The headlines from India are chilling, and as if from a time long gone: botched sterilizations in a government program to curb population growth. Twelve women dead, more than 60 hospitalized, community members outraged.
This had trouble written all over it from the get-go: poor, illiterate women in Chhattisgarh, one of the most impoverished states in India, were given incentive payments of a more than a week’s wages to undergo tubal ligation at a mobile health clinic. The health workers, too, received an incentive based on the number of procedures performed, possibly to reach a monthly target. And the conditions were nothing short of appalling: no alternative birth control methods, rusty instruments, poor infection control, tainted medicines (which it now appears may have caused the women’s deaths), and a lack of follow-up care once the surgery was done.
While this terrible incident has come to international attention because of its sensational elements, it fits a troubling, longstanding pattern. For many decades India has pursued an aggressive population control policy that seems far more focused on the interests of the state than those of the women and their families. Incentive payments that are hard for poor women to refuse, combined with numerical targets and an emphasis on permanent contraception, have added up to a family planning program that’s at odds with global norms.
The numbers tell the tale: More than 4.6 million women are sterilized in India every year, and sterilization accounts for more than 80 percent of contraceptive use in the country. Female sterilization is more than twice as prevalent in India than in places where the Pill, injectables, implants, IUDs, and other methods are offered, like China and Latin America. Many of the procedures are done in temporary camps, set up for quantity rather than quality. The doctor performing surgery on these women, for instance, had been honored by the state government earlier this year for performing more than 50,000 tubal ligations.
Surely, it’s time for this to stop.
Even the Indian government has said so. I was in the audience, along with Melinda Gates, Dr. Raj Shah from USAID, and many others, at the London Family Planning Summit in July 2012 when a representative of the Indian Government promised that, “Through the largest public health program in the world, the National Rural Health Mission and the upcoming National Urban Health Mission, addressing equity, ensuring quality, including adolescents and integration into the continuum of care are slated to be the cornerstones of the new strategy. The centerpiece of its strategy on family planning will be a shift from limiting to spacing methods, and an expansion of choice of methods, especially IUDs.” Those are all the right words. Then, just two weeks ago when the FP2020 2013-2014 Progress Report was released, I was impressed to read that “Family planning in India has undergone a paradigm shift, away from the old sterilization-centric emphasis on population control.”
If the paradigm truly has shifted, some people haven’t gotten the memo.
Despite all that good thinking, though, the job is clearly not done—and maybe it’s barely begun. I’m sure there are health authorities in India, as elsewhere, who are horrified by the current situation and would like nothing better than to promote change. But those who are trying to improve conditions in tough environments have to figure out how to put into operation the complex concepts promoted in those documents—things like “ensur[ing] that respecting and protecting rights is built into performance monitoring and accountability, indicators, procedures and practices.” That’s going to take hard work at all levels of government, paired with organized actions by citizens to hold government to account. Along the way, the international community—funders, technical partners and everyone else—should offer support and celebrate progress.
But more than that, we should all be brave enough at times like this to publicly condemn repressive policies and call for an immediate halt to lethal practices.
By policy work I mean the construction of public policy positions—more spending, less spending, better spending, better targeting, smarter monitoring, smarter regulation, deregulation, whatever—and then, mindful of (and well within) the limits placed on nonprofits and their funders, the mobilization of support from both elite and grassroots groups.
The potential pay-off is huge. When you have relatively few dollars and you want to solve big problems, policy work is one of very few possible pathways. A change in public policy can instantly scale a good idea, and can unleash vastly more resources than any private source could muster. If, for example, you’re trying to improve educational outcomes for kids in villages and cities throughout Uganda, you need the Ugandan government itself to take the lead, perhaps persuaded by a combination of evidence and advocacy from those outside government.
But far from being immune to the vicissitudes of politics, policy work is almost entirely subject to the rise and fall of particular people, parties, and platforms. No matter how rigorous the analysis you use to develop a policy position, and no matter how many problems it might elegantly solve, its fate lies in the hands of politicians, and voters—blue, red, green, rainbow-hued. That’s a high-risk place to be. One step forward? At the next election, you could well be three steps back.
