigger the latent entrepreneurial skills of the recipients.4

The financial implications of trading in carbon entitlements mean it will be in everyone's interest to minimise the amount of carbon we emit. Just as all of us strive to live within our financial means, we will strive to live within our carbon means, with the evident financial benefit this brings. The less carbon we emit, the better off financially we are, a major inducement to the global development of low carbon emitting societies.

The move to a low carbon society will encourage each of us to get the benefits of low carbon living. It will also enable the much more rapid uptake of measures to conserve energy, promotion of renewable fuels, building of carbon sequestering coal power stations, and a better informed debate on the need to build new nuclear power stations. However, no foreseeable technological change can compensate for all the energy we presently generate from fossil fuel. In a low carbon future, we will inevitably use more of our own human effort, prompting those of us living in rich industrialised societies to get much more exercise in our everyday lives. The psychological health benefits of exercise are substantial, and increasing the entire population's exercise levels is key to preventing atheroma, the leading cause of death in industrialised countries.

1. WHO. Ecosystems and human well-being: health systems. Geneva: WHO, 2005.
2. Simmons M. Twilight in the desert. Chichester: John Wiley, 2005.
3. Tooke M. Peak oil 2005. www.powerswitch.org.uk/downloads/pos.doc
4. Hanlon J. Is it possible just to give money to the poor? Dev Change 2004;35: 375-83

References w1-w6 and details of the NHS's ecological foot-print are on bmj.com

Extracts:
Bmj.com, Healthy response to climate change, R. Stott, Medact , 2006
Bmj.com, What health services could do about climate change, Sustainable Development Commission, A. Coote, 2006

related links:
(www.activetravel.org.uk)
(www.corporatecitizen.nhs.uk)
(www.carboncounter.org)

Poverty Questionnaire

1) what is your attitudes towards levels of poverty in developing countries
2) do you agree with the statement “poverty in developing countries is a
moral issue"
3) do you agree with the statement "poverty in developing countries could
have consequences that may affect me personally"
4) do you agree with the statement "poverty in developing countries could
have effects which damage the interests of this country"
5) Ways in which respondents thought that the United Kingdom can be affected by
poverty in developing countries
6) what is your perception of the level of contribution towards the reduction of poverty
by the United Nations, the International Monetary Fund and the World Bank,
individual governments of richer countries, the European Union, governments of the
developing countries themselves, international charities, business and private
investors, and the World Trade Organisation.
7 (7.1 - 7.6) what is your perception of the level of commitment of the UK
government to poverty reduction in developing countries
(7.7 - 7.12) Three ways in which you think the UK government should be
contributing to reducing poverty in developing countries
8) Extent to which you think that each Millennium Development Goal would
be achieved by 2015
9 what are your sources of information about the developing world
10) Ways in which the respondent, as an individual, felt that they could most effectively
contribute to the reduction of poverty in developing countries

Accountability: Being Heard

In the first half of the 1990s, 70 states were involved in 93 wars. More than half of these conflicts lasted over five years, forty per cent lasted over 10 years, and wholly one quarter have lasted over 20 years.1 At the same time, civilians are increasingly the targets of conflict rather than simply hapless victims: civilian casualties of war have increased from 10 per cent at the turn of the century, to 50 per cent in the second world war to over 75 per cent in contemporary conflicts. Since 1980, the number of refugees has increased from 2.4 million to 14.4 million2, while IDPs have increased from 22 million to 38 million3. The magnitude and duration of crises have left beneficiary groups reliant on international assistance for extended periods of time.

It has also been suggested that the shift from wars between national armies to wars between militia and guerrilla groups has contributed to the loss of the
rules of conduct of war. Finally, as civilians are increasingly the targets of war, those who come to their assistance - the NGOs - are less likely to be perceived as impartial and neutral.

Listening exercises have resulted in greater understanding of humanitarian actors of the needs, aspiration, problems, and capacities of affected people in conflicts. This has resulted to better policy making and accumulative knowledge for a comprehensive emergency response preparedness, community strengthening and sustainable conflict resolution. For humanitarian agencies listening skills provided tools to be more accountable to their constituencies.

Those that have been silenced by authoritarian regimes find a platform to have their voice heard through humanitarian aid workers. In an environment when collective expressions are suppressed aid workers have duty to change this. The process of listening may be a starting point for community strengthening and self advocacy. But listening should not be just an extractive exercise and need to develop ways for feeding back the compiled information into communities and local officials. The dissemination of findings can highlight concerns over issues regarding health, and educational deficiencies and unemployment and can be translated into an orchestrated advocacy strategy to change policies. Priorities expressed by affected people should not be ignored and need to be exposed to local, national authorities as well as international community.

The critical lesson of this process warns that greater attention should be focused on the issue of accountability. Listening is about respect, respect for the right of those that we tend to assist. Listening process needs to be more responsive and accountable to the voices. Good communication is not just about listening, it is also about making sure what you think you have heard was actually what you were told. It needs to be ensured that conclusions and recommendations based on the collected information are channeled back for revision. Community team should be established to facilitate an ongoing and mutually beneficial listening dialogue between humanitarian workers and target people. The depth of analysis generated from this exchange will be invaluable for implementing programmes, but the long term sustainability of these programmes are dependent on the measure of accountability that they bring to the relationship.

Oxfam GB, (2000), Listening to the displaced: analysis: accountability and advocacy in action, S. Harris



1. D. Smith, the International Peace Research Institute, The State of War and Peace Atlas, Myriad Editions Limited, 1997, p13.
2. State of the World’s Refugees 1995, Oxford University Press.
3 Smith, op cit p26.

Performance Management in Public Services

- What is meant by performance in the public service context, and how can it best be measured?
- Should a service be judged by, say, its accessibility or its financial cost, and who should do the judging?
- How can moves to increase the managerial responsibilities and decision-making powers of public servants be reconciled with democratic control and effective auditing procedures?
- How do we restore to our fellow citizens a sense of involvement in and ownership of key public services?
- How do we restore trust in the professionals who work in them?
- How do we give real local character and pride to hospitals, schools and other public services?

Ensuring participation and civic engagement in policy design and monitoring of reforms is expected to increase commitment and reform outcomes. Many administrations now support this approach, as they increasingly acknowledge that social dialogue and community enforcement are part of the agenda of democratic governance. The main challenge is how to make reforms achieve their goal. This is the basic idea underlying performance-oriented budgeting and management: to shift the emphasis away from controlling inputs and towards achieving results.

Initially it can begin by preparing group dialogues by consulting in a broad sense with civil society representatives, including NGOs, indigenous associations, local governments, academics, and the private sector. These consultations and other meetings with representatives of civic movements, intellectuals, the private financial sector and small enterprises, serve as input into initial drafting, policy design and funding.

