Health & Development n. 74 December 2016

HEALTH AND DEVELOPMENT

December 2016/ n° 74

Magazine on International Development and Health Policy December 2016 — No. 74

health and development 74 â „ december 2016

â „ doctors with africa cuamm

NEWS Hepatitis C in the world The number of people in the world with hepatitis C varies depending on the indicator considered. There are more than 100 million people with it if we look for antibodies in the blood against the hepatitis C virus (HCV). This includes all those who have come into contact with the virus, even if they did not then become ill with chronic hepatitis. There are about 80 million people with it who have the virus in their blood (HCV RNA), expressing an active infection or chronic hepatitis C. The figure shows the prevalence of hepatitis C in the world. The overall percentage of people _ 2.5%) in West Africa, Eastern Europe, and suffering from it is 1.1%, with the highest levels (> Central Asia. In Italy, estimated cases fluctuate between 1.25 and 1.75% of the population, which is between 750,000 and a little over a million.

FIGURE / PREVALENCE OF CHRONIC HEPATITIS C IN THE WORLD

Source: Gower E., Estes C., Blach S., Razavi-Shearer K., Razavi H., Global epidemiology of the hepatitis C virus infection, J. Hepatol, 2014; 61, (1 Suppl.): S45-57 (2).

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health and development 74 ⁄ december 2016 ⁄ 1

CONTENTS EDITOR

DIALOGUE

Gavino Maciocco EDITORIAL STAFF

P. 2 Andrea Atzori, Andrea Berti, Dante Carraro, Adriano Cattaneo, Donata Dalla Riva, Silvio Donà, Fabio Manenti, Ana Pilar Betran Lazaga, Martha Nyagaya, Giovanni Putoto, Angelo Stefanini, Anna Talami, Ademe Tsegaye, Calistus Wilunda

IMPROVING OUR WORK THROUGH EVALUATION

EDITOR-IN-CHIEF

HEPATITIS C. VIOLATED RIGHTS

Anna Talami

Text by / Gavino Maciocco

Text by / don Dante Carraro P. 3

A PUBLICATION OF

Medici con l’Africa Cuamm

FORUM

ADMINISTRATION

Via S. Francesco, 126 - 35121 Padova t 049 8751279-8751649 f 049 8754738 e-mail cuamm@cuamm.org EDITORIAL COORDINATION

Chiara Di Benedetto with editing assistance by Valentina Isidoris COVER ILLUSTRATION

Lorenzo Gritti

P. 6

ODON: AN ACCESSIBLE INNOVATION FOR SAFE CHILDBIRTH Text by / Andrea Berti and Simone Agostini Contributions by / Mario Merialdi P. 8

THE NEXT GENERATION PROGRAM: FIGHTING MALNUTRITION Text by / Giulia Segafredo, Andrea Atzori, Maria Brighenti

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EXPERIENCES FROM THE FIELD

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Doctors with Africa CUAMM, Via S. Francesco, 126 - 35121 Padova.

Articles and materials contained in this publication can be reproduced in whole or in part provided that the source is cited

THE CULTURE OF EVALUATION

REGISTRATION AND AUTHORIZATION

An interview of / Giorgio Tamburlini

Law Courts of Padua no. 1129 on 5 June 1989 and on 11 September 1999.

Health and Development is a triannual magazine on international development and health policy

A GOOD PRACTICE OF EVALUATION

P. 12

P. 14 Text by / Calistus Wilunda

DISPATCH

Poste italiane s.p.a. - Spedizione in Abbonamento Postale - D.L. 353/2003 (convertito in Legge 27/02/2004 n° 46) art. 1, comma 1, NE/PD

TAKING A CLOSER LOOK

TRANSLATION

Sara Copeland Benjamin, Miriam Hurley

P. 17

FIRST 1,000 DAYS FOR MOTHERS AND CHILDREN With the support of

Evaluating development projects is critically important, and plays an increasingly strategic role in the formulation of quality development assistance. Evaluation is a good thing because it helps us to measure the effectiveness of our work, think more deeply about processes, ensure transparency, and share best practices.

Text by / Giovanni Putoto

REPORT P. 18

THE CHALLENGES FACED BY CUAMM IN MOZAMBIQUE Text by / Michela Romanelli and Claudio Beltramello P. 19

ETHIOPIA: A COUNTRY TORN BY HUMANITARIAN AND FOOD CRISES Text by / Serena Menozzi

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DIALOGUE IMPROVING OUR WORK THROUGH EVALUATION A conference focused on the evaluation and monitoring of international health projects will be held at the University of Padua on December 2, 2016. Jointly organized by Doctors with Africa CUAMM and the Global Health Center, a multidisciplinary facility of the Tuscany Region, its aim is to share best practices and stimulate debate among those working in the international development field. teXt bY ⁄ don dante carraro ⁄ director of doctors with africa cuamm

There is nothing more constructive than evaluating and measuring the results and impact of one’s work and verifying the processes involved in carrying it out – in other words, putting one’s performance to the test. That’s how we at Doctors with Africa CUAMM envision international health project evaluation, aware both of its intrinsic value and its strategic importance in formulating ever more effective programs and activities. Recent years have seen a growing focus on monitoring and evaluation both in the world of planning in general and the field of international development more specifically, with the publication in recent years of numerous materials and guidelines on the subject 1. It is not just a matter of evaluating individual projects to ascertain whether expected objectives have been achieved (although that has become a must, especially in the case of activities funded by institutional donors). Rather, it is a broader, results-based approach, i.e. one that assesses the impact on a specific area of various factors, including ongoing projects, activities undertaken in partnership with local institutions and communities and our own presence. In order for development to be sustainable over time, all these factors must interact synergically.

Yet too often those conducting evaluations fail to use quality methodologies to measure and assess projects and activities. This is why we believe it is vital to organize an annual forum for debate on the subject, providing an opportunity to listen to and converse with experts as well as those who work in the field. This edition of our magazine features an interview with Giorgio Tamburlini that provides a conceptual framework on the topic (see page 12).

It has been quite a few years now since we at Doctors with Africa CUAMM, recognizing the fundamental importance of monitoring and evaluation, set down our own such path, defining objectives and methods early on during the project design phase.

We use both quantitative and qualitative methodologies, sometimes choosing one over the other and sometimes using a mix of the two 2. Qualitative evaluation has proven to be especially useful in cases where anthropological factors have a significant impact on project outcome: it allows us to better interpret and understand settings, and to go beyond the data to unearth critical aspects related to culture and tradition, providing insight into possible obstacles that we can try to overcome the next time around 3. Evaluation findings of every kind are vital. They make it possible to get an outside opinion on the impact of our work and the processes it involves; for example, a project may bring about good results, yet with a poor cost-benefit ratio.

They also enable us to learn from these processes (indeed, “formative evaluation” has become a real buzzword) and bring transparency to the way we collect data, making it easier to impart results to partners and stakeholders. Finally, nothing is more valuable vis-à-vis project accountability than evaluation.

We saw a good example of this recently when we wrapped up the first five years of our Mothers and Children First program.

A team of external experts conducted an evaluation to assess the work we’d done to improve maternal and child health, for a total of seven separate evaluations measuring the quality, coverage and equity of the services provided in each of the four countries involved in the program (please see Calistus Wilunda’s article on page 14 for an example from Ethiopia). The final assessment showed that the program had had a clearly positive impact, with an even higher number of safe deliveries (+108%) than expected; but it also brought to light some more problematic aspects, such as women’s low use of postnatal care services.

We will discuss all of this at our conference Evaluating international health cooperation projects in Padua on 2 December.