If every election is a roll of the political dice that puts at risk years of investment in public policy research and advocacy, how can funders contribute to real and sustained progress? I don’t have any silver bullets, but can at least offer a few ideas that we’re trying within the Global Development and Population Program.
Movements matter. While voters and the politicians they elect can shift preferences and positions at the drop of a hat, in almost any issue area it’s possible to find and strengthen the communities of people who have a deep and abiding commitment. These are the people who identify themselves with the issue, who don’t think of it as a job but instead as a cause that affects them in personal ways, and to which they enthusiastically dedicate their brainpower, energy, and time. Movements need patient funding, investment in leadership, and encouragement to refresh themselves as context changes. That patience, investment, and encouragement are vital, because without movements advocacy efforts are ephemeral.
Knowledge lives on. We’re investing in institutions that are not captured by a single advocacy agenda, but rather by a mission of support for evidence-informed policy. These include but are not limited to think tanks, which conduct and communicate economic and social research across a range of policy domains, from labor to taxes to social safety nets. As research institutions, they contribute to cumulative bodies of evidence—for example, about the relationship between investments in opportunities for women and economic outcomes at the society-wide level. As institutions that work on multiple topics, they are also able to respond to the questions and opportunities of the day.
Support people who are doing real things, regardless of the political climate. The drive toward large-scale impact almost inevitably points in the direction of policy work and away from support to front-line service delivery. That was certainly my own inclination coming into the Foundation three and a half years ago. But I’ve come to appreciate very much the value of also supporting organizations whose work is far from the low-oxygen policy zone, close to the ground where people need help. In our case this includes, for instance, the organizations that are expanding the provision of family planning services to women around the world, and citizen groups working in their own communities to solve problems. That’s not most of what we do, but it has intrinsic value and serves as a continuing reminder that while our scale may be small relative to the need, we do have the ability to get something accomplished without depending on favorable political winds.
These directions point away from short-term, specific, headline-grabbing policy asks. They point toward work that takes a long time and can rarely claim big wins. It might be harder to love, but it won’t break your heart.
It’s as unfortunate as it is unsurprising: young, low-income women—the very people whose lives are often turned upside-down if they become pregnant—are less likely to use birth control if they have to pay for it. And high up-front costs are a big part of the reason they’re far less likely to use the most effective methods, like IUDs. Time and again, research has demonstrated that if contraception is offered for free, more women use it.
That’s why advocates who want all women to have access to the full range of contraceptive methods were united in their support of the Affordable Care Act (ACA). That’s why they used every tactic—from mass mobilization to litigation to political horse-trading—to press their case. When the rules were written, they got much of what they wanted: legislation that expands health insurance to those previously excluded from the system, covering every contraceptive method with no co-pay. In a country with a fragmented health care system, fractious politics, and a deep ambivalence about the role of government, it was a major victory.
Among the many hopes for the Affordable Care Act, certainly one has been that the extension of health insurance will help women control whether and when they become pregnant. In theory, a lower price to consumers, particularly low-income consumers, should mean greater demand for birth control, including methods that protect from pregnancy for months or years. And more use of the most effective methods should mean greater control for women over their futures, fewer unintended pregnancies, and all the benefits that go along with those things.
That’s the theory. The reality is that to get to these outcomes that are so good for women, families, and society requires that a whole bunch of things work well. People who otherwise would not be able to afford preventive services like contraception counseling and care have to sign up for the newly available insurance. Private as well as public insurers have to follow the letter and the spirit of the law: all methods, no co-pay, no funny business. Providers have to be willing and able to provide quality care, including long-acting methods that they are less familiar with than the easy-to-dispense Pill. Women have to make the effort to get and use the birth control method that’s right for them. Oh, and the whole system has to remain solvent.
Whether the reality bears out the theory will be revealed in the data, if we watch carefully. Now that we’re close to a year into implementation, we’re starting to see that some of the links in the chain are strong while others need reinforcement.