As example, in Argentina, social concerns regarding public service delivery were assessed and an attempt made to engage the population in implementing potential solutions. A survey was conducted, interviews held with 100 participants, and three focus groups discussed social demands and key concerns in-depth. To acquire loans, transparency and accountability are more relevant issues. The study found increased citizen participation in monitoring policy implementation, with the emergence of mechanisms for citizen oversight, governmental accountability, and citizens’ access to information, as well as social inclusion measures to secure civil rights.

There is still much to do with respect to measuring the impact of civic engagement on efforts to improve public service provision. Such an assessment requires an extended period of time to observe impacts. Nonetheless, it is unquestionable that citizens’ rights and governance are promoted. Works continue to create capacities within civil society to monitor public management and service delivery. At the same time, governments need to provide greater transparency and access to information so that citizens can monitor governmental activities.

Studies have highlighted the importance of governance in shaping how well private sector firms perform. Much less is known about the role both leaders and governance play in influencing public sector performance. Governments have been engaged in reviewing and reforming the ways in which they keep control over large and complex operations in public services and how those responsible are held to account. Reasons include increasing claims on public expenditure, particularly pensions, healthcare and education, expectations of higher quality public services in line with rising living standards and, in many cases, reluctance on the part of citizens to pay ever higher taxes. Government also has to be more competitive in the face of other potential suppliers in areas like transport, communications and energy. It must show it can do the job it sets out to do.

There is ample evidence that with improvement of technologies, knowledge and knowhows people’s interest to intervene in their community are rising. The increase of choices in other areas of life has also raised level of expectation for delivery of public services. There appears to be a rising level of dissatisfaction with the policies for improvement since resources and tools are expected to bring about more rather than less equitable society. We see a crisis of trust, and a cynicism towards politicians and their ability to deliver solutions.

The government's desire to modernise public services tend toward increase of central control over public services and local government which can waste the public's money. The Gershon report for the Treasury estimated an annual cost of some £8bn for the central regulation of public services. At the same time, this central control has stifled the innovation and enterprise of frontline staff. The Treasury has already reported that local government is producing more efficiency savings than any other part of the public sector. Councils are redesigning their services around the user. We must give people back power and influence over their local service and the future of the places where they live.

The traditional accountability mechanisms hold ministries and agencies answerable for results. But action to change this is underway, to move away from external supervisors approving payments and other decisions in advance–so-called ex ante control–towards systems that internal management taking decisions first, but are subject to audits afterwards–ex post control. This is a change to develop faster and efficient decision making process with shifting large responsibility on public sector managers for taking right decisions in the first place and not just in payment transactions but in strategic management. In other words, better accountability can improve performance, too.

The importance is to back up performance-driven procedures with appropriate accounting and control mechanisms, and ensuring that the two develop in concert with each other. To this end, basing decisions on several types of information is a necessary and realistic approach, and so output performance is considered as part of a package that includes information on fiscal policy and even political factors.
Government shifting the balance of power and policymaking to locally-based officials, leads power to be exercised with and for local people. Similarly, councils must rise to the challenge of a more devolved system. They must be ambitious for their communities, be determined to devolve power further, relentless in driving for continuous improvement, and fearless in shifting responsibility and accountability from government to council leaders.



References:

Towards Sustainable Water-Supply Solutions in Rural Sierra Leone, Oxfam GB Research Report, April 2006

The Active Learning Network for Accountability and Performance, DFID, 2004

From Shouting to Counting, the lessons from communities, World Bank, 2004

T. Curristine, Performance and accountability: Making government work, OECD, 2005

D. Cameron, Public Services, www.conservatives.com

S. Lockhart, the Local Government Association

Public Health Challenges

In the words of Sen, health (like education) is among the basic capabilities that gives value to human life. For individuals and families, health brings the capacity for personal development and economic security in the future. Health is the basis for job productivity, the capacity to learn in school, and the capability to grow intellectually, physically, and emotionally. This point is widely acknowledged by analysts and policy makers, but is greatly underestimated in qualitative and quantitative assessments.

As with the economic well-being of individual households, good population health is a critical input into poverty reduction, economic growth, and long-term economic development at the scale of whole societies. An econometric study (Bloom and Sachs 1998) found that more than half of Africa’s growth shortfall relative to the high-growth countries of East Asia could be explained statistically by disease burden, demography, and geography, rather than by more traditional variables of macroeconomic policy and political governance.

The world is now experiencing a serious public health challenge, facing with the appearance of diseases such as Ebola, SARS, Bird flu and in particular, AIDS, combined with the alarming resurgence of diseases previously thought to have been under control. In order to understand better the political dynamics behind public health we need to recognize that the development of modern forms of governance has emerged simultaneously with new approaches toward the administration of human populations.

Improvements in health care were perceived as part of a nexus of reforms that ranged from better housing and nutrition to an extension of voting rights to ensure that the poor had adequate political representation. The contemporary politics of public health needs to be considered, however, in relation to wider discourses on security and human welfare that are quite different from those of the past centuries.

The contemporary exclusion of the world's poor from adequate medical care is a form of state-sponsored hostility, in which millions are denied even the most basic human rights. These “wasted lives”, the marginalized, the excluded have no value within the global economy. The needs of the global poor are less likely to be addressed effectively. Since most people threatened by AIDS, tuberculosis, unsafe drinking water, and other health threats are poor, they have little or no influence over the global politics of public health.

Existing primary health care services in much of the developing world have been drastically cut back, and services that were once freely available are now increasingly beyond the reach of the poor. And these harmful trends also extend even to the wealthiest global cities where a combination of poverty, homelessness, and cutbacks in primary health care since the 1980s has contributed toward the spread of tuberculosis and other diseases [1,2].

Studies show, people in lower social-economic classes are more likely both to be, and to become disabled, and disabled people are more likely either to be or become lower class. Figures from 2001 ESRC Study show that 8 per cent of people in Social Class I are disabled, compared to 24 per cent of people in Social Class V [3]. In a further survey, it was discovered that 73 per cent of disabled people with mobility and sensory impairments have difficulty accessing goods and services.


