Tackling Ebola with Locally Led Approaches: CLA Deep Dive

Jun 25, 2018 by Ilana Shapiro, Kristin Lindell Comments (0)
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“Why do you only come when someone has died? Why do you not come to help when someone is sick?” This question posed by rural Liberians during the 2014-2015 Ebola crisis revealed broken trust among local communities, the national government and international aid workers, and underscored the tension between local customs and national and international responses to the Ebola crisis in Liberia.

For Global Communities, an international non-profit working in Liberia since 2010, this question inspired action and motivated them to work in a way that fostered Liberia’s self-reliance in the fight against Ebola. Using a community engagement approach grounded in the principles of collaborating, learning, and adapting (CLA) to facilitate locally led development, Global Communities adapted Ebola virus disease prevention and intervention activities in response to local needs and cultural practices, and fostered community buy-in for behavior change. Their efforts focused on reducing Ebola infections through safe and dignified burials, education in Ebola-resistant hygiene and sanitation behaviors, and disease surveillance efforts.  

As part of our efforts to examine the evidence base for collaborating, learning, and adapting (CLA), the USAID LEARN contract in support of USAID’s Bureau for Policy, Planning and Learning recently completed a CLA case analysis deep dive to understand whether and how the CLA approaches used by Global Communities contributed to ending the outbreak of Ebola in Liberia. This study adapted methods from Contribution Analysis, Contribution Tracing, and Outcome Harvesting to analyze corroborating evidence and alternative explanations of the outcomes described in Global Communities’ 2015 CLA case competition entry: Rapid Collaboration, Learning, and Adapting: Community-Based Response to Ebola. Below, we discuss our key takeaways from the study. For a more in-depth review of the evidence and a description of CLA integration, check out a briefer and the full report here.

Front-end investments in CLA approaches fostered trust with stakeholders and supported efficient scale-up: Global Communities’ Ebola response built on the positive relationships and reputation it had developed with both government and community leaders while implementing the five-year Improving Water, Sanitation, and Hygiene program (iWASH). For example, at the first signs of the Ebola outbreak in June, 2014, officials in Liberia’s Ministry of Health who were working with Global Communities on the iWASH program reached out to them for help in co-designing an effective Ebola response. Global Communities also collected monitoring data and produced weekly reports on Ebola’s spread. This helped them rapidly reallocate resources to communities most in need throughout the outbreak lifecycle. In addition, based on feedback from community members that had been successfully implementing community-led total sanitation (CLTS) through iWASH, Global Communities commissioned a study about the relationship between CLTS practices and Ebola resistance.The study provided evidence of strong correlations between the presence of CLTS activities and Ebola resistance (Capps, et. al., 2017) and supported the expansion of CLTS into Global Communities’ Ebola response. During the Ebola crisis, interview participants and program materials frequently mentioned how relationships and evidence-based interventions facilitated rapid expansion and effective response efforts.

Collaborative networks unlocked local knowledge and mobilized an array of actors for collective benefit: This CLA approach drew together diverse stakeholders to share the knowledge they possessed in a unified effort to strengthen community resilience to Ebola. The creation of Disco Hill cemetery in Liberia, for example, involved traditional leaders, local communities, Liberian government officials, U.S. government officials, and international NGOs in a shared effort to support safe and dignified burials in Monrovia. During the Ebola crisis, contact with highly contagious dead bodies during burial rites and mourning ceremonies was identified as the most significant driver of disease transmission, accounting for up to 70 percent of new infections by some estimates (Roca, et. al., 2015; Rewar, et. al., 2014). The rapid rates of infection as well as a lack of open land in Monrovia pushed the Government of Liberia to resort to cremating bodies as a first response. This practice, alien to Liberian traditions, made local families resistant to seeking treatment for sick family members and distrustful of the government. The call for an official burial site initially emerged through Global Communities’ work with local communities, whose local leaders sent out urgent requests for a safe burial space. Then, Global Communities engaged with other key stakeholders—various ministries, the Environmental Protection Agency, to name a few—in order to get buy-in for the construction of the cemetery at Disco Hill. The creation of this cemetery resulted in an increase in safe and dignified burials and also contributed to curbing the overall outbreak as family members no longer felt they needed to hide their deceased loved ones from the government and international aid workers. These events corroborate findings in the CLA Literature Review and correspond to the CLA Case Competition Analysis finding that “Collaboration leverages resources for collective benefit.”