Oddly, sometimes when we talk about data, we end up ignoring the real world we’re so eager to measure. In the “data for development” crowd—and quite a crowd it is these days—we talk about the merits of indicators without thinking about whether the data exists to, you know, measure them—things like maternal mortality rates within small districts. We get excited about monitoring annual changes in birth and death rates, despite the fact that the surveys that yield the numerators are only done every five years and the census data that we depend on for denominators show up once a decade. We have an unlimited appetite for more and more granular information—down to the facility, down to the household, down to the smallest child in the most remote village—with little awareness of the potential costs of collecting, cleaning, and analyzing it.
Enter the practical voice of the original data scientists: demographers. From the time of John Graunt in the 1600s, demographers have developed efficient ways to collect information about population size and change. Equally importantly, they have figured out ways to assess the quality of that information, estimate the measurement errors, and compensate for incomplete and imprecise data. That’s not a sideline for demographers. It’s their job.
The special skill of demographers lies in our ability to understand the systemic linkages between human population stocks and flows across space and time. This deep understanding puts demographers in a strong position to evaluate what is feasible and realistic with data collected on human populations, the limitations of those data, and the validity of the results. The assessment and evaluation of data quality, the capacity to link and process data from a multiplicity of disparate sources, and the ability to see the data as part of a larger systemic framework, are central aspects of this skill.
In addition to offering a technical word of warning to those planning a data revolution, the demographers provide scientifically-grounded suggestions for addressing indicator design, data quality, and interoperability. If you’re constructing indicators that will actually be useful, or investing in new data collection, or trying to figure out how to triangulate information from multiple sources, you want demographers on your team. Luckily, with this statement they’re saying that they are now ready, willing, and able to enlist as data revolutionaries.
Last week I offered a short tutorial on how not to get a grant. Now, by popular demand, I’m sharing thoughts about what you can do—beyond not committing those seven deadly sins—to increase the chances of getting funding for a project from a foundation like ours.
As you read these suggestions, keep in mind two important caveats: First, these are my idiosyncratic views, and represent no more. Grain of salt, and all that. Second, many factors well outside the control of prospective grantees affect their chances of success. These include, for example, a funder’s grantmaking budget, the type of strategy being pursued and the particular moment in that strategy’s lifetime. When the budget isn’t growing and a strategy is already well underway, a funder may find it difficult to start a relationship with a new organization, regardless of the brilliance of the idea being proposed. If, on the other hand, a funder is in an exploratory mode or has recently seen a bump in her budget, she may be actively searching for new ideas and partners. That’s a great opportunity just waiting to be seized.
With those qualifications, herewith my best advice:
Know your niche. We have a field-wide view and are supporting a constellation of work within a particular area—in our case, for example, reproductive health and rights, women’s economic empowerment or transparency and accountability. Beyond a project’s intrinsic merits, we’re going to be wondering how your organization and the project you’re proposing fit into the bigger picture. Do you have special technical skills, the ability to reach audiences that others do not, or some other asset that would make a valuable addition to our portfolio? If so, help us see that.
Lead from strength and connect to mission. Tell us about the one or two genuine strengths your organization has that make you the right folks to take on the project you are proposing. Help us understand how the project fits into your larger institutional mission. We want to see how funding for a particular activity will leverage organizational assets and why you’re eager to pursue it.
Be able to answer the question “What would success look like?” Period.
Use the pitch as prototype. When you’re describing the project, demonstrate the skills you are going to need to successfully implement it. If it’s a research project, convey that you have done your own research on what and where we fund, and on who else is working on the same question. If it’s research intended for direct policy uptake, show that you can talk about technical issues in ways that non-specialists can understand. If it’s a data visualization project, show us the implementation plan in a way that communicates information about timing and level of effort in a compelling way. If it’s an advocacy project, put your best communications staff onto the task of communicating with us.