As we work to build up a shared vocabulary on evaluation, we hope the event will provide an opportunity for growth for every participant, and lead to increasingly effective, high-quality and transparent development programs.

NOTES 1 For related materials from the European Commission see http://ec.europa.eu/europeaid/evaluation-approach-andmethodology_en; for materials from the Italian Agency for Development Cooperation see http://www.cooperazioneallosviluppo.esteri.it/ pdgcs/Documentazione/DocumentiNew/All.2__del._99_Convenzione_MAE CI-AICS.pdf; and for LINK 2007 documents see http://www.link 2007.org/ wp-content/uploads/2016/10/Link2007_Policies_di_Valutazione.pdf 2 For a complete list of Doctors with Africa CUAMM publications related

to qualitative, quantitative and mixed evaluations, see www.mediciconlafrica.org/en/fieldresearch/ 3 Our qualitative evaluations include articles such as “A qualitative study on barriers to utilization of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming”

by Wilunda C. et al, in BMC Pregnancy and Childbirth, 2014.

For a complete list of our published work see www.mediciconlafrica.org/en/fieldresearch/

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health and development 74 ⁄ december 2016 ⁄ 3

DIALOGUE HEPATITIS C. VIOLATED RIGHTS The price for the new anti-Hepatitis C drugs being set for each country at the highest level possible for its national wealth makes it sustainable only if a minority of the ill are treated. The market’s economic power in determining the cost of innovation and discriminating against patients violates the right to health protection in the Italian constitution. teXt bY ⁄ Gavino maciocco ⁄ department of public health, universitY of florence

Like with HIV/AIDS, when the discovery of antiretroviral drugs changed the course of the disease and drastically reduced mortality, in 2013, a new class of drugs was discovered for Hepatitis C (called direct-acting antivirals – DAAs). These drugs were able to make the virus disappear within 12 weeks in over 90% of cases. These drugs’ availability is an extraordinary chance and offers hope for all those suffering from this disease. Until now, the only drugs available were not very effective and often poorly tolerated (such as interferon).

WHO issued a recent report on hepatitis C, “Global report on access to hepatitis C treatment. Focus on overcoming barriers”, about the need to overcome barriers to access to new drugs. WHO reports that about 80 million people worldwide suffer from chronic Hepatitis C and that about 700,000 deaths a year are caused by complications from Hepatitis C, especially cirrhosis and hepatocellular carcinoma. The problem is that the new drugs are very expensive. Two to three years since they have come on the market, only a small minority of the ill have been able to benefit from them, just a little more than a million out of 80 million.

The similarities with HIV/AIDS end here and the differences begin. When antiretroviral drugs were introduced, they were very expensive, accessible to the health systems of wealthy countries and completely inaccessible to poor countries. The pharmaceutical companies had a new strategy for Hepatitis C, setting extremely high prices in wealthier countries ($80,000 in the U.S. and $50,000 in Western Europe, for 12 weeks of treatment), and much lower prices in poorer countries (around $1,000), but still consider given the low local purchasing power.

“Setting the price for the new anti-Hepatitis C drugs for each country at the highest level possible for its national wealth means it is sustainable only if a minority of the ill are treated”, as Roberto Satolli wrote. “This triggers an unprecedented rationing, which both violates the principle of health equity, and forces the drugs to be used in the most ill patients, who can derive little benefit from them, while waiting for other patients to worsen, who might have avoided irreversible liver damage.

And this is not an unavoidable side effect. It is intentional” 1 . It is intentional both to maintain a wide swath of patients and prevent the infection from being eradicated, which is the WHO goal by 2030.

“The high cost of Sofosbuvir (the parent of DAA drugs) is creating major discrimination between severely ill patients, who have access to treatment paid by the Italian national health service, and patients in an early stage who are denied this opportunity until the disease worsens. This state of deep social injustice and unequal access to care is ethically unacceptable, especially considering that what is at stake is the right to health guaranteed by our Constitution. It is unacceptable that the cost of innovation is determined exclusively by the market economy”. This condemnation is found in the agenda unanimously approved by the Italian National Federation of Medical Doctors and Dentists on September 16, 2016. It also contains an appeal to the government to use an exception allowed in the patent treaty (“compulsory license” 2) which allows, for reasons of public health, the production of generic drugs, which therefore have a very low cost, accessible to all (also see the petition of Saluteinternazionale.info 3, which Doctors with Africa CUAMM has signed). But this proposal has not managed to pass, in Italy and elsewhere, and there is one simple reason. “The economic and political pressure exerted on governments to renounce using the flexibility allowed by TRIPs (Trade Related Aspects of Intellectual Property rights, the patent treaty ) – according to a recent United Nations report 4 – violates the integrity and legitimacy of the legal system of rights and duties established by the treaty and confirmed by the Doha Declaration. This pressure prevents States from protecting human rights and fulfilling their duties to public health”.

REFERENCES 1 R. Satolli, Epatite C. Prezzo dei farmaci, Ordini dei medici e Nazioni Unite, available at http://www.saluteinternazionale.info/2016/09/ epatite-c-prezzo-dei-farmaci-ordini-dei-medici-e-nazioni-unite 2 A. Cattaneo, Accesso alla terapia contro l’epatite C. La soluzione, available at http://www.saluteinternazionale.info/2016/07/accesso-

alla-terapia-contro-lepatite-c-la-soluzione/ 3 Epatite C. Il diritto alla cura, available on http://www.salute internazionale.info/2016/07/epatite-c-il-diritto-alla-cura 4 Report of the United Nations Secretary-general’s high-level panel on access to medicines, September 2016.

TACKLING THE CHALLENGES OF CLIMATE CHANGE IN AFRICA

Global warming is taking a severe toll on Africa. Increasing numbers of researchers from the Intergovernmental Panel on Climate Change (IPCC) believe that if we continue on the current trajectory the continent will see an increase in temperature of more than 2 degrees Celsius by the end of the century. If that were to happen, the impact on the economies of African countries and the lives of Africans would be devastating, with ever more dire consequences in terms of food security and the availability of clean drinking water.

One of the main focuses of the UN Climate Change Conference, COP22, held last November in Marrakech, Morocco, was on the continents that are most vulnerable to the impact of climate change, yet have little capacity to adapt to it, such as Africa.

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FORUM ODON: AN ACCESSIBLE INNOVATION FOR SAFE CHILDBIRTH A low-cost, strategic innovation for assisted childbirth during prolonged labor: The new low-cost Odon Device has great potential for helping babies during birth and protecting mothers from childbirth complications in developing countries that lack human and material resources. teXt bY ⁄ andrea berti and simone aGostini ⁄ sism – italian secretariat of medical students contributions bY ⁄ mario merialdi ⁄ director of maternal and child health at bd

A FRUGAL INNOVATION: ABOUT ODON

“These days, the true genius of innovation resides in simplicity.

This is not rocket science. This is frugal, strategic innovation that sets out to develop a game-changing intervention, and makes ease of use and affordable price explicit objectives”. These are the words of Margaret Chan, Director-General of the World Health Organization, from her opening address at the 65th World Health Assembly in Geneva on May 21, 2012 1. This frugal, accessible, and practical innovation is precisely what we find in the invention of the Odon Device. Recently invented thanks to a bit of luck and a bit of intuition, as is often the case, Odon could provide major support to safe childbirth for many women in coming years – including in poor countries. Odon is a simple, easy-to-use device, that opens a new chapter in assisting childbirth when there are complications that can be hard to manage in settings often found in developing countries that lack human and material resources.