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What will happen to my boy after I die?
My husband was ill for a long time since doctors were unable to discern his illness. Finally it came out that he was infected by AIDS. One of my children with myself had been infected. After his father died the school shut my boy out and allowed only to appear for the exams. Close family and friends who had no knowledge of the disease all were avoiding me, while those who were aware had mixed feelings filled with watchfulness and pitying. My only worry now is about the future of my child after I die. I have gained more knowledge about the disease and have come to terms to live with it (Iranian local paper, 2006).
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An examination of the social impact of the global public health crisis shows that women and children have been most badly affected by HIV/AIDS. It is married women in southern Africa and south Asia who make up the largest and most vulnerable group of women, since they are at risk of being infected by their husbands. A new generation of HIV-positive women activists, such as the Nigerian journalist and AIDS campaigner Rolake Odetoyinbo Nwagwu, are now engaged in a vital struggle to challenge the social attitudes and economic inequalities that have driven the devastating impact of AIDS on women and children in developing countries.

Generic drug production in countries such as India, Brazil, and Thailand has succeeded in bringing down treatment costs per patient from $10,000 to $300 per year, yet the WHO has revealed that less than one in 20 people who need antiretroviral treatment in the developing world are currently receiving it. The lobbyists claim that generic drugs undermine profitability, and hence, the incentive for new research.

The production of Knowledge in the fight against disease as public goods, are products that require public provision and financing. When public goods are local (such as police and fire protection) or national (such as public defense), local or national governments, respectively, are the key providers. The fight against disease requires important investments in public goods beyond the means or incentives of any single government and beyond the sum total of national-level programs.

The most important kinds of public goods are those that involve the production of new knowledge, especially through investments in research and development (R&D). Since knowledge does not have consuming quality it makes sense to be openly accessed by all. Yet if research outcomes are freely available, it is difficult to draw funds to invest in R&D in the first place. The combination of public financing of R&D in combination with patent protection for private investors in R&D must have logical for furtherance of research projects.

Thus, public support for R&D for basic scientific research is absolutely essential and there is strong support for this kind of public spending in most market oriented economies. Patent protection gives the incentive for product development and testing, which is both risky and expensive. Public financing should cover risk of the initial stages while patent protection should provide incentives for the later stages of the process. In the case of diseases specific to the poor countries, the incentive mechanisms fail at both ends. Poor-country governments lack the means to subsidize R&D, and patent protection means little when there is no significant market at the end of the process.

There fore, diseases such as malaria tend to be grossly underfinanced. The poor countries benefit from R&D mainly when the rich also suffer from the same diseases! It is helpful to distinguish between three types of diseases.

- Type I diseases are incident in both rich and poor countries, such as measles, hepatitis B, and Haemophilus influenzae type b (Hib), and examples of noncommunicable diseases abound (e.g., diabetes, cardiovascular diseases, and tobacco-related illnesses). Many vaccines for Type I diseases have been developed in the past 20 years but have not been widely introduced into the poor countries because of cost.
- Type II diseases are incident in both rich and poor countries, but with a substantial proportion in the poor countries. R&D incentives exist in the rich country markets but not in proportion to global need; HIV/AIDS and tuberculosis are examples: In the case of TB the situation is worse with very little R&D underway for new and better treatment.
- Type III diseases are overwhelmingly happening in the developing countries, such as African sleeping sickness (trypanosomiasis) and African river blindness (onchocerciasis). Such diseases receive extremely little R&D, and essentially no commercially based R&D in the rich countries.

Some diseases straddle two categories, particularly if treatment and/or prevention is sensitive to distinct strains in rich and poor countries. AIDS falls between Type I and Type II, and malaria falls between Type II and Type III. Still, the basic principle that R&D tends to decline relative to disease burden in moving from Type I to Type III diseases is a robust empirical finding. Type II diseases are often termed neglected diseases and Type III diseases very neglected diseases.

The imbalance of research between diseases of the poor (Type II and especially Type III diseases) and of the rich has been recognized and documented for more than a decade. In 1996 the Global Forum for Health Research was created to document the profound insufficiency of research effort on diseases of the poor. Many initiatives have been launched or continued to address the imbalance, but they remain profoundly under funded.

Just as the rich countries rely both on the combination of R&D subsidies and market forces (albeit based on patents) to deliver new knowledge all the way from basic science to product development, so too the increased subsidization of R&D should be combined with market forces to help ensure that scientific breakthroughs find their way out of the laboratory and in to the clinics. The closest analogy to patent protection would be a mechanism to ensure a producer of a new product that a sufficient market exists to earn a return on product development (including the clinical trials). Another mechanism would be the existing inadequate drug laws in the rich countries, which give added financial incentives (e.g., tax breaks or favorable intellectual property rights provisions) to R&D on diseases with low incidence, such as unusual genetic disorders; this legislation could be extended to provide similar incentives for diseases of high incidence in poor countries and low incidence in the rich countries.

We need to harness the new information technologies to this cause as well. The internet now makes it possible to distribute medical and scientific journal articles and other information in a low-cost, rapid manner to all places with basic hardware and connectivity. Provision of such equipment should be an important element of any donor-supported plan for improving health care based on modern information.

There has been calls for increasing R&D in following major ways: (1) increase funding for basic biomedical and health research; (2) increase funding for existing institutions that aim at new vaccine and drug development, such as TDR, IVR, and HRP, and the public-private partnerships for HIV/AIDS, malaria, and TB, and other diseases of the poor; (3) increased outlays for operational research at the country level in conjunction with the scaling up of essential interventions (4) expanded availability of free scientific information on the internet to increase the connectivity of universities and other research sites in the low income countries; (5) modification of the inadequate drug legislation in the high-income countries to include the diseases of the poor; and (6) precommitments to purchase targeted technologies (such as vaccines for HIV/AIDS, malaria, and TB) as an incentive, especially for later-stage product development.

In addition to R&D, there are other kinds of health public goods activities that require public subsidies, such as standard setting for public health, disease surveillance, and the promotion of best practices in health interventions, data gathering and analysis, disease surveillance, and the promotion of best practices in public health through the dissemination of best international practices.



1) Farmer P. Social scientists and the new tuberculosis. Soc Sci Med.
1997;44:347–358. [PubMed]
2) Gandy M, Zumla A. , editors. The return of the White Plague: Global
poverty and the “new” tuberculosis. London: Verso; 2003. 320 pp.
3) Disability Rights Commission
http://www.drc-gb.org/whatwedo/aboutus.asp


Extracts from:

OXFAM Technical Brief – Vulnerability and socio-cultural
considerations for PHE in emergencies, 2004

Gandy M (2005) Deadly alliances: Death, disease, and the global
politics of public health. PLoS Med 2(1): e4

Sachs, J., D., Macroeconomics and Health: Investing in Health
for Economic Development, WHO, 2001

UN Human Settlements Programme (Habitat). The challenge of
slums: Global report on human settlements. London: Earthscan;
2003

World Health Organization. Treating 3 million by 2005:
Making it happen.

References:
Barnett, T. AIDS in the twenty-first century: Disease and
globalisation. London: Palgrave; 2002.

