Ugandapanda

Today was EPIC at St. Philip Health Center. Our Visionary In-Charge Moses typified his Go Big attitude by advertising on the radio and churches on the same day…

1. Free HIV testing  (tested 90 people for HIV)
2. Free drop-in Cervical Cancer screening (screened 40 women)
3. The opening of our Inpatient service

And all that in addition to seeing 70 patients as part of regular outpatients. Crazy town.

You heard it right, we’ve opened our Inpatient, 24 hour service. St. Philip is now a mini hospital – sort of. Complete with beds, night staff and everything. We had our first 4 admissions today, 3 with severe malaria and one with bad epilepsy 4 seizures in one day. Great work moses and the team!

“Many attempts to do good fail, but the best are exceptional”
(William MacCaskill, Effective Altruism)

My first 3 Blogs focused on NGOs in the developing world, but this one explores simple question that’s relevant to all of us. Where should we donate money?

Donated money can do a lot of good. William MacAskill calculated that each dollar you give away if used well can be 100x more beneficial to a poor person, than it will be to you. That dollar which could pay for one days food for a girl in a refugee camp might increase her wellbeing 100x more than that sugar rush you get from a $1 coke (which I’m drinking right now). Makes sense right? This is really encouraging and should make us want to give more of our money away. But we have to send that money the right direction, otherwise its could be wasted.

What matters the most is the difference the money makes in the poorer country. Not how much is spent on overheads, or the reputation of the organisation you are giving too, but the bang for your buck. If you invest in a business, you want the best return for your investment. It helps to think the same way about your donation.

Who NOT to give to
Avoid giving money to high profile, big NGOs. (World Vision, OXFAM, TEAR fund, UNICEF etc.) You simply don’t get bang for your buck. I’ll break down what happens to the money you give them, and you’ll see why.

a) About 15-25% of money donated (varies between NGOs) is used for fundraising and administration in Western Countries. This on its own is not a problem.

b) Probably a higher proportion than 20% (its never published) is wasted on meaningless meetings, administration and high salaries for management in the poor country itself. This is an enormous problem.

c) The 60% (or similar) of your money remaining which is used to actually help the poor people, may not achieve what you expect. World Vision’s child sponsorship programme states “Your generous donations will help the whole community have access to vital resources like clean water, nutritious food, healthcare, education, economic opportunities, and more.” This sounds nice, but the holistic community approach is not as good as it sounds. The interventions may be only marginally useful, or worse foster dependence in the community. As far as I could see, they don’t even confirm whether or not they pay the child’s school fees. There’s nothing wrong with keeping it simple and just paying the school fees. Simple may not be sexy, but it could be better.

When NGOs do a wide range of interventions, they are usually not implemented by appropriately trained people. One staff with a bachelor degree in development will one month be doing an agriculture project, then the next month health education, then the next month starting a village savings group. Would you let your Teacher pull out your teeth?  I was recently outside an NGO office when I noticed a bunch of vegetable seedlings in pots. When I asked what they were for, the project officers said that they so they were about to start a big farming project, but the staff “didn’t have much” farming experience so they wanted to check what would grow! NGOs regularly send ‘quality improvement teams to our health centers who drive hundreds of kilometers in big vehicles, offer mostly useless advice and aggressively try and make us change the way we do things for the worse, often in a paperwork heavy direction. An NGO recently came to our Health Center and tried to get our nurses to implement a 16 column cash book, when we are currently struggling to sort out our 2 columns. Nice one.

Large NGO interventions are also unlikely to be based on what evidence shows works. They like activities which sound nice and inspirational to the Western Public but may be useless. There are plenty of examples like ‘playpumps’ (supported by UNICEF and World Vision) where millions of dollars are poured into useless causes, but this happens on a smaller scale all the time. Why didn’t they do it on a small scale, and study the effect before wasting money on that scale? Despite increasing pressure, NGOs still keen to base their interventions on evidence. Heiffer international (who give out cows) even refused an offer to have the effectiveness their method tested against other NGOs. I’m not saying that all development efforts must succeed, but the more we base our interventions on evidence, the better chance we have.

If you give to NGOs, some of your money is wasted, and the rest may used ineffectively. There’s also the issue of NGO corruption, which you may have already read about. So where do you donate if not to the big NGOs? I’ve outlined three possible approaches below, which are better ways of getting bang for your buck.