The idea was the brainchild of an Argentinian mechanic named Jorge Odon. In 2008, he made the connection between childbirth and a trick a couple of his coworkers did to get out a cork stuck in a bottle. Odon is for use in cases of prolonged labor to help the unborn child’s head out of the birth canal. It is made of a polyethylene bag-shaped folded sleeve to place around the unborn child’s head with a soft-bell inserter to help grip the head.

Its use is quite simple. The inserter is put into the vagina and the soft bell “captures” the unborn baby’s head and then lets the Odon Device slip progressively inside the vaginal canal and go around the head. Once it is in the correct position, a self-limited amount of air is pumped into an air chamber inside. This ensures a secure grip (between the fetus’s head and the device) and allows for traction. The inserter is then removed and the fetus’s head can be extracted, making use of the sliding effect between the surface of the birth canal and the Odon Device. When the head is out, the device automatically comes off and delivery is complete.

RISKS AND TRENDS IN USING CHILDBIRTH ASSISTANCE DEVICES

The Odon device, which is still under development, could replace the use of instruments like forceps and suction cups, and, to a

lesser extent, the Cesarean section. Though there is still no consensus about whether the suction cup is better than forceps in terms of adverse event risks, we have seen a decreased use of forceps, especially in higher income countries (though in developing countries as well.) There has been a general trend of using devices less often and a growing use of Cesarean sections.

The WHO has often expressed concern about these trends as the use of Cesarean sections is not always clinically justified. This problem can have a large impact because when Cesarean sections are used inappropriately, they involve significant risk of mortality and morbidity, both for the mother and the unborn baby. There is evidence that using childbirth devices could be crucial for reducing the inappropriate use of Cesarean sections.

ODON’S DEVELOPMENT

From the start, the device’s development was watched with close interest by Argentina’s medical establishment, bringing Odon’s potential to the attention of the WHO in the person of Dr. Mario Merialdi, who was head of the maternal and child health research in 2008.

Preclinical trials were started in 2008 on the Odon Device on a birth simulator provided by the University of Iowa in the U.S. The trial demonstrated the device’s effectiveness. It was also suggested that its use in the body could be facilitated by the elasticity of tissues and biological fluids with a lubricating effect on the device, as well as by uterine contractions and the mother’s pushing.

Odon was then presented at many international conferences about mother, child and newborn health, and met with considerable approval. The invention’s recognition came in several concrete stages. In 2011, it won the Saving Lives at Birth and INNOVAR awards for innovative technologies. Then in October 2012, the FIGO (International Federation of Gynecology and Obstetrics) mentioned the Odon Device in its guidelines as a possible future development for managing second stage of labor (the pushing stage). In 2012, the Odon device was introduced to the public in a talk with its inventor Jorge Odon in TED talk 2, the world-famous platform that invites thinkers and creators to speak publicly about their ideas for 18 minutes.

In 2013, BD, a medical technology company issued a press release

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stating its commitment to work with the WHO to manufacture the BD Odon Device(TM) on a large scale and bring it as quickly as possible and at an affordable price to countries with high maternal mortality where it would have the greatest impact. If the trials have successful outcomes and the device’s promise holds up, BD plans invention’s final launch within a few years.

At this point, the Argentinean mechanic’s invention has had promising results in a study in Argentina on 48 women with prolonged labor. A trial is planned for next year with a new large scale clinical trial, involving Africa as well.

health and development 74 ⁄ december 2016 ⁄ 7

FIGURE 1 / AN IMAGE SHOWING THE ODON DEVICE AND ITS USE

THE POTENTIAL OF A DEVICE “FOR EVERYONE”

The Odon Device seems to have great potential. An important aspect, in addition to its potential safety features, is that it could be used by qualified non-medical staff, making it perfectly suited to settings in which midwives and nurses are the only medical staff.

This feature means that it could have more widespread usage without needing to reorganize the existing systems. The primary goal is to increase safety and achieve good outcomes for procedures that are already provided. It seems that it could be well suited to low-resource contexts.

In disadvantaged settings, like the fragile areas of sub-Saharan Africa, the Odon Device could be an affordable alternative that could lead to less risky childbirth, with fewer infections and hemorrhages and no pain to the fetus.

NOTES 1 M. Chan, Best days for public health are ahead of us, Opening address to the 65th World Health Assembly - Geneva, May 21, 2012. http://www.salute.gov.it/imgs/C_17_pagineAree_1784_listaFile_itemName_5_file.pdf 2 TEDxJoven - J. Odón, Del taller mecánico a la sala de partos, available at https://www.youtube.com/watch?v=N-D8nt2EHQU

FIGURE 2 / AN IMAGE OF THE USE OF SUCTION CUPS AND FORCEPS

BIBLIOGRAPHY Who, A new, simple, low cost instrument for assisted vaginal delivery, available at http://www.odondevice.org/index.php M. Merialdi, Surrounded by Happiness at Birth, available at https://www.youtube.com/watch?v=5RyhVxiwrDo Rai 1, Medicina, available at http://www.odondevice.org/videos/Odon-Rai-2013.mp4 Who, Single use assistive vaginal delivery system, available at http://www.who.int/medical_devices/poster_a08.pdf?ua=1 Jack A., The innovators: devices and services to improve maternal and child health, available at www.ft.com

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FORUM THE NEXT GENERATION PROGRAM: FIGHTING MALNUTRITION Joint promotion of nutrition, growth and development is a primary objective for combatting food insecurity by 2030.

With the Next Generation Program, Doctors with Africa CUAMM will tackle the challenge of acute and chronic malnutrition in two regions of Tanzania over the next 4 years. teXt bY ⁄ Giulia seGafredo, andrea atzori, maria briGhenti ⁄ doctors with africa cuamm

TOWARDS SUSTAINABLE DEVELOPMENT

End hunger, achieve food security and improved nutrition, and promote sustainable agriculture. This is the second goal of the 2030 Agenda for Sustainable Development, which seeks sustainable solutions to ending food insecurity by 2030 1.

Improving nutrition is key to making progress in the fields of maternal and child health, education, employment, the role of women in society, poverty, and inequality reduction in developing countries.

The fight against hunger has expanded over the last 15 years, and progress has been made. Globally, the percentage of undernourished people fell from 15% in 2000–2002 to 11% in 2014–2016.

However, over 790 million people currently lack regular access to adequate food. If these trends stay constant, we will fall short of part of the “Zero Hunger” goal by 2030 1.

Malnutrition takes many forms. There are children who do not grow regularly and do not reach their full potential (chronic malnutrition). There are children who waste to skin and bones and are more susceptible to infections (acute malnutrition), and there are children who are overweight with alarming levels of glucose, salt, and cholesterol in their blood.

International political action and decision making and increased investment in nutrition programs are needed to achieve the Global Nutrition Report 2016 goals. Governments should also consider the indirect benefits of investing in nutrition; it is estimated that $16 of benefit is derived from every one dollar invested 2.

Globally, Africa and Asia have the greatest prevalence of all forms of malnutrition. In 2015 specifically, more than a third of children suffering from chronic malnutrition and more than a quarter of children with acute malnutrition lived in Africa 3.