Figure out how to articulate your theory of change in 60 seconds. That’s too little time to get across all the nuances, but enough to demonstrate that you’ve thought through the logic connecting dollars to impact. Being able to give a snapshot of your thought process is critical to demonstrating that you’ve thought long and hard about how to succeed, and that you can get others—staff, policymakers, us—to understand, and buy into, your vision.
Eschew abstraction. Help us get a picture in our minds of what you’re proposing to do. Instead of “convenings with decisionmakers” try “ three meetings in our Washington, DC, offices with officials from USAID and Treasury, along with a couple of the leading academics working on illicit financial flows.” Instead of “promoting a rights-based approach” try “analyzing the relevant provisions of the UN conventions, and developing a country-specific strategy, starting in Uganda, to support human rights lawyers working on precedent-setting safe abortion cases.”
Balance enthusiasm for your idea with openness. Once we’ve heard what you’re proposing to do, we may have some suggestions about ways to strengthen the idea and increase its potential impact. We’re looking for partners who will engage in a back-and-forth about what will make for the most successful project—but we’re not interested in working with groups that will do anything we suggest just because we’re on the funder side of the conversation. It’s a delicate balance and achieving it takes real effort on the part of everyone involved.
It’s a relationship, not a transaction. When we start a serious conversation about a grant, we’re committing far more than money. We’re committing time and a collaborative spirit, entering into a relationship of trust. And so are you.
Let’s stick with these eight, knowing that in the Chinese tradition eight is the number associated with one of the most important determinants of whether a pitch is successful: luck.
If there’s one thing you learn working at a Foundation, it’s how not to ask for funding. I imagine every grantmaker has his or her own thoughts about what makes a pitch imperfect. Here’s my personal list of the seven deadly sins that prospective grantees sometimes commit when they come to visit:
Act like we owe you. Let us know how prestigious and well-connected you are, and/or assert (without evidence) that your work is superior to that of partners we currently support.
Act like we own you. Tell us you’re infinitely flexible, just waiting to pursue whatever brilliant idea we happen to mention.
Do no homework. Do not spend time reading any of the materials on our website, and in particular do not look at the descriptions of our current grants in your field. Come in knowing nothing about our geographic and subject matter interests.
Get lost between the money and the goal. Make only vague statements about how financial support to your organization would translate into more or better activities, and then follow that up with even vaguer statements about how those activities would contribute to a Big Goal.
Claim unmitigated success. When you describe your track record, make sure it seems as though every project has yielded remarkable benefits. Do not breathe a word about disappointments or lessons from painful experiences.
Bring a team, but only let one person talk. Make sure you crowd the room with staff who sit silently listening to the boss describe their work. Hand out a lot of glossy materials. Leave us wondering about your overhead.
Talk more, listen less. Use every available minute to get across what you came to say, and leave no space for questions or conversation. To ensure this happens, make sure you bring a long PowerPoint presentation.
Unlike the actual seven deadly sins, it’s easy to avoid committing these peccadillos. And, mercifully, most of the people we meet with do make good use of the time. When they do, they find we’re eager to hear about creative and effective work being done by organizations whose goals we share. We like talking about the field we’re in, bouncing around ideas, engaging in the give-and-take of questions and critiques. We like leaving a meeting with new ideas and new professional connections—and sometimes, just sometimes, the germ of a future grant.
Toward the beginning of every month, the White House, the Federal Reserve, Capitol Hill, Wall Street and major media outlets wait anxiously for the Bureau of Labor Statistics to release its employment report. The statistics, based on household and employer surveys, are our economy’s vital signs, closely monitored to see whether American workers and private firms are doing well or fading fast. The data inform everything from unemployment benefits and job training programs to interest rates, employer tax breaks, and investment portfolios.
The figures are also leading indicators of political fortunes. Too many months of rising unemployment spells trouble for incumbents because voters base judgments about politicians’ performance on both their own personal job security and their understanding, as filtered through the media, of how the nation as a whole is doing.
