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Not All Good Development Intentions Are Created Equal

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It's a New Year, which always brings a renewed push to make the world a better place. There are more than 966,000 public charities in the United States alone, according to the National Center for Charitable Statistics. Just imagine how many nonprofits there are worldwide.

Add in development-oriented government agencies, nongovernmental organizations, anti-poverty alliances, etc., and the number of groups around the world aimed at bettering society is impressive — and staggering.

But behind the numbers is a basic question: Which ones are actually working?

The Washington Diplomat posed this question to a group of D.C.-based development experts. Below are three initiatives that won praise for making a tangible difference on the ground: a Mexican cash-incentive program that has become the model for many like it around the world, an American nonprofit that made donating bed nets trendy, and a global alliance that revolutionized child health through immunizations.

Incentivizing Well Being: Oportunidades

In December, Mexico's new president, Enrique Pena Nieto, announced a series of sweeping reforms to professionalize the country's lackluster education system, currently under the control of the 1.5-million-member National Union of Education Workers — not the federal government.

The move is ambitious — and needed: The World Economic Forum recently ranked Mexico's education system among the worst in the world; placing it 100th out of 144 nations surveyed.

Despite the admittedly dismal state of education in Mexico today, the country, largely under the previous administration, has quietly made significant strides to giving its youngest citizens a better future.

Last year, Mexican officials announced their country had achieved part of the U.N. Millennium Development Goals (MDGs) — notably the goal of achieving universal primary education — and were inching upward on the rest.

In addition to gains in education, Rolando Rodríguez Barceló, the director of general planning and strategic agenda in former President Felipe Calderón's office, wrote that the country was making a serious dent in extreme poverty and that "the past 10 years have seen a substantial improvement in many of the indicators used to measure the millennium goals."

But he added that the government had focused specifically on education "to break the intergenerational poverty cycle."

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Photo: GAVI / 11 / Riccardo Gangale
In 2011, the GAVI Alliance, formerly known as the Global Alliance for Vaccines and Immunization, introduced the pneumococcal vaccine into Kenya's immunization program. Aware of the high risks of contracting pneumonia in a shanty town, Josephine Anyango, 21, with her 11-month daughter Michelle, was among hundreds of mothers who vaccinated their children at a celebratory event in Nairobi.

Barceló noted that more than 95 percent of Mexican children enrolled in primary education completed it. That was up from 87 percent in 1999, according to MDG data. He also boasted that Mexico was going beyond the MDG threshold by growing preschool enrollment from 50 percent in 2000 to 81 percent in 2010. In addition, childhood mortality and malnutrition rates have been slashed, as have maternal mortality rates.

Although Mexico's development over the past decade was likely caused by a number of factors, many experts attribute a substantial chuck of the progress to a novel social welfare program that the country pioneered 15 years ago: Oportunidades, or "opportunities," formerly called Progresa.

Launched in 1997 and based on a similar Brazil program, Oportunidades pays poor families to invest in their children's health and education rather than simply allocating money without accountability or doling out food handouts. Academics call such programs conditional cash transfers (CCT) and Oportunidades has spawned similar CCT-based programs in more than two dozen other countries.

Oportunidades, which started as a 300,000-family pilot program and ballooned to cover 6.5 million Mexican families, is not a simple cash handout. The transfers are contingent on the family meeting certain criteria: Children must be enrolled in school and maintain an attendance rate of at least 85 percent. Families must also go to the doctor for regular checkups and meet various nutrition requirements. Pregnant women, for example, must receive five prenatal checkups.

The idea is to break poverty's vicious cycle, often passed from generation to generation. Because destitute families often can't pay for schooling — and sometimes rely on youngsters to work to support the family — children in poverty often grow up entering the same low-paying jobs as their forefathers. The theory behind Oportunidades is to invest in impoverished children, and not just their parents.

"Stats show that people who are better educated and are healthier have a better chance of getting out of poverty," said Eric L. Olson of the Mexico Institute at the Woodrow Wilson International Center for Scholars. "That's the best way to break the continuity of poverty."

Santiago Levy, Mexico's former deputy minister of finance and architect of the Oportunidades program, told Public Radio International that this concept works because of the conditions attached to it.