Garrett, L. Betrayal of trust: The collapse of global public
health. New York: Hyperion; 2000.

Study, Adapt, Experiment, Monitor, and Adjust

What Works for Poverty Reduction

The linkages of health to poverty reduction and to long-term economic growth are powerful, much stronger than is generally understood. The burden of disease in some low-income regions, especially sub-Saharan Africa, stands as a stark barrier to economic growth and therefore must be addressed frontally and centrally in any comprehensive development strategy. The control of communicable diseases and improved maternal and child health remain the highest public health priorities. If these conditions were controlled in conjunction with enhanced programs of family planning, impoverished families could not only enjoy lives that are longer, healthier, and more productive, but they would also choose to have fewer children, secure in the knowledge that their children would survive, and could thereby invest more in the education and health of each child. The improvements in health would translate into higher incomes, higher economic growth, and reduced population growth.

The available evidence is insufficient to guarantee that a strategy that has proved effective in dealing with an issue in one setting will work elsewhere. The proposed suggestion implies that those responsible for programs should seek to learn from and draw on what has worked elsewhere rather than to copy it. This might be done through a process that can be summed up in five words:

study, adapt, experiment, monitor, and adjust.

• Study the approaches used in those projects that appear to have
reached poor groups. Even approaches not directly applicable to a
particular setting can be highly instructive. Investigate, as well, the
reasons the poor do not use available health, nutrition, and population
services. Understanding the constraints faced by the poor or
imposed on them by current strategies can be an important first step
in finding solutions.
• Adapt to local conditions the approaches used in successful experiences
elsewhere, applying the knowledge gained through field experience
and through study of the constraints facing the poor.
Adaptation may often involve combining more than one strategy.
Nearly everywhere, it is also likely to call for a liberal dose of common
sense. Developing effective pro-poor approaches is an art, not a
science.
• Experiment with the adapted approaches by implementing them in a
few, but not too few, places to see how well they work. The populations
served have to be large enough to ensure that implementation
takes place under typical rather than optimal administrative conditions,
to get a good idea of what might happen were the approach
more widely introduced.
• Monitor the experience, using one of the relatively simple techniques
available, to ensure an accurate understanding of how well or how
poorly the approach performs. Monitoring does not have to be nearly
as complicated as some evaluation specialists might lead one to
60 Gwatkin, Wagstaff, and Yazbeck
believe, and it is necessary for a sufficiently correct assessment of program
performance. Program administrators relying on their informal
impressions almost always greatly overestimate the effectiveness of
their activities in reaching disadvantaged groups.
• Adjust the approach according to the monitoring findings. It is
unlikely that any approach will work perfectly the first time around.
At least one and possibly many rounds of adjustment will be needed.
Or, if the prospects of eventual success appear hopeless, drop that
particular approach and try something else.


The World Bank, 2006, What Did the Reaching the Poor Studies Find?
D. R. Gwatkin, A. Wagstaff, and A. Yazbeck

Poverty Mapping

Poverty, income inequality and natural resource degradation are among the important disturbing factors on the way to development in many developing countries. The incidence of poverty defined here is the proportion of households whose per capita expenditure is below poverty line for the respective area. Poverty maps are drawn to develop various kinds of decisions for poverty alleviation. However, like the poverty profile, the use of poverty maps does not provide an estimate of the causal linkage between poverty and the variables that influence it; such maps provide mainly .visual advice, hence, leaving researchers to look for empirical relationships between poverty and socio-economic indicators. There are significant differences in poverty and welfare levels between communities living in different geographical areas.

The major problems to this kind of analysis have been data deficiency and the correct application of analytical tools. However, using a combination of geo-referenced environmental information and household expenditure explore the statistical relation between poverty and the environment at a fine resolution. Cross sectional data can be used to explain the relationship between the location of the poor and the environment and how changes in levels of poverty relate to changes in selected environmental indicators. Specifically, they analyse how incorporation of the biomas information helps improve the precision of poverty estimates. A major strength of the poverty mapping method and inclusion of biomass data is that it calculates the standard errors, a measure of the accuracy of the estimate.

As such, an analytical link between the people and their local environments can be established, that is between the economic data and the Geographical Information Systems (GIS) based environmental data. Information on all dimensions of well-being; household and socio-economic characteristics including education, assets, employment and household consumption expenditure can be aggregated with data from the population and housing census, housing characteristics, location of residences and access to basic utilities to map the spatial distribution of poverty. In order to understand the relationship between poverty and the environment, some additional environmental variables must be combined describing land cover and land use, and roads, as well as rainfall, amount of arable land, distance to nearest towns with varying population densities, slope, rangelands, distance to hospitals, travel times to different towns and roads, and flooding areas.

The small area estimation method requires a minimum of 2 data sets: usually household survey data and census data corresponding to almost the same time period. This approach is useful in estimating poverty estimates for administrative levels (districts, counties and sub counties) on the basis of the census and survey data. The poverty estimates derived from this method are based on household consumption expenditures and a series of household characteristics common to both the survey and census. This method however does not measure any linkages between poverty and environmental variables.

The depth of poverty (or the poverty gap) takes into account not just how many people are poor, but how poor they are on average. It is equal to the head count index multiplied by the poverty gap ratio. This index gives a good measure of the extent or intensity of poverty as it reflects how far the poor are from the poverty line. It can therefore be used to calculate the amount of income that needs to be transferred to the poor in order to eradicate poverty under perfect targeting. However the poverty gap ratio is insensitive to income distribution among the poor.

The severity of poverty (or squared poverty gap) takes into account not just how many people are poor and how poor they are, but also the degree of income inequality among poor households. It is equal to the head count index multiplied by the average squared percentage gap between the poverty line and the income of the poor. It therefore attaches greater weights to the poorest of the poor. The poverty gap squared reflects the degree of inequality among the poor in the sense that the greater the inequality of distribution among the poor, the higher the severity of poverty.

The choice of environmental variables estimates can make a difference in terms of the level of poverty and thus the targeting of poverty alleviation programs. Methodological differences can result in different estimates of the incidence of poverty at district, county and sub county levels. It is interesting that the inclusion of the additional land use data can change the poverty estimates at all levels. The poor are actually using the ecological resources to improve their welfare but in the process they degrade the natural environment as well. Portraying less or more poverty could also be explained by the different land tenure systems in the different regions of the country, such as being communal or private. The tenure system could have productivity impacts and therefore household welfare.