A world away from the wealth of statistics available to advanced economics, African governments are profoundly impoverished, starved for data. Virtually no African government generates reliable, representative, reasonably current information about the size of the labor force, the number of people employed, or the number seeking jobs. In many cases, the only available information dates from the most recent census, and captures only the small fraction of productivity that occurs in the formal sector. If you want to see for yourself, look at this map of available data maintained by the International Labor Organization. The most basic employment data for the entire continent of Africa: n/a.
This massive problem can be solved. For just the past year, the world has had a modern, comprehensive definition of work and classifications of different types of productive activity, endorsed by the International Conference of Labor Statisticians. The new definition encompasses a broad array of productive activities, going well beyond the narrow formal employment arrangements. Happily, this updated way to measure work can be used in African and other contexts where relatively few workers are employed in enterprises recognized by government authorities, and most—particularly most women—are working in the informal economy, or in unpaid activities that produce goods or services within their own home or others’.
Not only is the right definition in place, but there’s a way to collect the data. While frequent labor force surveys may remain a distant dream, most African countries conduct nationally representative household surveys every five years or so. As the World Bank’s Kathleen Beegle and others have noted, questions based on the new definition could be developed for those surveys, capturing the essential information to describe in detail what the labor force looks like: who’s working, who’s not, what they’re doing.
Yes, it would take a combination of extra money and intensive technical support, plus coordination among the various international agencies that help fund and design household surveys. It would also take a genuine commitment by National Statistical Offices, and resources to help them skill-up to measure better. This will sound like a pretty familiar to-do list if you’ve been paying attention to the “data revolution” conversation.
But it’s not about just any old data for its own sake. The payoff in this case would be enormous and immediate: critically important information for economic policymaking, and a baseline measure against which future progress can be assessed. Moreover, by generating comprehensive information about the productivity of both men and women using methods that are not tainted by gender bias, it would be one of the most powerful ways imaginable to close the gender data gap.
The absence of crucial economic data in Africa isn’t a new problem, but with the help of data revolutionaries, can’t we find some new ways to solve it?
Sexual health of young people in the developing world. Gender-based violence. Stigma and discrimination. Unsafe abortion. Access to comprehensive reproductive health services for the marginalized.
Let’s face it: these topics are hard for a lot of people to talk about, and harder still for many funders to proudly and publicly support. They are challenges that can be best addressed by those who know the social context, and who have a lifelong commitment to these issues—a mission for social change. While they’re at the outskirts of many donor-funded programs and lie beyond the influence of sweeping rhetoric at international conferences, these issues are at the very heart of protecting the health and rights of women and men around the world.
And now, as of last Monday evening, there’s a place where civil society organizations with ideas and energy can find support from donors committed to progress on these tough issues.
AmplifyChange was launched during UN Week in New York, after months of preparation by its financial backers, the Governments of Denmark and the Netherlands, the Packard Foundation and ourselves, as well as the implementing consortium of MannionDaniels, the Global Fund for Women, and the African Women’s Development Fund. The aim is to help lift and, yes, amplify the voices of civil society in countries with the greatest deficits in sexual and reproductive health and rights. Support is available from the fund, now capitalized at about $19.4 million, for movement-building, strengthening the work of individual organizations, and sparking much needed innovations in advocacy. (The Guardian has a nice introduction to the effort, published earlier this week.)
As a foundation with no in-country presence and very limited ability to make the small, tailored grants that local groups often need, we are very happy to be able to channel resources in a responsible way to tackle these important issues. We’re looking forward, in particular, to seeing how the women’s funds, which are experienced at making small grants and providing technical support, help groups working on these challenging topics.
We’re also happy to have the chance to work with the courageous Governments of Denmark and the Netherlands, who are showing such leadership. We’re hopeful that AmplifyChange will demonstrate its value quickly, so that others who understand how crucial a full set of reproductive rights are to the empowerment of girls and women will join us—as funders, intellectual collaborators, and advocates.
Every once in a while you read something that’s such a clarion call you have to stop and listen. That’s how I felt about Belle Sawhill’s “Beyond Marriage” in last Sunday’s New York Times.