The Solution

Approach 1) Foster personal connections with friends, acquaintances or small NGOS doing work in developing countries, and give money to them. If you have a friend working in aid or development I’d advocate taking the time and money to  see the work they do, or at least talk to them over skype. When you are personally connected to your giving, you see exactly what happens with your money. The photo and the story of the actual kid you sponsored through school. The well built in the village you visited, the Health Center started. Big NGOs can’t usually manage this personal connection as there too many donors to keep personally connected with. Another bonus is that often close to 100% of your donation goes to the intended target. Cut the middle management! If you give money to build a hospital, 100% goes to building the hospital. If you give money for school fees, 100% is used to pay the fees.

Giving through individuals or to small organisations may not be the absolute most brutally effective use of your money, but we are connected, emotional human beings. The more connected we are to where our money is going, the better we feel and the more likely we are to both being socially conscious in our own lives, and continue to giving money to good causes in the future. “Now that I have seen, I am responsible” (Brooke Fraser)

Approach 2) Focus your donation on the most effective and efficient interventions. What aid will give the best bang for your buck? What organisations can best turn your 1 dollar of happiness into 100 dollars worth for your neighbour across the world? Most of us don’t have the time or brains to crunch the numbers, but luckily super-smart people at organisations like Givewell have done the work for us.

The results may surprise you. It turns out buying kid’s school uniforms is more effective than buying them books. You might have heard that small loans, or microfinance is a massive success in the developing world. One of the founders Muhammad Yunus even won the Nobel Prize for it. Unfortunately, the research seems to show that the billions spend on microfinance may have achieved exactly nothing. Perhaps those women in south-east Asia would have started successful businesses without the loans, the economy in those countries was growing so well anyway.

Givewell mostly selects large Public health programmes as the best value for money.  Malaria Nets, Iodising Salt, Deworming programmes. 6 out of 7 of Givewell’s highest rated charities are healthcare related. The seventh, ‘givedirectly’ simply gives money to the poorest people, no strings attached. Although I instinctively hate the idea, the evidence points to it working well. Unfortunately though, studies can only done on big organisations, so smaller endeavours and innovative efforts by individuals which may be at least as effective get missed.

Approach 3) Give to big NGOs that do one thing well and have clear goals. Although they may be a bit inefficient, and their work may not always be evidence based, at least they have experts trying to tackle specific problems. Amnesty International (human rights advocacy), or Doctors without Borders (Healthcare in warzones and famines) are good examples of this.

*Arowhenua

Give freely, Give well.

Its over 35 degrees, the sun is blazing, and smoke rises around us, blowing ashy clouds in our faces. For the last 3 hours we have been literally standing on piles of slowly burning rubbish which stretch as far as the eye can see. It’s a modern day gehenna, aka Gulu Municipal Council landfill. Today is the day Gulu is supposed to burn 306 boxes of sachet alcohol, the results of one wildly successful enforcement operation..

I’m impatiently pacing through the ash, making calls to determine what is causing the hold up. Wakonye Kenwa members, assorted media people, and groups from churches and mosques are sweltering and holding handkerchiefs over their noses, waiting with varying degrees of impatience.

You’d think that A) once a law with massive public support making cheap plastic-sachet alcohol illegal was passed, and B) 306 boxes of said illegal product was impounded by police, actually destroying the impounded boxes wouldn’t be too hard. Think again. This is Uganda, this is local government. This moment is a classic illustration of caution-driven paralysis that constantly threatens to grind things to a complete halt. To even reach the stage where we could be standing here in the ash, we needed to wade through:

National level corruption. The burning of sachets impounded in December 2016 was delayed for months because of resistance from the Ministry of Trade. The week before, we finally triumphed, which meant we could finally burn the impounded goods.

Obtaining unnecessary permission from Court Despite the insistence that we needed a court order, when we finally made it to the desk of the Chief Magistrate with the correct letters, he confusedly wrote a note saying no order was needed! If something is illegal, just destroy it. Sounds logical enough.

Obtaining unnecessary permission from police. The reason we are all waiting here in this fiery wasteland is that someone decided at the last minute that we need special permission from regional police. Long story. Apparently District officials are busy getting special permission. Which they decided they needed this morning.