MALNUTRITION IN TANZANIA

Over the last ten years, Tanzania has made incredible progress on several health indicators, but nutrition is not one of them. Nationwide, chronic malnutrition was found in 34.7% [33.7–35.7] of children aged 0 to 59 months, a very high percentage, according to the World Health Organization (WHO) classification. Acute malnutrition is less widespread than chronic malnutrition but has a considerable prevalence in children under five. In 2014, 3.8% [3.5–4.2] of children under five suffered from global acute mal-

FIGURE 1 / THE NEXT GENERATION PROGRAMME: A OVERVIEW

BENEFICIARIES IN 2 REGIONS IN 4 YEARS

COMMUNITY HEALTH WORKERS

HEALTH CENTERS

• Pregnant and breastfeeding women > 780,000 • Children under 2 years 577,000 • Children under 2 years with chronic malnutrition 232,000 • Children under 5 years 1,650,000 • Children under 5 years with chronic malnutrition 7,700

About 1,400 Role: Education about acute and chronic malnutrition, referral of severe cases to health centers

• Participation of 400 health centers • 7 malnutrition units, built or equipped

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THE NEXT GENERATION PROGRAM: JOINT PROMOTION OF NUTRITION, GROWTH, AND DEVELOPMENT

In December 2015, Doctors with Africa CUAMM launched an innovative program in two Tanzanian regions – Ruvuma and Simiyu – spanning four years, with the goal of using an integrated approach to address acute and chronic malnutrition. The program will integrate prevention and treatment of acute and chronic malnutrition, enabling health workers to manage these conditions, caring for women and children from conception through the first two years of life, following a long-term, 1000-day process.

Assistance will be given women and children both in community settings and in the healthcare facilities. Three aspects will make the program effective: Providing targeted interventions during the critical 1,000 day window, with the goal of preventing chronic malnutrition;

FIGURE 2 / PREVALENCE OF CASES OF MALNUTRITION IN TANZANIA

Stunting

Underweight

Wasting

50 50 PREVALENCE %

nutrition (GAM), and 0.9% [0.9–1.1] from severe acute malnutrition (SAM); an estimated 100,000 children were affected in 2015 4 (Figure 2).

Chronic malnutrition often does not receive the same attention as acute malnutrition and low weight, because its effects and threat to the child’s health and survival of are less immediate. By time a child turns two, most of the damage from the condition has already become irreversible, such as stunted growth (a strong indicator of future human capital). The most effective interventions for preventing the condition are in a time span from the moment of conception to the end of the child’s first two years (also called “the 1000 day window”).

Threats tied to malnutrition in Tanzania impact both health and the economy. Most of these losses are in agriculture, where height and physical strength are essential factors for the country’s productivity 5.

health and development 74 ⁄ december 2016 ⁄ 9

50

48

40

44

42 35

30 20

25

27

25 17

10 8

9

1992

1996

0

6 1999

4 2005

16 5 2010

13 4 2014

Improving identification of these conditions, strengthening the referral and follow-up for SAM cases, stemming from community work in caring for mothers and children throughout their life cycles; Improving costs and operational efficiency of health services while providing services for treating chronic and acute malnutrition in pregnant women and children from conception to 2 years.

Doctors with Africa CUAMM seeks to strengthen the local health system through this program by training workers, providing technical assistance in managing health data, implementing government directives, developing relationships with local authorities and connecting communities to the health centers. This innovative approach has yet to be tested and implemented in Tanzania but has been applied on a limited scale to a few global settings. It is a clear example of integrating several programs with the goal of optimizing resources and strengthening the health system, with special attention to the most vulnerable parts of the population, such as women and children.

REFERENCES 1 UN, 2016. The Sustainable Development Goals Report 2016, 28 October 2016.

2 International Food Policy Research Institute. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030, Washington DC, available at http://www.ifpri.org 3 UNICEF, WHO, World Bank Group, 2016. Levels and trend in child malnutrition, 28 October 2016.

4 The United Republic of Tanzania Ministry of Health and Social Welfare, 2014.

Tanzania National Nutrition Survey 2014 , 2 November 2016, available at http://www.unicef.org 5 UNICEF, 2016. Nutrition, 2 November 2016, available at http://www.unicef.org

CUAMM’S FIRST-EVER RANDOMIZED TRIAL

Doctors with Africa CUAMM’s firstever randomized trial is underway. A collaborative effort with the University of Padua, the study focuses on the effectiveness of the Kangaroo Mother Care (KMC) method together with the use of woolen socks and caps to ensure that the body temperature of preterm infants does not fall outside the normal range. In low-resource settings the risk of neonatal hypothermia is very high, and sometimes fatal. This method could prove to be of great importance even in the most destitute parts of Africa, where incubators are generally not available.

The first 100 young patients have already been enrolled in Mozambique, Ethiopia and Uganda, the three countries that are the focus of the study, and initial data have been collected and are being analyzed. The KMC method is a true exception to the rule: along with salts for oral rehydration, it is the only innovation developed in poorer countries and subsequently “exported” to wealthier ones.

nicola berti

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EXPERIENCES FROM THE FIELD THE CULTURE OF EVALUATION Raising awareness about the fundamental importance of monitoring and evaluating international health cooperation projects: this is the focus of the Doctors with Africa CUAMM conference to be held on 2 December 2016 at the University of Padua, where we will share and discuss guidelines, experiences and future challenges. an interview of ⁄ GiorGio tamburlini / centro per la salute del bambino onlus bY ⁄ chiara di benedetto / doctors with africa cuamm

“Evaluating international health cooperation projects”, a conference jointly organized by Doctors with Africa CUAMM and the Global Health Center, a multidisciplinary facility of the Tuscany Region, will be held at the University of Padua on 2 December 2016. It will be the second edition of the event – the first was held in Florence in September 2015 – and we hope to make it an annual one in order to turn the spotlight on the evaluation process for international development projects and foster a true “culture of evaluation”.

Too often underappreciated, evaluation is the phase of a development project or program that allows us to reflect on, analyze and improve activities as well as helping us to understand which processes work and make them replicable in similar settings, and to analyze and verify the impact of our results. We will delve into the topic on 2 December in Padua with experts such as Franco Conzato (European Commission’s DG for International Cooperation and Development) and Enrico Materia (Italian Agency for Development Cooperation); there will also be a panel discussion where several non-governmental organizations with extensive field experience will be invited to share their experiences with evaluation and spur a constructive exchange of good practices.

In the interview below, Giorgio Tamburlini – key speaker at the conference and director of the Trieste-based non-profit organization Centro per la Salute del Bambino (Center for Child Health) – guides us through the main topics to be discussed at the event.

Why foster a “culture of evaluation”? Does that mean there isn’t one now? And who will benefit?

Basically, we conduct evaluations in order to understand how to do things better and know when it makes more sense not to do them, or to do something different. Not much attention seems to be given in the field of international development assistance to “growing”, not just from a technical and organizational viewpoint but also a cultural one. And that’s something that can only take place through careful reflection, both at the organizational and individual level, about what has been and what is being done. Everyone – both donors and beneficiaries – benefits from a serious, systematic process of evaluation carried out in a timely manner that makes it possible to change course should that prove necessary. It’s also critical that beneficiaries be actively involved in the evaluation activities; their voice – al-

though this brings up the issue of representation: who are the beneficiaries, and who represents them? – is essential if we want to ensure that development aid programs are able to reflect and meet the real needs of communities. This brings up larger issues having to do with the true meaning of development assistance, but here one would need to consult the vast amount of literature on the topic 1.

Who should conduct evaluations?

It isn’t easy to self-evaluate, especially on your own, so it’s a good idea for evaluation activities to be carried out by individuals with experience and expertise, or at least be planned and supervised by people without any potential conflicts of interest in terms of the projects or programs that are being evaluated. That means they should be outside people or organizations that are not actively involved with the program or project. This can pose some problems. On the one hand, of course, there’s the issue of cost, which isn’t always viable for small organizations; on the other, there’s a risk that the people providing services on the front line are excluded from the process of reflection and forced to “adapt” to the evaluation criteria, with the result that they end up focusing more on the latter than on the aim of the program. Or they might perceive the evaluation as some kind of bureaucratic initiative being imposed on them from the outside, and fear its verdict due to concern about the survival of their organizations and their own jobs. But for those who are truly committed to fostering a culture of evaluation in their organizations, there are more complex approaches that limit the need for outside actors without eliminating it altogether, using forms of participatory partnership that can have a lasting positive impact on an organization and its people.