Sawhill lays out the facts: The social norm of marriage-then-babies is rapidly disappearing across much of America. More than 40 percent of babies are born outside of marriage; most of the pregnancies are unplanned and many of the couples split up before the children reach their fifth birthday.
Once children are born, parents—and often the moms alone—have to meet the many challenges of parenthood while foregoing education to find low-wage jobs, just to provide the basics of food and shelter. In all this, the children—the next generation of Americans—themselves face futures limited by poverty and family stress. ( Sawhill’s statistics were made vividly real a few weeks ago in a Times story describing the daily life of Jannette Navarro, a 22-year-old mother of a five-year-old child, as she juggles childcare responsibilities with her unpredictable shifts as a Starbucks barista.)
Many factors contribute to this grim cycle: High school drop-out rates, incarceration of young men, a minimum wage that is too low to permit even fulltime workers to pay rent. But it is one event, the birth of a baby to parents who just aren’t ready, that prevents an exit to higher incomes and family stability.
If women are not waiting for marriage to have children, Sawhill asserts that a new social norm has to be fostered: women and their partners must take the responsibility for waiting to be parents until they are ready, both emotionally and financially. The norm must shift from drifting into parenthood to taking that momentous step only with deliberation and forethought.
Hard as shifting social norms is, the good news is that we have birth control methods that switch the default setting from “get pregnant” to “don’t get pregnant.” When women choose an IUD or an implant, instead of the Pill, condom or blind hope, they can count on effective pregnancy prevention for several years. Then, when they want to get pregnant, they can remove the device and regain their fertility quickly. This technology is a boon to the cause of responsible parenthood.
And yet it is access to precisely this type of birth control that is under threat. Long-term methods like IUDs, which are cost-effective over the long term, are expensive. A woman working fulltime at a minimum wage job would spend her monthly paycheck just to get one, and many women who would benefit do not have insurance coverage to help share the cost. The Affordable Care Act and the expansion of Medicaid do promise to cover the high upfront costs of long-acting reversible contraceptives, as well as all other methods. But challenges to the contraceptive coverage provision and the reluctance of some states to expand Medicaid are limiting access. The government, Sawhill points out, is not doing all it could to support women and couples who want to wait until they’re ready.
What is most refreshing about Sawhill’s piece is that she clearly and persuasively connects issues that so often are discussed in isolation. Birth control is certainly part of women’s health care, yes. But it is far more than that. It is an essential determinant of how lives unfold, and it is deeply intertwined with the kind of society all our children will grow into over the decades to come.
I always cringe when the architectural metaphor of a “blueprint” is applied in global development. As in reports like “PEPFAR Blueprint: Creating an AIDS-free Generation.” So static, so centrally planned, so mechanical. Not an image befitting the dynamic system that characterizes so much of work aimed at improving lives and livelihoods in low-income countries (or anywhere else).
So, when I happened to find myself flipping through Matthew Frederick’s 101 Things I Learned in Architecture School(MIT Press, 2007), I did not think it would shed any light on my work. (I was looking through the book only because one of my kids is expressing interest in architecture as a career, and I wanted to understand what the training entailed.)
Then I stumbled on Lesson 29, which counsels architects to adopt a practice that entails (quoting here):
1.Seeking to understand a design problem before chasing after solutions;
2.not force-fitting solutions to old problems onto new problems;
3.removing yourself from prideful investment in your projects and being slow to fall in love with your ideas;
4.making design investigations and decisions holistically (that address several aspects of a design problem at once) rather than sequentially (that finalize one aspect of a solution before investigating the next);
5.making design decisions conditionally – that is, with the awareness that they may or may not work out as you continue toward a final solution;
6.knowing when to change and when to stick with previous decisions;
7.accepting as normal the anxiety that comes from not knowing what to do;
8.working fluidly between concept-scale and detail-scale to see how each informs the other;
9.always asking “What if . . . ?” regardless of how satisfied you are with your solution.”
I ask you: Could there possibly be a better description of the discipline of development?