Environmental factors have a significant relationship to a sub counties probability of being poor, such as, better soil will provide better levels of welfare for the communities and therefore result in lower poverty rates. Obviously this justifies the need for interventions to improve soil conditions through better soil conservation practices and possible use of fertilizers in areas with poor soils. Where areas with larger slopes are more affected by poverty does explain effects of erosion. Income inequality has significant negative impacts on poverty. This result is consistent with other findings (see for example CBS, 2005) that areas with higher poverty generally tend to have lower inequality levels. The other significant impact on poverty is representing the potential of the area to flood. A higher potential to flood implies greater vulnerability of the communities, other things being equal and has the expected positive impact on living standards. Communities nearer to the wetlands could be deriving some benefits (water, fish, papyrus and wetland farming) from the wetlands. Interestingly, sub counties with larger income inequality have a low probability of being poor. The importance of soil quality, wetlands, roads, hospitals, grasslands, farmland, built areas, slopes and rainfall are factors that affect the probability of areas being poor. Different factors account for different effects on probability of being poor and therefore the need to devise specific interventions for particular areas.

Evidently environmental factors are important in any poverty eradication effort. Such factors should therefore be considered in the design and implementation of any poverty reduction strategies and used as a guide for resource allocation. This analysis identify where the poor are, under what environmental conditions they live and why the poor are where they are, but there is a need to refine and extend this analysis, including more disaggregate analysis at the agro ecological zone level, as well incorporating supplementary information from other data sources such as the livestock and agricultural census, national agricultural survey, demography and health survey, and service delivery survey.


Oxfam Poverty Assessment,PRSP: A Guideline, www.oxfam.org.uk

CBS and ILIRI (2003). Geographic dimensions of Well-being in Kenya. Where are the Poor? Volume 1. Central Bureau of Statistics, Kenya

World Bank (2002), World Development Report. New York: Oxford University Press

P. Birungi, P. Okiira Okwi, D. Isoke1, (2005), Incorporating Environmental Factors in Poverty Analysis, the Poverty and Economic Policy (PEP) Network,


Elbers C., Lanjouw, J.O and Lanjouw, P. (2002). .Welfare in Villages and Towns: Micro level estimation of Poverty and Inequality.. Policy Research Working paper, World Bank

Jalan, J. and Ravallion, M. (1998). Geographic poverty traps. World Bank

Transitional health care for disabled, children and older adults

Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Transitional care is an essential and crosscutting area of health care for persons with complex health care needs, including older adults, children with special health care needs, and disabled populations. As such, performance in this area needs to be measured including in coordination of care, and continuity of care. Representative locations include (but are not limited to) hospitals, nursing facilities, the patient's home, primary and specialty care offices, assisted living and long-term care facilities. Transitional care is primarily concerned with the relatively brief time interval that begins with preparing a patient to leave one setting and be received in the next. Many transitions are unplanned, result from unanticipated medical problems, occur in "real time" during nights and on weekends, and happen so quickly that formal and informal support mechanisms cannot respond in a timely manner.

Whether our goals are to improve quality, enhance patient-centered care, ensure patient safety, or implement cost effective practices, performance measurement for transitional care provides useful information. Studies on performance measurement for transitional care has come up with multiple factors: accountability is poorly defined, financial incentives are not aligned, information systems are not well connected across settings, each setting requires the use of unique data bases and documentation, and most practitioners have received minimal training for cross-site collaboration. Attention is needed to stimulate quality improvement in transitional care, define accountability, re-align financial incentives, and establishing electronic health information systems.

To date, the area of transitional care has been underrepresented. Ideally, transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It should include logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition (Coleman and Boult, 2003).

The focus of transitional care is to ensure that the health care needs of patients with complex care are met irrespective of where care is delivered. But the health care delivery system, whether examined by payment, quality improvement initiatives, accreditation, performance measurement, or how clinicians define their practice, is increasingly setting-centered. In many respects, the term "health care system" is a misnomer. There are few mechanisms in place for coordinating care across settings, and often no practitioner or team assumes responsibility during patients' transitions. Further, health care professionals are often unfamiliar with the capacity of these settings for delivering care. There have been concerns for hospital patients being discharged and readmitted in short time.

A discussion of the context within which transitional care occurs need describing the factors that contribute to patients' vulnerability. Not surprisingly, transitions in patients' care settings parallel transitions in their physical health status. These patients are not only adjusting to new settings but also to new or worsening health symptoms or changes in their ability to carry out daily functional tasks. Patients in institutional settings often adapt to the environment by becoming dependent and complacent while their needs are being addressed; however, upon discharge to home, patients and family members are abruptly expected to assume a considerable self-management role in the recovery of their condition, with little support or preparation. The prevalence of transient or mental impairment and limited health literacy among patients experiencing care transitions only exacerbates this challenge to preparing for self-care. Family caregivers are both the first and last line of defense for assuring safe and effective care transfers for these vulnerable patients. Their contributions in this area are vastly underestimated as they compensate for the many deficiencies of health care system. It is difficult to discuss family care giving without discussing the challenges of coordinating care across settings. Conversely, it is nearly impossible to discuss the challenges of coordinating care across settings without recognizing the essential role of family caregivers.

An expanding evidence base demonstrates that quality problems exist for patients undergoing transitions across sites of care. Qualitative studies performed in the US, Europe, Canada, and Australia, have produced remarkably consistent results.
These studies have shown that patients are often unprepared for their self-management role in the next care setting, receive conflicting advice regarding chronic illness management, are often unable to reach an appropriate health care practitioner who has access to their care plan when questions arise, have minimal input into their care plan, and are annoyed by having to repeatedly provide the same information to each new set of practitioners. Family caregivers voice feelings of frustration that they are often excluded from care planning meetings, despite their central role in the execution of this care plan. They are also dissatisfied with having to perform tasks that their health care practitioners have left undone (Coleman et al., 2002;Grimmer et al., 2000;Harrison and Verhoef, 2002;Levine, 1998;vom Eigen et al., 1999;Weaver et al., 1998).

Quantitative studies have documented that patient safety is jeopardized due to high rates of medication errors and lack of appropriate follow-up care. During care transitions, patients receive medications from different prescribers who rarely have access to patients' comprehensive medication list. As such, no one clinician is ideally positioned to monitor the entire regimen and intervene to reduce discrepancies, duplications, or errors. Thus although much of the recent attention on medication errors has been setting-specific, the lack of coordination between prescribers across settings may pose challenge. It was found that patients discharged from the hospital experienced associated adverse drug events. Studies indicate that there is a need to more formally support the role of family caregivers in general and in the context of coordination of care across settings in particular since patients who did not have a recommended work-up initiated were 6 times more likely to be re-hospitalized (Moore et al., 2003). Significant lapses in information transfer also threaten patient safety. Each time a patient's medical record is recreated, it increases the chance for a medical error to occur. Further, inadequate information transfer potentially increases health care expenditures. There is the danger for the information that is transferred to be incomplete and even inaccurate. Each of the types of qualitative and quantitative problems conspire to increase rates of recidivism to high intensity care settings when patients' care needs are not met, increase the frequency of medical errors, and increase costs of healthcare.