Is conducting evaluations something new to development cooperation, or a well-established good practice?

No, it’s definitely not new. When I first got involved with development aid issues more than thirty years ago, people were already talking about and trying to conduct evaluations both while projects were underway and after they’d ended. In the beginning not much use was made of the findings, in part because many projects wrapped up after just a few years, so a good part of the lessons learned (that is, when someone actually went to the trouble of drawing conclusions

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from the data that had been collected) got lost over time. But that still happens today, even now that evaluation has become a must, with the dissemination of international guidelines and criteria. The ones published by the OECD Development Assistance Committee (DAC) are just one example; eight years ago the Italian Observatory on Global Health (Osservatorio Italiano Salute Globale – OISG) issued a publication that included a summary of them in Italian 1,2.

being familiar with system approaches, usually the system approach to the health system and its various components, but not just that – there’s also the system of stakeholders, with their interests and their values. Ideally, analyses of project results and process should be done in parallel: it’s only by understanding the reason why a particular result was achieved or not that we can make the most of that success or failure.

What gets evaluated? Processes or results?

What happens when an evaluation shows us that something hasn’t worked, or that the expected results haven’t been achieved?

I’ll answer that by again citing the chapter on evaluation in the OISG publication. The DAC criteria for the evaluation of development assistance, for example, include relevance, effectiveness, efficiency, impact and sustainability [see Table 1]. In recent years two increasingly important concepts have joined these criteria: empowerment, which is defined as the process of increasing the “capacity of individuals to make choices and to transform those choices into actions”, and harmonization, i.e. the alignment and coordination of objectives, strategies and logistic approaches among the various agencies involved with a program or project.

But let’s be honest: it’s already relatively uncommon for evaluations to be conducted on results in terms of goals achieved and costs incurred. At times one hears talk about sustainability, a word (less so the underlying concept) that became ubiquitous in the 1990s. With regard to relevance and impact, in order to carry out a comprehensive analysis one needs to take a multidisciplinary approach involving philosophy, bioethics, economics, and perhaps other fields. The Health Impact Assessment 3 has become a discipline to itself, involving dedicated methods and experts. As for evaluating processes – which we should really call “process analysis” – this is fundamental if we want to understand exactly what’s been done and most of all, how, and consequently what kind of things, and how, should be done differently. The concept of the “black box” comes in handy here for analyzing causality; it was actually coined with respect to development aid 4. This kind of analysis requires TABLE 1 / OECD DEVELOPMENT ASSISTANCE COMMITTEE (DAC) CRITERIA FOR EVALUATING DEVELOPMENT ASSISTANCE

CRITERIA

DESCRIPTION

RELEVANCE

CONSISTENCY OF PROGRAM ACTIVITIES AND OUTPUTS WITH THE NEEDS OF BENEFICIARIES, FIRST AND FOREMOST, AND WITH THE OBJECTIVE (OR MISSION) OF DONORS.

EFFECTIVENESS

EXTENT TO WHICH THE OBJECTIVES OF THE PROJECT/PROGRAM HAVE BEEN ACHIEVED.

EFFICIENCY

OBJECTIVES ACHIEVED IN A COST-EFFICIENT (DIRECT AND INDIRECT COSTS) MANNER.

IMPACT

SHORT- AND LONG-TERM EFFECTS OF THE PROJECT, BOTH POSITIVE AND NEGATIVE, ON THE SYSTEM WHERE IT HAS BEEN IMPLEMENTED, AND THUS ON ALL OF THE SOCIAL DIMENSIONS OF THE BROADER SETTING.

SUSTAINABILITY

EXTENT TO WHICH ACTIVITIES – AND THEIR IMPACT – CAN CONTINUE OVER TIME, EVEN AFTER DONOR FUNDING CEASES.

Well, then it’s clear that something needs to be done differently.

There are still many problematic issues: too little evaluation is done, and frequently it’s done poorly. Findings often get no further than someone’s desk or bookshelf, so they’re never analyzed or discussed by the project’s stakeholders, including the beneficiaries. Finally, there’s still too much inertia in organizations, which find it difficult to envision and implement change. If you take all this into account, it’s clear that changes in course to improve the outcome of a project or give it shared meaning don’t happen very often.

How is evaluation done? And what is its relationship with operational research?

I’d need at least a full edition of Health and Development to give you a nutshell answer to the first question. There’s plenty of important literature on the topic, including articles and other work. Essentially, it requires bringing together specific know-how, experience and – I’ll never get tired of repeating this – different perspectives, something that only a multidisciplinary and independent group can ensure.

With respect to the relationship between evaluation and operational research, the basic difference has to do with the fact that evaluation is done for specific projects and its purpose, broadly speaking, is to improve them while they’re underway, reshaping goals and strategies, or to reformulate them if extensions are granted or the organization’s operational guidelines or strategies have been redefined. The aim of operational research, which requires the use of more rigorous methods, is instead to generate knowledge with a potentially universal value, or in any case of more general significance than what we obtain from the evaluation of individual projects. Project evaluations don’t usually get published – at the most you find them in the so-called gray literature – while good operational research should be published in scientific journals.

REFERENCES 1 Third report by the Italian Observatory on Global Health: Global Health and Development Aid. Rights, Ideologies and Illusions, Edizioni ETS, 2008.

2 OECD/DAC, Glossary of Key Terms in Evaluation and Results Based Management, www.oecd.org 3 www.who.int/hia/en 4 Bourguignon F. and Sundberg M. Is Foreign Aid helping? Aid Effectiveness: opening the Black box, in American Economic Review, 2007.

14 ⁄ health and development 74 ⁄ december 2016 ⁄ doctors with africa cuamm

EXPERIENCES FROM THE FIELD A GOOD PRACTICE OF EVALUATION An evaluation measures the impact of the Mothers and Children First program in Ethiopia, where in a five-year period the number of deliveries by a skilled birth attendant in peripheral health facilities rose while the number of traditional home deliveries dropped – a sign that women’s awareness of health services has grown. teXt bY ⁄ calistus wilunda ⁄ department of pharmacoepidemioloGY, universitY of KYoto - Japan

BACKGROUND

The maternal mortality ratio dropped significantly in Ethiopia over the past twenty-five years, from 1,250 per 100,000 live births in 1990 to 353 in 2015 1. The country has also made remarkable progress in reducing child mortality, meeting its MDG 4 target of reducing child deaths by two-thirds between 1990 and 2015 2. But despite these achievements, Ethiopia still has a high number of maternal deaths 1 and a disproportionately high number of neonatal deaths (43% of under-5 deaths are neonatal) 3.

The country’s high maternal and neonatal mortality figures reflect poor maternal and neonatal health service coverage, the poor quality of care provided in health facilities, and inequity in access to health services. Maternal health service delivery in Ethiopia is affected by multiple health system constraints, including inadequate basic health infrastructure, shortage of skilled staff, weak referral systems, limited availability of equipment, limited financing for services, weak management, and poor staff motivation 4,5.

Health workers were trained on maternal and neonatal health care; Staff members of HCs were given supportive supervision; All health extension workers (HEWs) received refresher trainings; The referral system was strengthened through provision of a free ambulance service, provision of communication equipment to HCs, and training of staff on referral protocols; All user fees, including those for management of obstetric and neonatal complications and caesarean sections at the hospital, were waived; Community sensitization activities were conducted by strengthening village (kebele ) command posts, radio broadcasts, and distribution of maternal health information, education and communication materials.

