Talking about “aid failure”

This blog entry is in response to the wonderful Aid Bog Forum that Tales From the Hood has organized. The prompt is about discussing “aid failure.”

I think that by framing a conversation about “aid failure” we are missing a vital point, which is that there is no such thing as failure when you are trying something new.

To me, when we talk about true failure, I think that it means repeating a mistake that you have already made and should have learned from and adjusted, or doing something completely inappropriate or negligent – like not doing a needs assessment and building a school somewhere where a clinic is much more needed and a school would not even be used.

The way we in this forum seem to be talking about “aid failure,” is trying out a project that you think will work, based on a good needs assessment, surveying the community and getting buy-in and it still not working the way you thought it would. Can you really call that failure?

We need to make sure people understand that there is a difference between failure and negligence – many times people confuse the two and think that if it’s failed, then someone was doing something wrong or negligent, but that is not the case in most situations. I think we need to change the language we are using, let’s call it “lessons learned,” let’s call it “an experiment,” let’s call it  “trial and error,” but to say that we are failing, doesn’t make any sense when we don’t know the right answers to begin with.

As Shotgun Shack talks about, the world is complex, solutions are complex, they are not straight forward, and many times the things that seem to be right end up being wrong. Unfortunately, we also live in a world where we are taught through our education system that there is only one right answer. We are trained to take standardized tests, where there are only 5 possible answers, A-E, and that only one is correct, and that if you don’t get the correct answer, you have failed that question. But that isn’t true in the real world; there are no right answers, only better and worse solutions.

In science, this notion of “failure” is accepted. Scientists try out experiments, and when they don’t work, they still publish the things that didn’t work, so that other scientists know not to try the same experiment. However, these publications that explain the “failures” help other scientists working on the same issue to figure out ways that it might work, based on the things that didn’t. Look at the work being done on the HIV vaccine, or malaria vaccine. How many times have scientists trying to develop these failed? Many! We still don’t have either one. But because they share information on the failures, we are getting closer to these vaccines being a reality.

Obviously, unlike with science, you cannot repeat an experiment in aid work and always expect to get the same result – the way we always hope when we put out our “models” and “best practices.” But having a detailed idea of what went right and what went wrong – in a totally objective way – will help people to think things through if they are trying to do a similar project and realize that through your “failures” maybe there are things they haven’t thought about that they need to consider.

I think that what needs to happen is that organizations need to start writing reports that are totally honest, comprehensive and candid. These are reports that lay out the facts of the project in a scientific way. I don’t think it is a problem to contrast successes with failures – as Bottom Up Thinking and A View From The Cave mention – as long as both sides are comprehensive. If we can explain what worked and why, and what didn’t work and why not, everyone will be the better for it.

Unfortunately, donor culture expects us to have the right answers, but that is partly our fault. The way that we report is usually flowery and positive, instead of honest and candid. Reports are very rarely a true depiction of what is going on and they have gotten used to hearing our wild success stories. This is especially a problem when we realize that an intervention that we trying is not working, but continue to do it because we don’t want to look bad to the donors – now that is failing because we realize we can fix it, but we don’t.

There is a problem with restricted money and “failure” – which is that sometimes the money you get in that is restricted to a certain project is no longer relevant, but you have this extra cash, and most organizations would rather figure out restricted ways to spend it then to go to the donor and return it, so they create these random projects to spend this extra money and the projects don’t really do anything.

One part of the solution is cultivating a culture that is okay with not knowing the answers right away, that understands that mistakes aren’t bad and that just because you made a mistake doesn’t mean you failed, and that can acknowledge that something didn’t work in order to create a dialog about how to make it better. This needs to be done on an individual level, an institutional level and a cultural level. Obviously this is incredibly difficult, and takes time, but through outlets like the blog Admitting Failure, or the FailFare, we are beginning to shift culture to be more open and accepting of “failure” and discussing “failure”, or rather, interventions that did not work.

Another part of the solution on the organizational side is to just give the restricted money that you can’t use effectively back, or ask to change the restrictions on it. This is incredibly difficult for organizations to do, because they do love getting money, and for good reason, it is definitely hard to come by these days. However, if you have a pot of money for a project that isn’t going to work, the organization needs to step up and say to the donor, “we just cannot use the money you gave us for this, it isn’t going to work.” Like Marc F. Bellemare suggested, there will be donors who are going to love that and appreciate it, and willing to change the restrictions and even want to give you more, and there will be donors who are turned off by it. But hopefully eventually we can get to a point where we have trained people to be okay with that, or even better, give more unrestricted funds.