The absence of performance measurement for transitional care is one of the barriers to quality improvement. Lack of financial incentives and accountability make these "hand-offs" of care extremely vulnerable to medical errors, service duplication, and unnecessary utilization. And without processes in place to measure performance, the serious quality problems will remain undetected, and consequently, ignored. From this perspective, integrating transitional care into performance measurement activities can have impact as a primary driver of quality improvement.

There are a number of points of leverage addressed by transitional care from which to build such initiative. These include attention to the problem of patient safety in general and medication safety in particular, efforts towards making the health care system more patient-centered, cost containment, and expansion of health information technology. Performance measurement could drive improved quality, patient safety, cost containment, and development and dissemination of health information technology.

Oxfam: Access to basic health care

What we do

Azerbaijan programme overview

Oxfam is improving the provision of primary health care in 31 poor rural communities. Communities are helped to run and finance primary health care schemes themselves, with members of the scheme paying a small monthly fee to receive treatment and basic drugs. Where needed, we rehabilitate or construct health clinics and improve water and sanitation systems in the village.

Through our lobbying work on health, we have already achieved amendments in the law regarding health issues and vulnerable people.


Supporting disabled peopleThe Blind People’s Association (BPA) runs a ‘talking library’ in Baku which lends newspapers and books, recorded on tape, to around 4,500 blind and visually impaired people. Oxfam supports BPA, and together we are calling for better education and improved economic and social rights for disabled people by influencing the government and the media.

Making A Living

In the mountainous regions and central plains of Azerbaijan job opportunities are limited and transport links are scarce. Finance for Development, supported by Oxfam, provides poor people with low interest loans to help them start-up or develop small businesses - for example carpentry or hairdressing. Credit groups are trained in good management, and business and bookkeeping skills. Finance for Development is working with 450 credit groups in northwest Azerbaijan.

Oxfam funded a survey and the findings led us to focus on improving and expanding leather production and dairy produce. We are supporting local production such as agricultural producers, dairy producers and leather producers, and helping them create workers’ unions.


Keeping institutions accountableGovernments receiving assistance from the World Bank and the International Monetary Fund have to prepare ‘Poverty Reduction Strategy Papers’ (PRSPs) to hold them accountable for how they plan to spend funds. Oxfam is supporting civil society and the government to provide a fair poverty reduction strategy for Azerbaijan. We are encouraging local municipalities and communities to participate in the implementation of the plan and to monitor the quality of the activities.

We are also working with the government and local municipalities to develop and strengthen local self-governance and encourage institutional reform in 19 municipalities. Municipalities were established seven years ago, but these local authorities lack the capacity and resources to serve community needs. We are strengthening their skills in strategic planning, programme and policy development, needs assessments, and monitoring.

We are working to improve the transparency of government budgeting processes so that communities are given free access to budget information. Oxfam is designing specific mechanisms for direct public participation in budgeting processes at the local level. Municipality budget tracking is being carried out in 13 municipalities. As a result of our work, budget information was shown to the public in 2004 – state and local authority budgets were shared in public hearings and newspapers - a first in the history of post-Soviet Azerbaijan. We are currently analysing the state health care budget. We are also conducting gender analysis of the current budget at different levels to determine how resources can be shared equally between women and men.


Disaster PreparednessIn Azerbaijan, which is at risk from earthquakes and flooding, Oxfam is strengthening its staff team to be able to effectively respond to humanitarian need. We are also in discussion with the deputy Prime Minister’s office about how to increase the country’s preparedness.

What We Do

Armenia Programme Overview

Health for all

Since the collapse of the Soviet Union, Armenia’s state health service has been severely under-funded. Communities have been left without essential treatment, drugs and safe water.

Our partner organisation, Support to Communities, is assisting communities to run and finance primary health care schemes in 128 villages.

Members of the scheme pay a small quarterly fee to receive basic treatment, free drugs, and regular visits from doctors and medical specialists. Where needed, our partner rehabilitates water systems at the clinics.

Together with our partners, we are seeking to influence the national health policies of the government so that everyone has access to affordable primary health care. We are calling on the government to incorporate this health scheme model into the national health strategy.

Through our partner, Future Generation, we are also providing sexual health education for more than 5,000 teenagers and adults, to increase awareness of HIV Aids and sexually transmitted infections.

Disability Rights

Disabled people in Armenia often face discrimination and isolation from society. It’s typical for them to be kept ‘out of sight’. Oxfam supports Kamk and Korov, an organisation that runs a theatre company for deaf youth and is working with the government and media to raise awareness of deaf people’s rights.

Together with Kamk and Korov and our partner Bridge of Hope, we are promoting equal opportunities and lobbying for disabled children to be integrated into mainstream schools. We have already achieved this in four schools in the capital Yerevan. Through their direct work with disabled people, and their advocacy work with decision makers, these two organisations are improving the lives of around 28,000 people –disabled people and their families.

Moniroring and Evaluation

M & E

Monitoring is a continuous internal process, conducted by managers (or those assigned responsibility for M&E), to check on the progress of development interventions (or in this case research programmes) against pre-defined objectives and plans – “keeping the ship on course”.

Evaluations basically ask what happened and why and answer specific questions related to the relevance, effectiveness, efficiency, impact and sustainability of the programme’s outputs. The audiences and tools are different for monitoring, reviews and evaluations.
It is very difficult, if not impossible, to monitor or evaluate unless the research programme’s purpose and outputs are specified in a way which is both clear to all parties involved and which can be assessed. Similarly if M&E is not built in at an early enough stage to allow ownership by key stakeholders, methods to be developed, baselines to be established, indicators to be developed and systems for reporting data to be built in.

Monitoring and Evaluation is used to make sure the research programme is on-track towards achieving its outputs and purpose. Application of mixture of tools means that the M&E system serves both lesson learning and accountability functions. Learning is emphasised in every instances, not just in formal evaluation. Accountability refers to both financial accountability (leading to broader accountability to the public) and also accountability for the achievement of research programme outputs, which impact on stakeholders and lead to poverty reduction. The overall message is that M&E needs to be understood as an integrated reflection and communication system that must be planned, managed and resourced; it is not simply a statistical task or an external obligation. 1

The logframe is a powerful participatory tool in the Logical Framework Approach. It is a matrix that details the logical steps for implementing the programme and organizes thinking (i.e. activities to outputs to purpose to goal). It relates activities and investment to expected results and allows allocation of responsibilities. Logframes are used to identify what is to be achieved, and to determine to what degree the planned activity fits into broader or higher-level strategies. It is used as management tool which sets-up a framework for M&E where planned and actual results can be compared.