The present study aimed to evaluate the impact of the project in 3 area: access to antenatal care (ANC), delivery by a skilled birth attendant (SBA), and postnatal care (PNC). The evaluation was conducted to assess the progress made in improving access to maternal and neonatal health services in the three districts, and to inform the design and implementation of subsequent projects. A full report of the evaluation is available in Reproductive Health 6.

THE MOTHERS AND CHILDREN FIRST PROGRAM EVALUATION METHODOLOGY

Between 2012 and 2015, Doctors with Africa CUAMM implemented a multifaceted maternal and child health project in three districts (woredas ) in South West Shoa Zone, Oromia region. Its aim was to improve access to maternal and child health services by tackling demand and supply side barriers to service access; it focused mainly on health centres (HCs) and the community.

The project was embedded in the health system of the districts and involved implementation of the following activities: Technical and material support was provided to the zonal health office; Improvements were made to the infrastructure of HCs, including equipping maternity wards with the medical equipment they lacked and providing generators, solar panels and running water; HCs were provided with a regular supply of consumable supplies and drugs to supplement what the government was already providing to them;

The evaluation utilised a before-and-after intervention design based on data collected through two cross-sectional surveys conducted in February 2013 and March 2015.

Each survey included approximately 500 women who had given birth within the two years prior. They were asked questions related to safe practices and health care services during pregnancy and childbirth and following the delivery of the newborn 6.

DEFINITION OF INTERVENTION PERIODS

Three time periods were defined based on the month and year that each woman gave birth, i.e. pre-intervention period (February 2011 to July 2012), early intervention period (August 2012 to December 2013) and late intervention period (January 2014 to March 2015).

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90 80 70 60 50 40 30 20 10 0 Feb-Apr ’11 May-Jul ’11 Aug-Oct ’11 Nov ’11-Jan ’12 Feb-Apr ’12 May-Jul ’12 Aug-Oct ’12 Nov ’12-Jan ’13 Feb-Apr. ’13 May-Jul ’13 Aug-Oct ’13 Nov ’13-Jan ’14 Feb-Apr. ’14 May-Jul ’14 Aug-Oct ’14 Nov ’14-Mar

The evaluation was based on four outcomes: 1) Attendance of at least four ANC visits provided by a health professional or a HEW; 2) receipt of all three basic services during ANC (blood pressure measurement and urine and blood sample analyses); 3) delivery assisted by an SBA; and 4) receipt of PNC provided by a health professional or a HEW within seven days of delivery.

Trends in the outcome indicators were graphically displayed. Logistic regression was used to assess the impact of the project on each outcome, taking into account each woman’s age, place of residence, wealth index tertile, parity, educational level, educational level of partner, and religion.

FIGURE 1 / COVERAGE OF AT LEAST FOUR ANTENATAL CARE VISITS AND RECEIPT OF ALL THREE ANC COMPONENTS

PERCENT

OUTCOMES

MAIN RESULTS

DISCUSSION AND CONCLUSIONS

The evaluation demonstrates that our project was associated with increased coverage in terms of receipt of all three basic components of ANC and delivery assisted by an SBA, but not with the four ANC visits and PNC. Coverage of delivery assisted by an SBA was driven by the increased utilisation of HCs, which were largely underutilized prior to the project. The increase in receipt of all three basic components of ANC suggests that the project improved access to quality ANC. Overall, the project strengthened

4 antenatal care visits

3 ANC components

FIGURE 2 / TRENDS IN PLACE OF DELIVERY

90 80 70 60 50 40 30 20 10 0 Feb-Apr ’11 May-Jul ’11 Aug-Oct ’11 Nov ’11-Jan ’12 Feb-Apr ’12 May-Jul ’12 Aug-Oct ’12 Nov ’12-Jan ’13 Feb-Apr. ’13 May-Jul ’13 Aug-Oct ’13 Nov ’13-Jan ’14 Feb-Apr. ’14 May-Jul ’14 Aug-Oct ’14 Nov ’14-Mar

PERCENT

A total of 999 women were surveyed. Most of them were rural dwellers, married and uneducated. During the implementation of the project we found an increase in the percentage of women who could mention at least three danger signs during pregnancy, who had a positive attitude about maternal health care and a good perception of the quality of the maternal health services accessible to them, and who took specific actions to prepare for the birth of their child.

We also found an increase in coverage of the four ANC visits, receipt of the three basic components of ANC, and delivery assisted by an SBA, but no change in PNC coverage (Figure 1).

The greatest increase seen was in the coverage of delivery assisted by an SBA, a phenomenon that was driven by a larger proportion of deliveries taking place in HCs (Figure 2), which rose from 7.3% in the pre-intervention period to 35.6% in the late intervention period. After taking into account socio-demographic factors, women in the late intervention period were about twice as likely to have received all three components of ANC than those in the pre-intervention period. Women in the late intervention period were five times more likely to have had a delivery assisted by an SBA than those who delivered during the pre-intervention period.

Home

Hospital

Health Centre

the ability of the health system to provide maternal and neonatal health services, but more still needs to be done to ensure further progress and sustainability.

Our project focused mainly on HCs because the hospital was already providing good quality care and being well utilised. Women utilising HCs are more likely to be poorer (and rural residents)

16 ⁄ health and development 74 ⁄ december 2016 ⁄ doctors with africa cuamm

than those utilising the hospital 7, thus the project also helped to improve equity in access to health services.

The fact that the project failed to improve PNC coverage highlights the challenge of providing PNC not only in this particular setting but in Ethiopia as a whole. In the three districts that were the focus of this study, women with uncomplicated deliveries are usually discharged after six hours, and may not return to the health facility in the following few days for a variety of reasons. In 2012, in an attempt to improve PNC coverage, the Ethiopian government adopted a strategy involving a mixture of facility-based and community-based PNC, thereby leveraging the efforts of HEWs. However, a survey conducted in 2014 showed that only

0.8% of women in the Oromia region had received PNC provided by a HEW within two days following delivery of their babies 8. Further efforts and new approaches are needed in order to improve PNC in this setting.

The main limitation of this evaluation design is its inability to account for secular trends in service use. Ethiopia has been experiencing a general nationwide increase in the coverage of maternal health services. For instance, the national percentage of deliveries assisted by an SBA increased from 10% in 2011 to 16% in 2014 3,8. In our study, the coverage of delivery assisted by an SBA more than doubled in a shorter time, underscoring the positive impact of the project.

REFERENCES 1 WHO, UNICEF, UNFPA, World Bank Group, UNPD. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization, 2015.

2 UNICEF, WHO, World Bank Group, United Nations. Levels & Trends in Child Mortality: Estimates Developed by the UN Inter-agency Group forbChild Mortality Estimation. New York, USA: United Nations Children’s Fund, 2015.

3 UNICEF, World Health Organization. Countdown to 2015: Fulfilling the health agenda for women and children, the 2014 report. WHO, Geneva, 2014.

4 Ministry of Finance and Economic Developement, United Nations Ethiopia.

Assessing progress towards the Millenium Development Goals: Ethiopia MDGs report 2012 United Nations Development Program, Addis Ababa, 2012.

5 Federal Ministry of Health. Ethiopia Health Sector Development Program III 2005/06 – 2010/11: Mid-Term Review. Addis Ababa: FMoH, 2008.

6 Wilunda C., Tanaka S., Putoto G., Tsegaye A., Kawakami K. Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: before-and-after comparison. Reprod Health, 2016.