If there is a way to get donors to put aside a percentage for innovative and experimental work (I mean, it all is, but some is more extreme than others) – basically funds that are earmarked for “failure,” that maybe that is a good start.

I definitely agree with Waylaid Dialectic – we need to get the beneficiaries to be part of the reporting process to really begin to address what worked and what didn’t. At the end of the day, it doesn’t matter if we think something succeeded if they think it isn’t helping. But, with that being said, in many places people will not be open and honest with you about failure because they want you to be there and they want you to stay and think that telling you what’s wrong will drive you away. Also, many cultures and societies aren’t as open with direct criticism and even talking about talking about failure; it isn’t even something fathomable to talk about. We need to figure out how to encourage more openness between the beneficiaries and the organizations trying to implement a project.

Like Soichiro Honda said, “success in 99% failure” or Benjamin Disraeli said “All my successes have been built on my failures.” You are inevitably going to do things wrong, get things wrong, and that is good as long as you have learned from them and do not repeat them. It is productive to fail because a lot of the time that is when you figure out how to succeed.

Community Health Worker Training – Any suggestions?

One of my responsibilities for my job is creating an updated and improved community health worker training manual. Below is the table of contents for the manual with all of the different topics and subtopics that we are going to cover. I was hoping that people might look over it and give feedback about what I could add or just any feedback in general on CHW training.

This is not the instructor training manual, so it does not include the activities, just the content to be covered. I would really love and appreciate any feedback and ideas on how to improve and expand. (In the introduction unit, Baylor and Tingathe are the names of the organization that the CHWs will be working for.)

UNIT 1: INTRODUCTION

  • Introduction to Training
    • Introductions
      • Getting to know each other
      • Ground Rules
      • Logistics of Training
      • Goals of training
      • Overview of what you are going to learn
      • Schedule
      • Administrative Information
    • Introduction to Baylor
    • Introduction to Tingathe
      • Goal and missions of Tingathe
      • History of Tingathe
      • Tingathe Program Components
      • Tingathe Strategic Objectives
      • Tingathe Patient Philosophy
      • Prior success and setbacks of Tingathe programs
      • Relationship between CHV and Site Supervisor
      • Tingathe at You the CHV
      • What does it mean to be a CHV?

UNIT 2: BASIC OVERVIEW OF HIV

  • Introduction to HIV in Malawi
  • Myths about HIV- brainstorming session
  • Basic overview of HIV 
    • What is HIV/AIDS?
    • How you get HIV
    • How you transmit HIV
    • How you prevent HIV
      • Condoms
      • Introduction to Prevention of Parent-to-Child Transmission
        • Overview of Prevention of Parent-to-Child Transmission (PMTCT)
        • Barriers to PMTCT – (include Loss to follow up – see slide from CSTP presentation)
    • Recognizing signs of HIV in children and adults
      • The difference between having HIV as a child and as an adult
  • Diagnosis
    • HTC
    • Dry Blood Sample (DBS)
    • Rapid Test
    • Importance of being tested early

UNIT 3: HIV TREATMENT

  • HIV Treatment
    • What is ART?
    • Who is eligible?
    • WHO staging
    • CD4 criteria
    • pregnant and lactating women
    • children under 2 years of age
    • Prior to starting ART
      •  confirmatory testing
      • Pre-ART counseling
      • importance of 2 caregivers
    • ART regiments in Malawi
      • Commonly used first line regimens for 15 years and older
      • Commonly used first line regiments for 15 years and younger
      • PMTCT regimens
      • Side effects for first line regimens
      • Alternative first line regimens
      • Second line regimens
    • Adherence
      • Definition of Adherence, Loss To Follow Up and Defaulter
      • Overview of good adherence and bad adherence
        • Role of the caregiver in adherence
      • Strategies on maximizing adherence