To be a useful management tool, a logframe must have good indicators:

DFID defines an indicator as: Quantitative or qualitative factor or variable that provides a simple and reliable means to measure achievement, to reflect the changes connected to an intervention, or to help assess the performance of a development actor.

It is important to note that different audiences have different needs from the same or similar indicators (the moving treetops are an indicator of wind, but the fisherman wants to know about wind direction, the farmer about the strength of the wind). Indicators should be smart. The critical issue in selecting good indicators is credibility, not precision in measurement. Indicators do not provide scientific “proof” or detailed explanations about change. Indicators that are carefully considered and shared among partners are much better than guesswork or individual opinion.

Criteria for indicators should include specific or precise meaning, should be valid, measurable or practical, attainable with clear direction, relevant, and entail timing.

The process of a research program should be established based on logical flow of moving from outcome and purpose into funding phase for achieving goals. The hierarchy of objective moves from new knowledge acquired through the research, toward communicating the outcomes to decision makers, and finally ensuring persuasive argument for policy changes.

The outputs and purpose can be verified by a number of indicators, which serve to monitor the progress of the programme throughout its implementation phases and provide an early warning system for possible shortfalls.

The development of research and communication capacity to use, carry out and communicate research is an important outcome. However, some programmes may wish to integrate capacity building within the logframe, rather than have a specific output on capacity development. If there is no output on capacity development, then it should be included as a verifying indicator against an output – i.e. there must be an indication that the Capacity Building component of the research programme is being monitored and evaluated. Research programmes must focus on the outputs of the research – what has actually been achieved, what the research programme has changed and also providing the evidence of where, when and how this change has happened.

Learning and reflection, as a monitoring process in research programmes, is important for monitoring what is working well and what is not working so well. Any lessons arising from the research programme and how these lessons will be used to improve performance in future years can be summarized under headings such as: Working with Partners, Good Practice/Innovation, Project/programme Management, and Communication.

The Final Report must identify the main lessons learned in the research programme. These lessons are needed for case studies, future design of research programmes, to inform future research strategy and other uses. Case studies and success stories as valuable sources of information should be used regularly.


Oxfam GB monitors and evaluates its work in order to:

• Check progress against objectives and unexpected results
• Learn from experience and adapt projects to optimise their impact
• Provide information and learning to stakeholders and be accountable for our actions and the resources we manage

Seven questions about performance and impact

All processes of impact assessments should contribute to answering following questions:

1. What significant changes have occurred in the lives of poor women, men and children?
2. How far has greater equity been achieved between women and men and between other groups?
3. What changes in policies, practices, ideas, and beliefs have happened?
4. Have those we hope will benefit and those who support us been appropriately involved at all stages and empowered through the process?
5. Are the changes which have been achieved likely to be sustained?
6. How cost-effective has the intervention been?
7. To what degree have we learned from this experience and shared the learning?


Proactive and participatory monitoring and evaluation

Development projects need to provide documented and unambiguous information about their impact on poverty. Implementation completion reports may effectively assess or systematically document project lessons. Participatory methods for monitoring and evaluation provide rapid assessments, and are used as substitutes for thorough evaluation. But for the most part these methods do not use quantitative methods—stunting efforts to systematically trace a project’s impact on beneficiaries. Projects should include both quantitative and participatory mechanisms for tracking change and project impact. Both quantitative and participatory methods are needed to assess a project’s impact on poverty. The monitoring and evaluation strategy can include random sampling to document the impact of certain components as well as a monitoring, evaluation, and information system that uses ongoing participatory evaluation methods to evaluate inputs and outputs. Projects can rely on systematic monitoring of inputs and outputs flowing through the organizations implementing the project.

Impact Evaluation can address:

• Does the program have impacts on participants
• Are impacts stronger for particular participant groups
• Is the program cost-effective relative to other options
• What are the reasons for a program’s performance
• How can the design or implementation be changed to improve performance

Complementary and ongoing participatory monitoring and evaluation, including a quantitative evaluation design, offer two clear benefits in the fight against poverty.

First, ongoing participatory evaluation enables just-in-time inputs into management decisions at the local and central levels. Such inputs promote better management and more responsive alignment of project inputs to achieve project objectives. The dynamic nature of most projects during implementation requires a responsive mechanism so that inputs are adjusted to changing environments—while also providing a means to verify impact on beneficiaries as it occurs.

Second, the quantitative methods used in household and community surveys are important for assessing a project’s impact and for verifying the determinants of that impact. Such assessment and verification is especially essential during a project’s midterm review, when inputs can be realigned as needed. Such efforts can also provide more information for the next phase of the project.




1 Adapted from IFAD M&E Guide, 2002 download the full version from


sources:

http:// www.dfid.gov.uk/research.
http://www.ifad.org/evaluation/guide/index.htm .
UNDP:SelectingIndicators.http://www.undp.org/eo/documents
/methodology/rbm/Indicators-Paperl.doc
http://www.undp.org/eo/methodologies.htm
Case studies are valuable sources of information and appear on the DFID website (www. dfid.gov.uk) and R4D – DFID’s research portal (www.research4development.info).
http://www.oxfam.org.uk/what_we_do/issues/evaluation/
The World Bank, The Impact Evaluation
Thematic Group, PREMnet., (http://prem)

Oxfam: Debt Cancellation

A new report from Oxfam today shows that decisions made at last year's G8 have led to real improvement in the lives of some of the world's poorest people. However, Oxfam is concerned that while debt cancellation is starting to be delivered, the growth in aid in key G8 nations is not enough to meet the promises made at the Gleneagles G8.

The report comes as G8 Finance Ministers, including Gordon Brown, meet in Moscow today to prepare the ground for the leaders' summit in St Petersburg next month. It reveals that while official figures show large aid increases in 2005 and 2006, this is only a temporary spike caused by the inclusion of a substantial one-off debt cancellation deals for Nigeria and Iraq. When these deals are no longer part of the equation at the end of 2007, aid figures will plummet unless the finance ministers change gear on the present rate of aid increases.

Oxfam's director Barbara Stocking said:

"The debt cancellation brokered at last year's Finance Ministers' meeting in London is already helping to deliver essential health and education services but G8 governments must not continue to double count debt cancellation as part of their aid budget."
True aid figures continue to be obscured because official figures still count debt cancellation deals as new foreign aid. Four years ago, at the Monterrey Financing for Development conference, rich countries promised to stop this double counting. Despite their promise, the practice remains unchanged.