7 Wilunda C., Quaglio G., Putoto G., Takahashi R., Calia F., Abebe D. et al.

Determinants of utilisation of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study. Reprod Health, 2015.

8 Central Statistical Agency [Ethiopia]. Ethiopia Mini Demographic and Health Survey 2014. Addis Ababa, Ethiopia: Central Statistical Agency, 2014.

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TAKING A CLOSER LOOK FIRST 1,000 DAYS FOR MOTHERS AND CHILDREN Following up on the positive results of the five-year program “Mothers and Children First,” Doctors with Africa CUAMM is launching a new action plan focused on the first 1,000 days, from the start of pregnancy to weaning. Nutrition is at the program’s core, taking care of mothers and children in this important phase of life. teXt bY ⁄ Giovanni putoto ⁄ doctors with africa cuamm

Doctors with Africa CUAMM’s new five-year program was launched on November 5 in Padua, in the presence of the President of the Republic Sergio Mattarella. The program is called “Mothers and Children First - 1,000 Days”, and will continue on our work of the last five years of supporting mother and child health. Women and children remain the focus, but care is stretched over a longer span of time: 1,000 days, from conception to about 2 years of age, when children have been weaned and a completed a good portion of their physical and mental development. The first thousand days of life, counting the nine months of pregnancy, are a sensitive, fundamental period for development. Inadequate care in this period can lead to deficits and disabilities for the rest of a person’s life.

And nutrition plays a key role here. The problem of malnutrition is both widespread and long-standing. One in three children under five in Africa is undernourished, and in some countries up to 1 in 3 women is malnourished. There are multiple causes. In the family setting, access to quality food may not be ensured; a mother’s physical and mental condition may be compromised because of stress and domestic violence; and home hygiene may be inadequate; at a societal level, famine, food insecurity, ill-conceived economic policies, and no social safety nets compound the situation. This has interrelated, tragic consequences: 45% of deaths in children under 5 are associated with malnutrition, and 20% of maternal deaths are related to pregnancy-induced anemia. Children who survive often have compromised development with cognitive, motor, and social-emotional deficits; as adults, they tend to develop chronic illnesses and pass these problems onto their offspring. Malnutrition is damaging in economic terms as well, both for individual incomes, almost a third less for those malnourished than for their peers, and nationally, with a Gross Domestic Product loss that the World Bank estimates between 4-10%.

But now there are innovative interventions that can help combat malnutrition by focusing on prevention and treatment of anemia in pregnancy, early exclusive breastfeeding, and on treating acute and chronic malnutrition. These interventions are highly effective, including in terms of economic returns – for every 1 dollar invested in breastfeeding, society gains 35 dollars, and for every 1 euro invested in anemia there are 12 euro “gained.” These gains, of course, come from the health of the people, their ability to work and therefore create growth for the country.

This situation is the starting point for the new challenge Doctors with Africa CUAMM has set itself for the next five years (2017–2021). This is the second phase of the “Mothers and Children First” program. We will keep on providing assistance for childbirth and newborns while aiming to provide nutritional benefits (such as micronutrients) and nutritional education, during pregnancy and after birth through two years of age. Nutrition will be the keystone of the new program, which will involve ten hospitals and ten districts in all of the seven countries where CUAMM works, reaching about 3 million people. Our goals will be to treat at least 10,000 children suffering from severe acute malnutrition and help 50,000 children as they grow to combat chronic malnutrition. Our actions will strive to strengthen the local health system, joining the interventions and services in the community and the peripheral health center and hospital network. A crucial factor will be investing in local human resources through ongoing training and assistance provided by specialized personnel so that mothers and children receive effective and lasting health, nutritional, and social benefits. Through innovation, evaluation, and research, in partnership with universities, research and development centers, and businesses, we will find which tools – starting with local resources – are the most effective in creating an ongoing and sustainable program.

REFERENCES Maternal and Child Nutrition series, Lancet 2013.

Early Child Development series, Lancet 2016.

Investment Framework for Nutrition, World Bank 2016.

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REPORT THE CHALLENGES FACED BY CUAMM IN MOZAMBIQUE Despite forecasts of rapid economic growth in Mozambique, most of the population continues to live in extreme poverty. Doctors with Africa CUAMM carries out activities here to guarantee health care for mothers and their children and train a new generation of Mozambican doctors. teXt bY ⁄ michela romanelli and claudio beltramello ⁄ doctors with africa cuamm

Following the discovery of massive gas reserves in northern Mozambique in 2011, the country has lived in anticipation of a new phase of frenetic development that has, however, failed to materialize for most of its citizens.

There are two contrasting sides to Mozambique, which was ranked 180 out of 188 countries by the 2015 Human Development Index (HDI). With an average annual GDP growth of 7% in the last decade, it has made significant economic progress for 20% of the population, yet for the more than 50% that lives beneath the poverty threshold, things are moving very slowly indeed – and sometimes even going backwards.

Mozambique gained independence from Portugal decades ago, in 1975, but continues to suffer from the consequences of its 16year-long civil war, which ended in 1992. Over the last year it has experienced a severe crisis brought on by several factors: the drought at the end of 2015; an escalation of hostilities between the country’s two opposing political parties, Frelimo and Renamo, which started out in a limited way but then spread to several of its provinces, leading to growing numbers of internally displaced persons and refugees in Malawi in the first half of 2016 1; the devaluation of the local currency and the withdrawal of international support following the discovery of hidden debt.

When the cost of oil fell, there was a drastic setback in the runaway development, construction of luxury hotels and commencement of tourist-related activities that had earlier swept through the city of Pemba, in Cabo Delgado Province, where the gas reserves were identified in 2011 off the coast just a few kilometers from Tanzania.

People’s purchasing power has weakened dramatically and the cost of rice has doubled, forcing people to “invest” half of their basic monthly income in order to buy a quantity sufficient to feed an average family for a month.

Even as Mozambique continues to be identified as one of the African countries most likely to achieve significant economic

NOTES 1 Approximately 2,500 refugees were reported through July 2016 (Al Jazeera).

2 Data from the Demographic Health Survey (DHS), 2011.

growth, the living conditions of most of its citizens – especially the most vulnerable among them, mothers and their children – have failed to change for the better. The infant mortality rate is 75 deaths per 1,000 live births (in Italy the figure is 3.3) and the maternal mortality rate around 500 deaths per 100,000 live births (in Italy the figure is 4). There are not enough hospital services and/or health care personnel to meet the country’s needs, and most pregnant women lack access to medical care. It is in this context that Doctors with Africa CUAMM, which has been present in Mozambique since 1978, launched a project in 2016 focused on mothers and newborns in the provincial hospital of Pemba as well as others in larger districts, health centers and local communities, providing training to midwives on infant care and how to recognize warning signs for complications.

The health indicators in Cabo Delgado Province are among the worst in the country, with a maternal mortality rate of 822 deaths per 100,000 live births, infant and newborn mortality rates of 82 and 35 deaths per 1,000 live births, respectively, and 43% of children under the age of five suffering from chronic malnutrition 2. In its capital city, full of the skeletons of unfinished buildings and a palpable sense of anticipated yet unrealized development, Doctors with Africa CUAMM is working to improve the situation by building the country’s most cutting-edge neonatal pediatrics unit.

To be inaugurated on 21 December, it will be both the destination for the province’s most at-risk newborns and a hub for training staff working in the country’s hospitals and peripheral health centers. In addition to advanced resuscitation and neonatal care techniques, other more simple yet critically important practices for keeping newborns healthy will be taught, such as skin-to-skin contact after birth, the Kangaroo Mother Care technique for preterm infants, and the use of woolen caps and booties to prevent hypothermia. It will be a place where hope can take root, and a contribution be made to the future of this wonderful country.