CLA approaches supported social inclusion and facilitated diverse, culture-specific adaptations: Global Communities emphasized the importance of including diverse stakeholders, especially vulnerable and hard-to-reach populations, in this effort. For example, they worked closely with traditional leaders to reach the most rural schools. They also organized Muslim burial teams to ensure Muslim-specific burial traditions were respected and set up separate Christian and Muslim sections within the Disco Hill cemetery. Global communities employed CLA approaches that respected cultural traditions and recognized local culture as fluid and dynamic with behavioral changes rooted in continuity with existing beliefs. They engaged trusted sources for messaging, encouraged social learning, and provided both means and opportunities for local agency.

Considerable evidence from the deep dive suggested that Global Communities’ CLA-driven, community engagement strategy to fight Ebola in Liberia fostered local ownership and effective behavior change in communities, facilitating their journey to self-reliance. Local ownership of new health practices not only helped contain the immediate spread of Ebola, but addressed some of the underlying vulnerabilities in community health behaviors and national health care systems to support sustainable disease prevention. Donor flexibility and the active participation of diverse leadership created an enabling environment that was crucial to achieving these results.

Our analysis indicated that CLA approaches implemented by Global Communities made important contributions to ending the Ebola outbreak in Liberia.

So, what are the implications of these findings? The analysis reaffirms the importance of local engagement for better development results and should prompt us to look for opportunities to collaborate with local stakeholders. The evidence also demonstrates that investing in CLA upfront bears results. As leaders and decision-makers in our organizations, we can make time now to integrate CLA approaches into our work, knowing that the return on our investment will likely be significant.

Read the brief or full report to learn more.

Citations:

Capps, J.M, Njiru, H. & deVries, P. (2017, August). Community-Led Total Sanitation, Open Defecation Free Status, and Ebola Virus Disease in Lofa County, Liberia. Journal of Health Communication, 22, 72–90.

Roca, A., Afolabi, M., Saidu, Y., Kampmann, B. (2015, April). Ebola: A holistic approach is required to achieve effective management and control. Journal of Allergy and Clinical Immunology, 135(4): 856–867. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4382328/

Rewar, S. & Mirdha, D. (2014). Transmission of Ebola Virus Disease: An Overview. Annals of Global Health, 80(6). 444–451.

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Collaborating, learning, and adapting as a vehicle for integrated development

Jun 20, 2016 by Kristin Lindell Comments (0)
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Image from FHI 360 Integration SummitFollowing the Ebola outbreak in West Africa, the international development and disaster management communities struggled to contain the virus for over two years. Not only did the virus claim over 10,000 lives, it also broke apart families and significantly weakened entire economies. What could have been done differently? During the integrated development summit hosted by FHI 360 on June 13, 2016, academic and author Ben Ramalingam argued that the outbreak represented a wicked problem, necessitating an integrated development approach. As the virus spread, global health professionals noted that those suffering from poverty were most vulnerable to Ebola--meaning it exacerbated inequality. However, interventions failed to holistically address the conditions that made people susceptible to Ebola in the first place. Why, he asked, does the international development community continue to respond with siloed solutions to such interconnected challenges?

The conference focused on moving the needle toward greater uptake of integrated development programs, with the goal of better development outcomes. The following constraints to integration were identified:

  • Restricted funding and congressional earmarks: The way in which major funding mechanisms are set up shapes development. More flexibility could incentivize organizations to experiment with increased integrated programming.
  • Sectoral expertise: How can a health-focused non-profit be expected to also tackle environmental rights?  Integrating often means diversifying a team or organization’s expertise, which isn’t easy.
  • Sector-specific government institutions: In most countries, government institutions tend to focus on one thematic area, hindering the ability for partner organizations to efficiently implement an integrated strategy. Meeting with multiple ministries to  kick off an integrated project, for example, is time consuming.