"An important component of the program is what we call co-responsibility," he said. "It really is money that people 'earn' by their good behavior ... so families feel differently about [these] resources ... to the extent that the mothers, in particular, feel that they've earned the right to these resources."

Oportunidades is structured so that poor families receive payments that boost their incomes by between 20 and 30 percent. The grant amounts vary, depending on the level of education of each family member, their access to electricity and tap water, and household assets.

The fixed, bimonthly stipends have two parts: one for food and the second for education, which increases as a student progresses to higher grades. Scholarships for girls tend to include more money because their attendance rates lag behind their male counterparts.

In addition, the supplemental money usually goes to the female head of the household because studies have shown that women are more likely than men to spend extra funds on the family.

Compliance is verified by schools and clinics, though how rigidly this is enforced is questionable given that only 1 percent of participants are found noncompliant.

Still, evaluation is a key component of Oportunidades, which, according to the World Bank, is the first social program in Mexico to carry out a rigorous, independent evaluation of the program's impact, including randomly assigned treatment and control groups. Brazil, for example, started a similar education program in 1995 — which is the largest of these types of CCT programs, encompassing more than 11 million families — but it didn't include such a strong emphasis on tracking progress.

In contrast, Oportunidades sought out the International Food Policy Research Institute (IFPRI), an independent research group based in D.C., to evaluate the program. The reason, in part, was to establish the program's effectiveness so it would survive changeovers in government — which it did.

But beyond that, the rigorous oversight and data collection in Oportunidades "changed the culture of development ... adding an appreciation for seriously evaluating the things we do — not by stories, but by numbers," said Maureen Lewis, a visiting professor in Georgetown University's Global Human Development Program. "That is a very helpful thing to have in development so you're really questioning and trying to figure out what works."

Oportunidades has spawned a whole new way of thinking in the development world. Here in Washington, the Center for Global Development took the CCT concept one step further and created Cash on Delivery Aid (COD Aid), which links payments more directly to a single specific, measurable outcome. At the core of this approach is a contract between funders and recipients that stipulates a fixed payment for each unit of confirmed progress toward an agreed-upon goal. Once the contract is struck, the funder takes a hands-off approach, allowing recipients the freedom and responsibility to achieve the goal on their own. Payment is made only after progress toward the goal is independently verified by a third party. At all steps, a COD Aid program is transparent to the public.

COD Aid programs are still in the pilot stage and will have to overcome obstacles such as technical feasibility (what constitutes a measurable outcome) and buy-in from recipient governments, who may have neither the capacity nor the will to make development a priority.

But proponents of Oportunidades say it is paying dividends and has proved its worth.

"The results of the evaluation of IFPRI show that after only three years, poor Mexican children living in the rural areas where Oportunidades operates have increased their school enrollment, have more balanced diets, are receiving more medical attention, and are learning that the future can be very different from the past," said the coordinator of the Oportunidades-IFPRI evaluation, Emmanuel Skoufias, who is now a World Bank economist.

But the results went beyond education and health care. Nora Lustig, a professor of Latin American economics at Tulane University, wrote in Americas Quarterly last year that the program has played a role in decreasing income inequalities in Mexico — and is well worth the .5 percent of Mexican GDP that officials spend on it annually.

Oportunidades funding and spending on similar programs make up a "small share of total government social spending," she wrote, "but go a long way in terms of redistributing income to the bottom of the income scale."

Nothing But Nets

At the end of the 19th century, Calcutta-based British physician Sir Ronald Ross discovered that mosquitoes were the main carriers of a deadly disease that had plagued humankind for millennia: malaria.

Despite this discovery more than a century ago, a child still dies of malaria every minute. We know how to prevent it, yet according to the World Health Organization, malaria claimed 655,000 lives in 2010 alone — about 85 percent of which were children under 5 years old, mostly in Africa.

But over the past decade, malaria has been on the defense. It's a dying disease that many say will disappear altogether eventually, and much of this success can be attributed to the simple bed net.

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Credit: UN Photo / Eskinder Debebe
U.N. Secretary-General Ban Ki-moon looks at a child's mosquito net to protect against malaria inside his home in Ethiopia.