UNIT 4: COMMON ILLNESSES AFFECTING THOSE WITH HIV

  • STIs
    • What is an STI?
    • STI symptoms and complications
    • STI prevention
    • How to talk with patients about STIs
  • TB
    • What is TB?
    • TB and HIV
    • How TB is transmitted
    • TB symptoms with and without HIV
    • TB screening and treatment
    • What your patient should do if they have TB
    • TB prevention
    • Diagnosing TB
  • Monitoring Nutritional Status
    • How to do a nutritional assessment
      • Measuring height and weight
      • Measuring MUAC and oedema
    • What is malnutrition?
      • Rates of malnutrition
      • Types of malnutrition
    • Using the Wt/Ht% Table
    • Determining the nutritional status of your patient
    • Pregnancy and malnutrition
    • Treating malnutrition
    • Causes of malnutrition
    • Preventing malnutrition

UNIT 5: LIVING HEALTHY

  • Infant Feeding Counseling
    • Exclusive breastfeeding
    • Complimentary feeding
  • Overall preventative service for HIV infected patients
    • CPT
    • IPT
    • ITNs
    • Basic Hygiene
    • Nutrition
  • Family Planning
    • How family planning works
    • Why family planning is important
    • Talking about family planning with your patient
    • Family planning and HIV
    • Common forms of contraceptives
      • Male and female condoms
      • Emergency contraceptives
      • Injectable hormones/ Depo-Provera
      • Oral Contraceptives
        • Combination Pills
        • Progestin only pills
      • IUD or “Loop”
      • Norplant
      • Sterilization
      • Lactation amenorrhea method (LAM)

UNIT 6: CHALLENGES IN HIV CARE

  • Stigma and Discrimination
    • What is stigma?
    • What is discrimination?
    • How does stigma lead to discrimination?
    • How does stigma and discrimination relate to HIV?
    • How are people with HIV stigmatized?
    • How are stigmatized people with HIV discriminated against?
    • What are the causes of stigma and discrimination related to HIV?
    • How does stigma and discrimination affect people with HIV and their families?
    • How does stigma and discrimination against people with HIV contribute to the spread of the virus?
    • Reducing stigma and discrimination
      • How can you reduce stigma and discrimination against people with HIV?
      • How does reducing stigma and discrimination help communities?
  • Mental Health and Psychosocial Care for people with HIV
    • Telling someone that they have HIV
    • Psychological and social impacts of HIV
      • On the individual
      • On the family
      • On the community
      • On the country
    • How to provide psychosocial support
      • How to provides support for your patient
      • How to help communities become more supportive of people with HIV
    • Other sources of psychological support
  • Dispelling myths from brainstorm in Unit 2

 UNIT 7: CHW WORK STRATEGIES

    • Roles and Responsibilities of CHV  
      • Active Case Finding
      • Gathering Locator Information
      • Patient follow-up
        • HIV exposed infants
        • Pregnant women
        • Lactating women
        • HIV infected children
          • Not on ART
          • On ART
          • Other household members
          • Filling out Health Passports
          • Tracing defaulters
          • Role at the clinic
          • Community Education and Sensitization
          • Expectations of a CHV
            • Knowing when to say “I don’t know”
            • Professionalism
              • Accountability
              • Reliability and dependability
              • Punctuality
              • Ethics in your work
              • Integrity and honestly
              • Take yourself seriously
              • Confidentiality
              • Good communication
                • With your patients
                • With your colleagues
                • With your supervisors
                • Written communication
                • Respect and tolerance
              • Community Health Worker Strategies
                • How to do a home visit
                • Dealing with potential problems during home visits
                • Developing relationships with your clients
                • Dealing with clients who are not adherent
                • Time management
              • Self-Care
                • Taking care of yourself so that you can take care of your patients
                • Mental self care
                • Medical self care

UNIT 8: COMMUINTY EDUCATION, SENSITIZATION and MOBILIZATION

  • Community Education, Sensitization and Mobilization
    • Skills
      • How to be a teacher
      • Topics for education talks
    • Strategies
      • How to choose topics for education talks
      • Strategies for community mobilization
      • Challenges with community mobilization
      • How to evaluate a health talk?

UNIT 9: INDICATORS AND DATA COLLECTION

  • What is M&E and why do we do it?
  • Gathering data
    • Walkthrough of mastercards, clinic attendance list
    • Monthly targets
    • Spotting the mistakes
  • Organizational Skills
Follow

Get every new post delivered to your Inbox.