Just at the point when people were begging to leave, the truck carrying the sachets appears with an envoy of cars. The moments that followed, unbelievably, made the wait worth while.

District Councillors were so eager to burn the things they leapt on the truck to start throwing boxes down:

It was a decent blaze, with plenty of cheering:

Our members got their pictures taken with their political hero, Norbert Mao, who they absolutely adore. You can tell just how excited they are:

And finally, the media finally switched their camera away from the politicians and the big shots, to zoom in on members of Wakonye Kenwa group, the ordinary people who began the whole struggle for this new law. Here is Angee Santa, telling her story:

 Here is the national TV coverage of the event, unfortunately this shortened version for interview doesn’t include Angee’s interview,  but its some fantastic footage!!

Last year Israel kicked World Vision out of their country for alleged corruption. They claimed a World Vision staff had syphoned off millions of US dollars to a terrorist organisation. Whether this was true or not, the naivety (or dishonesty) of World Vision’s response was staggering. Their leaders seemed to claim that their organisation was free of corruption. Their Australian CEO Tim Costello even said “We have nothing to do with fraud”. You’re joking!

How could an NGO work in an unstable, corrupt country like Palestine without some of their money being stolen? Its impossible. It comes with the territory, part of the business. In parts of the world where corruption is a way of life, its also a way of life within NGOs. A better response from World Vision would have been “There’s bound to be some corruption within our organisation, especially in an unstable area like Palestine, but we do everything we can to minimise that”. Internal and external audits need to be done, but achieve little. The books can be perfect, yet huge amounts of money can still be stolen.

I work for ‘GuluHealth’, the Dicoese of Northern Uganda Health department. We are an amazingly effective (no bias of course), Christian organisation who manage 12 permanent Health Centers in villages. In the 2 years I’ve worked here, I’ve discovered all kinds of corruption. Nurses steal drugs. Staff overcharge patients and pocket the balance. Once a staff member forged a signature to try and steal 10,000 US dollars, but luckily the bank called us before they gave him the money! Nearly everyone I’ve talked to who works for an NGO here has multiple stories of corruption in their organisation. Its part of life. It happens.

Despite all this, I believe our organisation is far less corrupt then big NGOs operating in our area. For a start due to a sharp nose, I think we discover corruption much earlier than NGOs and we provide few opportunities for money to be stolen.

So how does NGO corruption work in ‘real life’? How do you steal money given generously by donors, intended to help the poorest people in the world? Let me take you on a journey into our world! Your auditor won’t pick any of this up I’m afraid.

1) Bribes “If you help me with something small, I will get your Health Centers onto our project”. Simple as that. I was only surprised it was that blatent. Thankfully this NGO responded well when I contacted their British Management, and eventually included some of our facilities on merit rather then on bribes. Unfortunately that corrupt guy is still working for the NGO and still on his merry way raking in bribes. The opportunities for bribes are endless. A substandard building company pays an NGO worker to win a big building contract. An underskilled job applicant bribes the interviewer. Apparently already discredited NGO staff even try to bribe government officials to keep operating in the area! makes NGOs much less effective, as shoddy work or no work gets done when decisions are based on the highest bidder rather than merit.

2) Fake Reports. A good friend working for a large, reputable NGO shared their heartache at having to write a shiny report for work that never even started. Their boss told him to quickly churn out a report for a farming project which the NGO “hadn’t got around” to doing. That’s right, they received the money, did nothing and wrote a wonderful report (with pictures). The donor will never know. Their accounts still showed that staff got paid, vehicles went to ‘the field’ and the report was written, but they did nothing. Just because you hear a wonderful story about Josephine’s life being transformed through a new Ox-plow, doesn’t mean it actually happened.

3)  Fake Receipts. When I ask for a receipt, people often ask if I want it blank, or how much money they should write on it. Receipts are meaningless pieces of paper in this part of the world, and should be treated as such. A white NGO pickup (what else) is “bought for 15,000 US dollars according to the receipt, but only 10,000 was actually paid – the other 5000 is kept by the NGO worker. A fuel receipt is written for 50 litres, but only 30 litres was put into the car.