The parasite that causes malaria is transmitted by the female Anopheles mosquito, which only bites at night. So hanging bed nets over sleeping families living in vulnerable, swampy areas might sound stupidly simple, but it's extremely effective. Studies show that the use of bed nets can reduce malaria transmission by 50 percent and lower child mortality by up to 20 percent.

As a result, the number of organizations dedicated to distributing free bed nets has skyrocketed in the past decade. Perhaps the most popular is Nothing But Nets, a bed-net distribution campaign founded in 2006 by the nonprofit United Nations Foundation.

The campaign exploded onto the scene six years ago when former Sports Illustrated columnist Rick Reilly, a well-known ESPN journalist, wrote a column urging Americans to donate to the UN Foundation's anti-malaria project, which at the time didn't have a name.

Reilly had been disturbed by a documentary he saw that showed children dying every 30 seconds of easily preventable malaria.

"We need nets. Not hoop nets, soccer nets or lacrosse nets. Not New Jersey Nets or dot-nets or clarinets. Mosquito nets," he pleaded in his column, comparing the daily malaria deaths in Africa to the number of Americans who died on Sept. 11 — about 3,000. "That's a 9/11 every day!"

"Save a life by donating $10, or use the money to buy a new Beastie Boys CD?" That was how he framed the issue.

The column was titled "Nothing But Nets." Thousands responded to Reilly's call to action, donating more than $1 million to the campaign within a month.

"We became a movement overnight almost without trying, then we actually tried and became even bigger," laughed Chris Helfrich, director of Nothing But Nets. "What we quickly realized is that by having others with tremendous reach championing the issue and asking others to get involved, you could build a movement."

The UN Foundation decided to build on Reilly's momentum; it renamed its bed net campaign after the column and added a fundraising component. Naturally, its first supporters were sports fans and athletes.

Nothing But Nets is structured so that a $10 donation pays for an insecticide-treated bed net, shipping to the country in need, installation and education for the recipients about why the nets are needed. The campaign has raised more than $40 million so far, sending about 6.5 million nets to vulnerable areas, according to the campaign's online "net-o-meter."

The United Nations has praised the program. A two-page fact sheet on MDG No. 4, a goal to decrease child deaths, singled out the campaign's work in a "what has worked" column.

Of course, Nothing But Nets is not alone in its bed-net fight against malaria. One of the biggest players is the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has distributed 270 million nets.

According to the Global Fund, the percentage of households owning at least one insecticide-treated mosquito net in sub-Sahara Africa is estimated to have risen from 3 percent in 2000 to 50 percent in 2011.

The World Health Organization says prevention measures like bed nets have decreased malaria mortality rates by more than 25 percent since 2000 — 33 percent in Africa alone.

"It is our full intention for this campaign to be around until there are near-zero malaria deaths," Helfrich said. "We can do this in this generation. I don't think it's outside the realm of possibility that we can defeat malaria in the next 10 years. It's about getting nets on the ground."

Ambitious Alliance

About 1.7 million children die from vaccine-preventable diseases annually; that's one toddler every 20 seconds who succumbs to something like measles, pneumonia or diarrhea. But usually one vaccination shot is enough to protect a child for life, and that knowledge, UNICEF says, is pushing the world to ensure that all people have greater access to immunization.

In USAID's "Frontiers in Development," a 2012 collection of essays about development, philanthropist Bill Gates singled out one organization that is changing those numbers, whittling those death tolls down every year: the GAVI Alliance.

Formerly known as the Global Alliance for Vaccines and Immunization, the alliance is a global public-private partnership launched in 2000 that seeks to reduce child mortality rates by helping poor countries buy and deliver immunizations. Since its establishment, the GAVI Alliance has financed the immunization of 370 million children and prevented more than 5.5 million premature deaths.

"Vaccines are phenomenally cost-effective," said Gates, founder of Microsoft. "And because of GAVI, the world will bring the newest vaccine technology to almost all children right away, rather than making the poor wait, and die, for 20 years before the innovation trickles down."

The Bill and Melinda Gates Foundation is one of many players in the alliance, and therein lies its power: The alliance has brought together the skills of all the main specialists in immunization — the World Health Organization, UNICEF, the World Bank, the Gates Foundation, donor governments, developing countries, international development and finance organizations and the pharmaceutical industry — under one cohesive, single-minded umbrella.