Stocking continued:

"The UK government must use its influence to ensure that G8 countries deliver both debt cancellation and increased aid if they are to make poverty history. The millions of people who campaigned for an end to poverty last year will be watching the G8 leaders carefully to ensure they keep their promises."
Last year the G8 promised to increase aid by $50 billion annually by 2010. Although this represents only 0.36% of GNI compared with the O.7% promised at the UN thirty years ago it could pay for every child to go to school and save the lives of 500,000 women who die each year in pregnancy or childbirth. Oxfam's report indicates that all G8 countries, including the UK, must announce clear timetables to increase their aid to meet the 2010 Gleneagles commitment.

Barbara Stocking added:

"At the current rate of progress real aid is not rising nearly fast enough across the G8 countries to meet their Gleneagles aid commitment to increase by $50 billion by 2010. The G8 must make clear how and when they will deliver real aid increases, to pay for vital services such as health and education."

Since the Gleneagles G8, the UK has played a critical leadership role in increasing its aid to Africa and securing new international commitments for more aid to education, increasing its own aid to the Education for All Fast Track Initiative. However Oxfam argues that the UK government needs to look closely at its own record to ensure the aid budget rises in line with the promises they have made.

ENDS

Notes to editors:

Footage is available of schools in Zambia and hospitals in Malawi

The report shows that according to OECD figures, aid (minus debt cancellation) has gone down in Germany, France and the UK. In the UK this figure rises to + 7% when payments to the Commonwealth Development Corporation IN 2005 are deducted. Although real aid in the UK is rising, it is not rising fast enough to meet the UK commitment of 0.7% GNI by 2013.

19 countries, including 13 in Africa, had all their debts to the IMF cancelled in January 2006, and are directing the savings to poverty reduction. Cancellation of their debts to the World Bank and African Development bank will follow in July 2006. When fully implemented, the G8 debt cancellation deal will save poor countries $1.5 billion dollars which they can invest in fighting poverty.

ENVIRONMENTAL CHALLENGES IN THE ORUMIYEH LAKE

The lake and its value

The Orumiyeh Lake is located in the north-west part of Iran at an elevation of 1,276 m asl, covering an area of 5,100 km2 and draining a “closed” catchment of over 50,000 km2. It is a hyper saline water body with an average depth of 5 m and volume of some 18 billion cubic meters (BCM). The salinity of the lake (about 260 g/l) is too high to support the diversity of aquatic fauna, except for algae and microscopic shrimps that are called Artemia. The microscopic shrimps are, however, the main reason of bird diversity and, particularly, the migration of Flamingos to this area. The lake area has been the national park since 1971, and the second Ramsar site since 1975. The lake is also surrounded by a number of saline and freshwater wetlands.

The total estimated surface water resources in the entire basin equate to 9 BCM (7 BCM surface water and 2 BCM groundwater). The average annual precipitation rate over the lake is approximately 250 mm, which corresponds to about 1.2 BCM. The annual average rate of water inflow to the lake is about 4.6 BCM. The average annual rate of evaporation from the lake surface is about 5.8 BCM, which is equal to the total input to the lake from rain and inflow. The existence of the lake is, therefore, dependent on the equivalent freshwater inflow. Reduced water inflow may lead to declining water levels and increasing the salinity concentration to levels exceeding the tolerance limits of Artemia. The loss of Artemia shrimp in turn may cause a decline in the number of birds which migrate to the lake. It also could lead to the loss of economical income of the local people selling Artemia. The decline of water level may expose the salty land, which leads to salty winds that are extremely damaging to the environment, and the 380,000 ha irrigated as well as the 420,000 ha rainfed land. All this will have an adverse impact on the 4.4 million people living in the basin.

Increasing water stress

The past two decades have seen an intensification of water resource and agricultural development in the basin. Future development may lead to the extension of irrigation by 235,000 ha, brining the total irrigated area in the basin to 615,000 ha. Due to the already existing development, the Orumiyeh Basin has suffered intensive and increasing water stress, which revealed itself through irrigation water deficit, rapid drawdown in some aquifers, a 3.5 m water level drop in the lake and a 7.3 km retreat of the shoreline during the recent droughts of 1988–2001, increasing salinity and crystallization of salt on the shores, and a significant decrease in Artemia and Flamingo populations in the lake and the surrounding wetlands. In the end of 2002 the salinity exceeded the tolerance level of the Artemia in the water, and it almost completely destroyed the shrimps, but fortunately some managed to survive in small pockets around the inlets of the largest rivers.
The Orumiyeh Lake Basin is relatively “rich” in water resources compared to many other semi-arid regions of Iran, but even here local and temporal water shortages occurred in all the key water user sectors, especially in the dry years, threatening both the unique ecosystem and the agricultural production. In the valleys, irrigated agricultural production provides an income to a large part of the population, producing mostly fruits and vegetables for the market. In the last decade, the irrigation needs could not be met in many cases at several locations. And with damages to orchards and agricultural lands, a serious depletion of groundwater resources occurred, including saltwater intrusion from Lake Orumiyeh.

The question of balance

The total annual gross water demand in the basin at present is estimated to be 4.4 BCM, of which agricultural demand is about 4.2 BCM and the balance is due to domestic requirements and industry. The projected total future demand for these sectors is about 6.4 BCM. The difference of 2 BCM between the present and the future water demand is mostly due to the increase in agricultural demand, which exceptionally healthy), it is necessary to ensure a long-term mean annual inflow of 4.6 BCM. The variability ofinflow between years and seasons will lead to Artemia losses and salt deposition at times (as has already occurred in the dry spells of 1998-
2002), but the damage may not be irreversible. In other words, the present condition shows that there is a fragile balance between the inflow and evaporation from the lake. But with future irrigation developments the inflow to the lake will be reduced by about one-third (future increase in water abstractions by 2 BCM). In such conditions, the inflow to the lake will be below the required threshold, which is up to (estimated) 70 percent of the time throughout the year on average. This will lead to frequent drops of lake salinity levels below the acceptable range of salt content (about 150–280 g/l for Artemia). The adverse environmental consequences of this are clear from the above, and the associated economic losses have to be quantified in order to ensure what decisions on future water resources development need to be taken. The challenge is to make a trade-off between water potential and the demands of different sectors in order to preserve the environmental sustainability in the region.
Improvement of irrigation efficiency in order to reach a more sustainable coexistence between agricultural and environmental demands seems to be the major task of water and demand management in this basin. The present irrigation efficiency is 30-35 percent, which leaves a lot of room for improvement and saving water that may ensure future irrigation development and satisfy environmental water demand of the Orumiyeh Lake.

Source: IWMI, Intl Water Management Institute