4) “Legitimised” Corruption (as I like to call it). Bloated accommodation and travel allowances are paid, well in excess of actual costs. Massive budgets are written for trainings, well in excess of what is necessary. Everything possible is written into the budget which benefits the NGO staff, not the people who the money should be helping.

5) Skimming money off the top. Our friend worked for a NGO for 500US dollars a month. A visitor came from England, and asked how much he earned. When he told her, she looked surprised. A week later, he was told he would be backpaid 2500US dollars in unpaid salary for the previous year. He was supposed to be paid 750US dollars a month the whole time, 50% more than the salary he’d been told. Someone stole that money, syphoned into another account. Not many visitors would ask these kind of probing questions. She did well.

We can’t solve the problem 100%, but we can do much better

Solutions

1) Open the can of worms. Be honest that there is corruption in your NGO. Corruption is embedded in the working culture of Northern Uganda, Palestine and much of the developing world. There’s no organisation free of corruption. ‘Danish Church Aid’ has a public record of all corruption investigations, and it hasn’t hurt their donations at all.

2) Stop using receipts as accountability. Find out the actual cost of an good or service, then give work that much money to buy it. Forget about the receipt, keep it for your auditors only! If it’s a big ticket item like a car, involve multiple people in the purchase, which makes stealing money that much harder.

3) Put money through in-country foreign workers. This is an unfortunate, but pragmatic solution. They don’t have to be American or British, they could be Kenyan or Indian or whatever – just people from another context, with no family or cultural ties to the area. As a local manager in big NGO projects, the pressure is enormous to help your family with jobs and money, and dish up as much money as possible money to staff down the chain. Its not fair to expect local people to manage huge amounts of money without stealing some of it to fulfil these cultural expectations. Help both local staff and your beneficiaries by putting the money through a foreign worker.

Patronage is one of the strongest cultural norms in Uganda and elsewhere in the developing world. The President dishes out lucrative government jobs and money to consolidate power. Rich people are expected to pay school fees for poorer relatives, and in return expect unfailing loyalty. It staggers me that USAID runs 100 million dollar projects in Uganda with no Americans on the in-country management team. I believe this was a major reason why two recent USAID Health projects collapsed under the weight of corruption. Lacor hospital is a perfect example of this approach done well. Local Staff run the hospital and make all the decisions. The hospital employs 400 local full time staff, and only one foreigner. What is their job? All the money goes through them. They check money goes to the right places, and clamp down on small scale stealing as it happens to ensure things don’t get out of hand. Brilliant.

4) Value Character above Qualification when you hire workers. Even if other candidated are more qualified or even potentially better at the job, good character will help your NGO more in the end.

5) Look Harder…

6) Zero Tolerance for thieves when (not if) you find them. I know this sounds obvious, but you’d be surprised how many people don’t get fired when they steal from NGOs. Staff have to know they will at the very least fired, and hopefully arrested when they are caught stealing. In my organisation, I’m not allowed to take thieves to the police, which is frustrating. Firing people you loved and trusted is hard. I’ve broken my own rule and not fired thieves because I didn’t want to fire my friends. At the end of the day though it only ended up hurting the poor, sick people we serve.

7) Open communication channels between in-country staff where the money is being used, and donors and other staff in other countries. Be open about it rather than hush-hush and ashamed. If you find corruption in your organisation it means you’ve done well, not that your project has failed, or your NGO is going down.

If you found this third installment useful, check out my first and second blogs on my keyboard warrior’s mission to make the NGO world a better place 😀

She reminded us of why we are here. In a horrible way. She’d come to the new clinic the night before for an emergency delivery. Tragically, the baby was stillborn. The poor women was sick, weak, and crying. She had malaria at the time the baby was still born, and she’d had it a month earlier too, not treated properly. Malaria killed that baby. She’d been to a government clinic while she was pregnant, but they were out of stock of Fansidar, the drug that all pregnant women should get to prevent malaria. An easily preventable death. Bold, in italics and underlined. Preventable.  Ambrose treated her for malaria, and prayed with her. We won’t make those kind of mistakes. She reminded me why we’re here. Starting clinics, where there are none.