Even in the face of these constraints, certain frameworks, mindsets, and practices can make integration easier. At the conference, speakers and participants alike identified collaborating, learning, and adapting (CLA) as a vehicle to facilitate integrated development. Below are some of the primary conclusions connecting CLA and integration that stood out:

CLA is required for integration to be effective

Robert Mwadime, representing FHI360 Uganda and the USAID-funded Community Connector Project (CC), highlighted that without CLA, integrated development becomes much more challenging and quite likely is not done well. CC’s adaptive mechanism permitted an integrated livelihood and nutrition intervention to roll out in modular phases. Monitoring, evaluation, and learning then fed into each new phase of the mechanism, shaping program design along the way. Given the complex nature and operating environment of integrated models like CC in Uganda, the mechanism itself and the principles of CLA allowed for more effective program delivery.

There are no silver bullets in international development

Development is extremely complex and there are no simple solutions to the challenges we are trying to address. Only through the application of innovative and multi-sectoral programs can we achieve the Sustainable Development Goals (SDGs), argued Susan Reichle, Counselor to USAID. The SDGs reflect a network of outcomes and goals that can only be reached through holistic approaches. A CLA approach, which includes practices like adaptive learning, strategic collaboration and context monitoring, creates an environment conducive to iteration and integration. This allows development practitioners to work within rather than in spite of the unique circumstances each development challenge presents.

The elements needed for CLA and Integrated Development to work are the same

In relation to integration, the following concepts kept coming up: strong leadership support, a cadre of change agents or champions, and flexible funding mechanisms all make integrated programming easier. These elements also make CLA more likely to be adapted by individuals and organizations according to the research we’ve done at LEARN. Essentially, both approaches need the same catalysts to thrive and evolve.

And finally, why does any of this matter? We hope that CLA and integrated development will contribute to better development results, a shorter recovery time in the face of another Ebola outbreak, or improved quality of life for over one billion people living in extreme poverty. Ultimately, as one conference participant mentioned: we shouldn’t fall in love with our projects, but rather with the goal of making our world better.

To What Extent Does CLA Improve Development Outcomes? Reflections on Systems Thinking and Wicked Problems

Apr 20, 2016 by Kristin Lindell Comments (0)
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After a recent Systems Thinking workshop at the State Department, I came home to find one of my favorite necklaces tangled into an impossible metal ball. Every time I tried to loosen one piece of the chain, the knot only seemed to tighten. Then, I made the connection: I realized I held a literal wicked problem in my hands.

As I stood, fingers haphazardly pulling at pieces of metal chain, I began to consider Systems Thinking, wicked problems, and how they relate to the work we’re doing on the USAID LEARN contract. Wicked problems (as we can imagine given their name) do not have straightforward solutions. In fact, trying to tackle them through traditional mechanisms may worsen the situation or cause unintended negative consequences. Just like my necklace, loosening one side of the knot only to made the other side more difficult to pull apart.

In the international development space, many policy makers and practitioners think about wicked problems, like poverty or environmental degradation, on a daily basis. A Systems Thinking approach provides an alternative framework for conceptualizing the root causes of these problems. The State Department session’s presenters, Drs. Laura and Derek Cabrera, said that Systems Thinking helps us to:

  • Understand patterns and anticipate future challenges
  • Conceptualize underlying structures that support these patterns
  • Identify existing mental models, or the way we see the world, to challenge existing assumptions and formulate innovative solutions


In particular, if we start to challenge our own mental models, we might realize that the way we see the world does not reflect reality. Since Systems Thinking requires us to take a step back and identify our thinking patterns, we can truly assess cause and effect relationships between a problem and its drivers.  In turn, this framework can help cause systemic change--and in theory, untangle my necklace.

In the second half of the workshop, Dr. Cabrera asked the audience to consider how Systems Thinking can be applied to our current jobs. As a new member of the Monitoring, Evaluation, Research and Learning (MERL) team on the USAID LEARN contract, my mind immediately made a connection to designing evaluation questions that address what we’d ultimately like to know: Does collaborating, learning and adapting (CLA) lead to better development outcomes? Through a Systems Thinking lens, some of the evaluation questions I have include: 

  • Who are the key stakeholders in CLA and how does their behavior influence its adoption?
  • How do grassroots level stakeholders view CLA in terms of its effectiveness on development?
  • What barriers or gaps exist in CLA adoption and how can these be addressed?
  • What role does CLA play in the broader system that makes better development possible?

In international development, we know we’re dealing with problems so complex they’ve been deemed “wicked”. In my mind, though, just because an outcome is difficult to measure doesn’t mean it shouldn’t be measured. Let’s leverage approaches like Systems Thinking to help us understand more about CLA’s impact on these wicked problems.

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