How To Combat Ebola, HIV, Zika For A Few Dollars: Understanding Unintended Outcomes

02/02/2017 02:25 pm ET | Updated Feb 03, 2017
Hand washing, community-led total sanitation, Liberia

In my last blog, I focused on the importance of measurement and evidence in designing and implementing the most effective global development programs. But one of the important things we learn from community-based development is that people and communities are dynamic and development, as a process, can lead to unexpected outcomes from which we can learn and adapt.

One area where Global Communities has seen such unexpected outcomes is in community-based preventative health, where we work with local people to give them the knowledge they need to take charge of their health, develop resilience and prevent infection. An extraordinary example of this was the Ebola crisis in Liberia. Global Communities had already been working on a USAID-supported water and sanitation program in the first counties to be struck with Ebola, making 284 communities “open defecation free,” through the community-led total sanitation process. When Ebola struck we pivoted to conducting safe burials, as traditional burial techniques were considered responsible for the spread of 70 percent or more of Ebola infections. Through community meeting and dialogue sessions that involved the voices of all religions, traditional leaders, and environmental health technicians, we were able to make hygienic, safe burials acceptable across all Liberia, and buried more than 4,000 victims of the disease. With safe burials in place, the rate of infection fell. But as the crisis abated we learned that the 284 communities which were open defecation free, had also remained Ebola-free, despite being surrounded by Ebola hotspots. This was a completely unexpected but extraordinary discovery. Those who even began the process were 17 times less likely to have experienced any Ebola infection. The cost to making a community open defecation free can be as little as $130. Today, we continue these efforts and have brought 2,019 communities through this community-led process to completion, with a further 2,625 in the process now, creating a sanitation barrier between Liberia and neighboring Sierra Leone and Guinea.

From experiences like this we learned to listen to the local communities and the outcomes they describe, whether they are the expected or not, and then to study those outcomes with a view to replicating or adapting our methodologies to other contexts and countries. In Kenya, Global Communities works with USAID and the President’s Emergency Plan for AIDS Relief (PEPFAR) on providing health education to school children. The HOPE Program worked primarily in schools to help improve students’ knowledge about HIV and AIDS, sexually transmitted infections (STIs), and how to prevent health risks including unintended pregnancies. Support was also given to schools, teachers and the Ministry of Education to help improve classroom instruction.

Anti-drug wall mural being painted by youth, HOPE Program, Kenya

By the end of the program, we had accomplished our targets: young men and women knew much more about preventing HIV and STI transmission. 93 percent recognized how abstinence could stop infection of the virus, and 57 percent understood the role condoms can play in preventing the spread of disease. We also saw increased acceptance of those living with HIV, with 93 percent of youths saying they would remain friends with a HIV positive person. This represented significant progress, given that the stigma around HIV and STIs has long been prevalent in East Africa. And the cost? We were able to train more than 79,000 people for $19 per person, per year.

But that wasn’t all. We heard from teachers, parents, and the youth themselves that they were seeing positive changes that we had not anticipated, including improved coping skills, better inter-ethnic and inter-generational communications, and even better academic performance. Surveys of the youth revealed that 86% of primary school males, 62 percent of primary school females, 77 percent of secondary school males and 81 percent of secondary school females felt that their academic performance had improved. Students and parents also reported dramatic improvements in communication between students of different ethnic groups, students and their teachers, and students and their parents. Finally, data showed an overall reduction of risk behaviors, including less conflict in schools, more awareness of gender-based violence, and increased awareness about drug and alcohol use. The peer to peer learning model, around which the program was designed, where students are trained to deliver the program’s messages to other students, was responsible for these outcomes. We are now implementing a follow-on program to continue improving the health of Kenyan youth.

In both cases, the preventative health work we undertook had much broader impacts than expected, impacts that can build social cohesion and education, making these programs tremendously more cost-effective. An ounce of prevention is worth a pound of cure, as Benjamin Franklin said. From the Ebola crisis we have taken the community meeting and dialogue sessions that made such a difference in community education and resilience and, with USAID’s support, we are applying them in Honduras today, to help communities prevent infection with Zika virus.

It is important to measure impact well beyond outputs and expected outcomes and look at the broader, holistic impact of global development. A significant part of that, in community-led development, is the greater social cohesion within and across communities, and the growing access and influence of communities with government, civil society and the businesses around them. To that end, Global Communities partnered with an academic from the University of Southern California to develop a Social Capital Index to understand and measure our impact more broadly. We piloted this index in South Sudan and are now rolling it out in Ukraine. We expect this will help us understand the fullest impact possible of community-led development, to understand which projects are most effective in developing empowered communities, and to help us and others design the best, most cost-effective programs.

In my next blog, I will focus on cost-effectiveness and leveraging local capital toward global development, to help communities around the world develop self-sufficiency.

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