One of the first patients with Nurse Ambrose – Not the mourning mother

The fourth and final new clinic. For now at least. I breathed a sigh of relief as the last cupboard was carried off the pickup into the health center. Not only because we had been stuck in the mud (I thought for a while permanently) 20 minutes earlier, but because starting these wee clinics has been a big, satisfying effort.

P

According to the locals, the village is called Okwoto (Flatulence). But if you ask the Bishop, it’s Obanga Pe Wany (God is not selfish). You’ll find neither name on google maps, but you can find the clinic its right here. The two room rectangle building to the left of the road in the middle of the map, next to a big tree. Note the long grass thatched building 40 meters to the north. That’s the local Anglican church. It’s a small, busy center, next to a swampy river. I find it hard to talk to people here, not because my Acholi has gone downhill, but because they speak a different language, Lango. Its pretty close to Acholi, but some words are completely different, including annoyingly the words for medicine and health center!

Pastor Awele, Ambrose and some of the community in front of the clinic.

Its worth noting all the steps Ambrose has to take with every patient. Its not easy running a high quality clinic all on your own! Its more work for each patient than being a Family Doctor in the western world.

• Talk to the patient, examine the patient, make the diagnoses based on our guidelines book, while you are writing the patient notes.
• Do a finger prick test for malaria
• Collect money from the patient, write a receipt and give it to the patient.
• Write the patient details in our record book (Name, Age, Sex, Village, Diagnosis, Drugs to be given etc.)
• Take drugs out of the box, cut the right amount, package them in a drug envelope and then label the drug envelope with instructions.
• Explain the medication the patient has to take, and advice about the illness.
  “Don’t go in a cooking hut if you have pneumonia”
  “Come back for IV treatment if your child gets seizures”
  “Wipe your bum from front to back” – Very important to stop urine infections.
• Pray with the patient

Church in the foreground, clinic in the background. Ambrose stands with the Reverend.

P.S. The first week was promising, on Labour day (ironically) Ambrose saw 19 patients. That’s a big effort when you consider the list of tasks for each patient. I’ll give a report soon on how the first 3 clinics are going. Its still early days but there’s a mixture of success and slow starts!

Three of our staff came into our office after a week long Malaria training. After they raved about how wonderful the training was, I asked them a question. “What is one thing you are going to change, or improve at your Health Center after the training?” Even after prompting and trying to give them ideas, we couldn’t come up with anything. Not one thing. Eight of our staff were there for a week. 320 working hours. Our staff already treat malaria really well. They didn’t need a training on malaria.

The problem

Of all the issues I’ve had with NGOs, meetings and ‘trainings’ is the issue which which has driven me the most crazy, and provided the most hilarity. Don’t get me wrong – trainings can be a core part of NGO work, I run them myself! Just last week Marie Stopes needed to teach our staff how to insert family planning methods, and it worked really well. Often though trainings are a colossal waste of money and time, and more importantly devalue learning by putting barriers, or distractions in the way. I think this is so important, I’ve created my own ridiculous jargon phrase ‘learning distraction’ to emphasise the point. Maybe it can be new NGO speak!

I have so many problems with trainings and meetings, but I’ll limit myself to 7, no… 8.

1) Allowances for participants. Allowances for transport, accommodation, day allowances. ‘Big men’ turn up for 30 minutes to get a wad of cash, reinforcing harmful cultural stereotypes. As well as wasted money, it’s a learning distraction. How can you concentrate on learning when you are waiting for more money than you have seen in weeks? Friends have told me that they sit there all day planning how to spend their 50,000. At one meeting there was nearly a riot when allowances were less than expected. 30 minutes was spent discussing the situation. It was telling when a participant said “this training will be useless if we are not facilitated properly.” In the minds of the participants, I think he was right. At another one day meeting, I was handed 150,000 in allowances, plus a 8 gig pen drive “from the American People.” All 40 of us were. You do the math.

2) Lack of important and practical material taught in effective ways. Material should be evidenced based, with experts, or at least people knowledgeable in their field teaching new information or skills. Models and frameworks are tossed into the ether, never to be used again. Material is often not taught in effective ways that will be practically useful. Much time is also wasted on inefficient group work, which is often a mix of sharing good ideas which most people already know, and reinforcement of bad ones. I’m all for participation, but it needs to be well thought through.