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ETHIOPIA: A COUNTRY TORN BY HUMANITARIAN AND FOOD CRISES Ethiopia is under severe strain due to its fragile political and humanitarian situation, which is caused in turn by massive migration flows and an unprecedented food crisis. Doctors with Africa CUAMM is at work in the country to provide maternal and child health care services and treat those affected by malnutrition. teXt bY ⁄ serena menozzi ⁄ doctors with africa cuamm

In a world ridden with inequality, Ethiopia is a paradigm of complexity, a place where double-digit economic growth goes hand in hand with protracted humanitarian crises. The country is no stranger to emergencies of both a political and humanitarian nature. With nearly 100 million inhabitants, it is located in a geographically “awkward” position, sharing borders with South Sudan, Eritrea and Somalia, so-called failed or collapsed states beset by internal conflicts. Ethiopia is the largest refugee-hosting nation in Africa, and the fifth largest in the world, following Turkey, Lebanon, Pakistan and Iran 1. According to the United Nations High Commissioner for Refugees (UNHCR), 761,302 refugees and asylum-seekers were registered there as of 30 September 2016 2, 39.5% of whom originating from South Sudan and almost all hosted in refugee camps in Gambella Region, where one out of three inhabitants is a refugee.

The situation is extremely delicate, especially given the fact that Ethiopia is facing one of its worst food and humanitarian crises in decades. Over the past year the tragic impact of the severe El Niño-induced drought, combined with subsequent flooding, have crippled the country’s agropastoral sector, with dire consequences for the survival of millions: there are now 9.7 million Ethiopians in need of food aid 3, 400,000 children suffering from severe acute malnutrition (SAM) and another 2.3 million from moderate acute malnutrition 4.

This is the situation of unending crisis in which Doctors with Africa CUAMM works, carrying out initiatives in the country’s South Omo and South West Shoa Zones. In our effort to tackle the country’s exceptionally fragile conditions, we focus on three main types of activities that involve both hospitals and local communities.

In South West Shoa Zone, CUAMM not only works on maternal and child health care but is also carrying out a program to help children affected by SAM at the pediatric unit of the St. Luke Hospital in Wolisso. In 2015 495 children were hospitalized for severe malnutrition, most of whom younger than 2. At the same time, CUAMM is working to further strengthen the health system of the entire district, improving the links between and efficiency of the three levels of assistance, from the community to the peripheral health network to the Zone’s central hospital.

In South Omo Zone CUAMM is doing something different but equally important. The region is mainly inhabited by isolated nomadic groups that live in a constant state of food insecurity. The challenge here is related to multiple cultural barriers that hinder development and the strengthening of the health care system: most women, in fact, continue to give birth at home out of respect for centuries-old traditions. Thus it is vital to expand activities at the community level and provide assistance to mothers and children in this poor, change-resistant setting while at the same time respecting the local culture 5.

The third type of activity that Doctors with Africa CUAMM plans to start up in upcoming months will be in Gambella Region, a transit center for thousands of refugees. The aim will be to put into service a health and assistance system able to meet the needs both of the area’s resident population and of refugees from neighboring countries who live crammed into makeshift camps.

Doctors with Africa CUAMM’s task in Ethiopia is not an easy one, but by identifying and implementing a range of priority activities we can do the invaluable work of reaching out to and helping extremely vulnerable communities who are too often forgotten.

REFERENCES 1 UNHCR, Global Trend. Forced Displacement in 2015.

2 Refugees and Asylum-seekers – ETHIOPIA as of 30 September 2016.

3 OCHA Weekly Humanitarian Bulletin Ethiopia, 24 October 2016.

4 ETHIOPIA Humanitarian Requirements Document - MID-YEAR REVIEW, August 2016.

5 I. Micheli, Assessing the sociocultural and traditional factors affecting the MNCH service utilization, pregnant and newborns feeding practices in Hamar and Daasanach Districts oh South Omo Zone - Final Report, University of Trieste, 2016.

20 ⁄ health and development 74 ⁄ december 2016 ⁄ doctors with africa cuamm

DOCTORS WITH AFRICA CUAMM Founded in 1950, Doctors with Africa CUAMM was the first non-governmental organization focused on healthcare to be recognized by the Italian government. It is now the country’s leading organization working to protect and improve the health of vulnerable communities in Sub-Saharan Africa.

CUAMM implements long-term development projects, working to ensure access to quality health care even in emergency situations.

HISTORY In our 66-years history: 1,569 individuals have worked on our projects abroad; 422 of them have gone on to repeat the experience at least once 1,053 students have lodged at CUAMM’s university college 163 major programs have been carried out by CUAMM in cooperation with the Italian Foreign Ministry and various international agencies 217 hospitals have been served 41 countries have been the beneficiaries of CUAMM’s work 5,021 years of service have been provided, with each CUAMM worker serving for an average of three years.

IN AFRICA Today, Doctors with Africa CUAMM works with local communities in Angola, Ethiopia, Mozambique, Sierra Leone, South Sudan, Tanzania and Uganda, implementing 42 major development projects and around one hundred smaller related ones. Through this work we provide support to: • 16 hospitals; • 34 local districts (with activities focused on public health, maternal and child health care, the fight against AIDS, tuberculosis and malaria, and training); • 3 nursing schools; • 2 universities (in Mozambique and Ethiopia).

180 International professionals: • 125 doctors; • 12 health workers; • 3 nursing schools; • 23 administrative workers; • 7 logisticians.

IN EUROPE Doctors with Africa CUAMM has long been active in Europe as well, carrying out projects to raise awareness and educate people on issues of international health cooperation and equity. In particular, CUAMM works with universities, institutions and other NGOs to bring about a society – both in Italy and in Europe – that understands the value of health as both a fundamental human right and an essential component for human development.

PLEASE SUPPORT OUR WORK Be part of our commitment to Africa in one of the following ways: • Post office current account no. 17101353 under the name of Doctors with Africa CUAMM • Bank transfer IBAN IT 91 H 05018 12101 000000107890 at Banca Popolare Etica, Padua • Credit card call +39-049-8751279 • Online www.mediciconlafrica.org Doctors with Africa CUAMM is a not-for-profit NGO; donations made to our organization are tax-deductible. You may indicate your own in your annual tax return statement, attaching the receipt.

In Health and Development you will find studies, research and other articles which are unique to the Italian editorial world. Our publication needs the support of every reader and friend of Doctors with Africa CUAMM.

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health and development 74 ⁄ december 2016

AFRICA IN NEED EVERY YEAR IN SUB-SAHARAN AFRICA: 4.5 million children under the age of 5 die from preventable diseases that could be treated inexpensively; 1.2 million infants die in their first month of life due to lack of treatment; 265 thousand women die from pregnancy- or childbirth-related complications.

Doctors with Africa CUAMM works in

SIERRA LEONE SOUTHERN SUDAN ETHIOPIA UGANDA TANZANIA ANGOLA MOZAMBIQUE where we offer healthcare services and support to such women and children.

Please help us wage the battle against these silent yet deadly scourges.

With 15 euros you can ensure ambulance transport for a woman about to give birth.

With 25 euros you can provide treatment to prevent mother-to-child transmission of HIV. With 40 euros you can provide a pregnant woman with an assisted delivery.

With 80 euros you can fund a week-long training course for a midwife.

Magazine on International Development and Health Policy December 2016 — No. 74 www.doctorswithafrica.org