By 2008, the alliance had received $3.8 billion in cash and pledges and distributed $2.7 billion to countries with a gross national per-capita income below $1,000 in the hopes of strengthening their immunization programs.

Now, the alliance is seen as a funnel of immunization funds all over the world. It has committed $7.9 billion to developing nations so far, 80 percent of which goes toward purchasing vaccines, according to its website.

"Vaccines can prevent much of the needless suffering caused by infectious diseases — enough to help create a space where families can busy themselves with things other than sheer survival," UNICEF said in its latest State of the World's Vaccines and Immunization report, published in 2009.

"Considerable progress was made in routine immunization against measles worldwide, particularly in Africa, protecting millions of children against this often-fatal disease," praised a U.N. fact sheet. Between 2000 and 2008, for instance, GAVI helped to fund 860,000 immunizations against malaria.

But that just scratches the surface of GAVI's work. Since its founding, the alliance has immunized nearly 300 million children against hepatitis B. According to WHO, hepatitis B cases have dropped by 64 percent in the past decade.

A dramatic example of this turnaround can be found in China, which accounted for almost one-third of all hepatitis B-related deaths worldwide. Just over a decade ago, barely 40 percent of children in China's poorest areas were immunized against hepatitis B, according to the GAVI Alliance. Approximately 10 percent of China's population was chronic carriers of the disease, which is responsible for hundreds of thousands of deaths every year in China due to liver cancer and cirrhosis.

Though China for years had sought to improve investment in the hepatitis B vaccine, which it hoped would be given within the first 24 hours of a baby's birth, the cost per vaccine was too expensive.

But with GAVI helping to split that cost, a $76 million Chinese government initiative led to a dramatic drop in hep B cases. Since the Chinese government introduced the vaccine to its routine immunization program in 2005, the percentage of newborn children immunized with the first dose at birth climbed from 64 percent to over 90 percent in most areas. Less than 1 percent of children under 5 are now chronic carriers of hepatitis B.

"With financial support from the GAVI Alliance and other partners, more children are being immunized than ever before," praises the UNICEF State of the World report on vaccines. "Since 2000, GAVI Alliance support for immunization enabled many low-income countries to strengthen their routine vaccine delivery systems."

The alliance has also been praised for its innovative financing strategies to provide stability in case of future cash crunches.

At one point, GAVI estimated a $3 billion funding gap out of the $8.1 billion it needed to meet its goals through 2015. It took a few approaches to remedy the problem. First, it required all countries receiving funds to prepare a multiyear immunization plan that required able governments to gradually increase their share of the cost of new vaccines. By the end of 2008, 30 countries had begun to pay for part of their vaccinations. By 2011, that number increased to 59.

Secondly, the alliance opened up a new avenue of funding called the International Finance Facility for Immunisation (IFFIm), which uses long-term, legally binding commitments by donors to issue bonds on international capital markets. By 2008, the sale of bonds had raised $1.2 billion from investors worldwide, money the GAVI Alliance needed immediately.

"It allowed us to use capital markets to raise money," said GAVI CEO Seth Berkley about IFFIm while addressing the Child Survival Call to Action conference in June. "It also allowed us to be much more responsive to the needs that we had."

Despite the millions of children who have received their vaccines, last year UNICEF estimated that more than 19 million children under 5 remain unimmunized and thus vulnerable to a host of preventable diseases.

But pessimism no longer bogs down the issue; indeed, organizations like GAVI and its partners are more optimistic than ever that they're on the cusp of eradicating preventable child deaths. At the Child Survival Call to Action conference in Washington, D.C., last June, governments, nonprofits and philanthropists signed pledges to end such deaths by 2035. Of course, GAVI and its partners are an integral part of that ambitious promise.

"We do have an opportunity to make history here," said UNICEF Deputy Executive Director Geeta Rao Gupta, urging attendees to follow through on their pledges. "This goal ... is attainable if we believe it is attainable."


About the Author

Rachael Bade is a contributing writer for The Washington Diplomat.

Last Edited on December 27, 2012

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