3) General Opulence. Meetings are held in the fanciest hotels. Food is fancier than local wedding food. Everyone is given wee books and pens (and sometimes pen drives!). Bottled water is given on demand. This makes trainings and meetings into a status symbol and I think contributes to a space where people are trying to impress each other, rather than learn together. A huge learning distraction.

4) Meaninglessness of resolutions and action points made. Of the 10 or so meetings/trainings I’ve been to, almost none of the resolutions made have been carried out. So far I’ve been elected onto 3 follow up ‘committees’ that have never met, and never will.

Hard to know exactly what comes next…

5) Paying the people organising the meeting extra money on top of their salary. Why do you pay staff extra to do something that should be part of their regular job? This just encourages NGO staff to hold unnecessary trainings to fill out their wallets as well as their time.

6) Wasted person hours. Half a days material covered in 2 days. Two days material covered in a week. For our malaria meeting 320 hours of quality patient care were taken from us, for next to nothing gained.

7) Unnecessary attendees. People who only speak Acholi at English meetings (happens at most meetings I’ve been to). Random local government officials who have nothing to do with what’s being discussed. ‘Big Men/Women’ who hijack the meeting with speeches and other agendas.  Having unnecessary attendees present causes random off-topic discussions bringing yet another learning distraction.

8) Use of unhelpful NGO jargon, which muddy the waters and provide yet another learning distraction. Much NGO speak has become a quagmire. People all know vaguely what the word means without being able to pin it down. There is also straight confusion, where the speaker means one thing, and the listener hears another. ‘Volunteer’ for example to the western ear means working for no pay out of the goodness of you heart, while to a local listener can mean quite a well paid job! Here’s my NGO-Speak Bingo game I use at meetings to entertain myself. I’ll generally win within the first 30 minutes of the meeting.  I’m not the only one who thinks this is ridiculous.

What does it really mean?

Solutions

Lacor Hospital (the biggest mission hospital in Uganda) has a great solution. They don’t let any staff go to trainings and meetings unless they absolutely have to. And it works really well. When I asked a hospital boss why they don’t allow their staff to go, he said. “Trainings are usually 100% useless and they waste time. Why should our staff go?”

When we do hold trainings, here’s 8 ways to make them better

• Don’t give allowances. The exception perhaps, is an actual refund of public transport costs for people who don’t live in town. If you’re doing a training in the village, people already live there. If you are training educated people, most of them live in town so no transport is needed
• Hold a lot less trainings. Many don’t need to happen. A classic category which are often unnecessary are “stakeholder” meetings, where the NGO invites government officials, religious leaders, community members etc. to tell them about the project in their neighbourhood. They achieve very little and can even add barriers when officials inevitably suggest more meetings, or use the opportunity to add unnecessary bureaucracy to the project. I was really impressed that a hundred-million dollar maternity project we’re working with had zero stakeholder meetings. They talked with us, trained our nurses and then started.
• Invite only people that are going to benefit directly. Target carefully. Don’t invite people who only speak Acholi if you are going to hold the training in English. Don’t invite big people just for the sake of it. Invite people who will be keen to learn, and have a lot to gain.
• Get Experts and top quality presenters to take sessions where you don’t have the expertise. Spend your money here, rather than on other areas of the training. Don’t just get your NGO staff to cover topics that they are not experts in. If you’re going to do it, do it properly.
• Hold meetings and trainings in more austere locations. The District Council hall in Gulu costs only 10,000 to hire. Many trainings and meetings could be squeezed into NGO offices.
• Hold shorter trainings. Can you do this in one day rather than two? What material is less important that you can cut? Can you remove the morning or afternoon tea break?
• Serve Beans and Greens with Posho and Rice for lunch. Why should every meeting have 2 kinds of meat? Make the thing less about the lunch and more about the learning. People will still appreciate a free lunch (eventually, after they get over the meatless disappointment J).
• Ban the Jargon words (start with the bingo table) which can’t be used by trainers or participants. Be specific, use real life examples. Give people a list of words at the start of the training that they aren’t allowed to use. Make it fun by rewarding people who notice when the banned words are used.

Maybe capacity building is required to provide sensitisation to the stakeholders on this issue. I should organise a one week training who will provide facilitation? (Oh dear…) Anyway let me know what you think. Maybe you can add number 9 and 10!