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Why Strengthening Civil Society Matters + Co-Creating Solutions Rocks

A team focused on the Middle East and North Africa collaborates on challenges facing civil society at the Civil Society İnnovation initiative workshop in Istanbul, Turkey, Nov. 6, 2014. / Joshua Haynes, USAID

A team focused on the Middle East and North Africa collaborates on challenges facing civil society at the Civil Society İnnovation initiative workshop in Istanbul, Turkey, Nov. 6, 2014. / Joshua Haynes, USAID

USAID is facing a development challenge that is not discussed as much as higher profile threats like Ebola, climate change or extreme poverty, but one that threatens to exacerbate all of those crises and impede the world’s ability to ameliorate them. It’s the growing restrictions against freedom of association, assembly and expression.

In the past two years, over 50 laws limiting civil society space have been proposed or enacted by governments around the world trying to tame the power of citizens to meet, organize, write and inspire, according to the International Center for Not-for-Profit Law, a USAID partner.

For example, in Kyrgyzstan, the government is considering a law that would echo the draconian stifling of dissent in Russia. In Kenya, the government is again floating a law that would restrict civil society organizations (CSOs) from accessing foreign funding. Again and again, we are seeing these restrictions in an increasing number of countries around the world, even those with democratically elected governments.

As a small aid agency, USAID relies on international and local CSOs that do the work of development. We also support the development of vibrant civil society sectors where we work because we know that civil society is necessary for the growth of democracy, which is in turn necessary to sustain development outcomes.

Workshop participant Josh Machleder of Internews uses a creative prop during the “product in a box” exercise explaining how to nurture civil society activism under restrictive conditions. / Reboot

Workshop participant Josh Machleder of Internews uses a creative prop during the “product in a box” exercise explaining how to nurture civil society activism under restrictive conditions. / Reboot

So this backlash against civil society affects not only USAID’s democracy work, but its work in all sectors, including health, humanitarian assistance, the environment, education and economic growth.

In response to these headwinds, President Obama launched the Stand with Civil Society initiative in 2013, where he called on governments, multilaterals and private philanthropy to explore innovative ways to support civil society. USAID took up that challenge. At the Clinton Global Initiative in September 2014, the president announced the Civil Society İnnovation Initiative (CSİI): USAID, together with the Swedish International Development Cooperation Agency (Sida), the Aga Khan Development Network and other partners, will develop up to six regional civil society innovation hubs that will connect CSOs to each other through peer-to-peer learning and to tools (technological and otherwise) to support their work and amplify the voice of civil society.

But how can USAID launch a new program designed to support civil society and protect its space without input from civil society? More than soliciting input, USAID wanted to create a process that would allow civil society to co-design the CSI with us.

That’s where the Global Development Lab came in. The Lab is not only fostering innovative solutions to development problems, it is also exploring process innovations to make USAID a more nimble, smarter donor. The Development Innovation Accelerator is a new instrument that lets USAID co-create a program with its partners to allow more dialogue and input from many more stakeholders and create a more transparent process for project design.

USAID’s Swedish colleagues were along for every step of the way and, in July, we put out a call for expressions of interest for the CSI. We received over 300 responses from 85 countries around the world. Then we invited 45 of the applicants to a three-day co-creation workshop in Istanbul in early November.

I took a number of lessons away from the workshop.

First, the co-creation process generates a better outcome than the more traditional donor-led method of project design. One CSO called it an actual “consultation” and not an “insultation,” where civil society has two minutes to speak in front of a government/donor entity.

Second, expert facilitation is key. We had an incredibly diverse group of CSOs (international, regional, national, grassroots), representing many sectors (human rights, democracy, health, environment, humanitarian assistance). The more diverse the group, the more time needs to be spent on getting everyone on the same page.

Third, co-creation is complicated, but it’s worth the extra investment of time. It was clear that this global workshop will need to be followed by workshops at the regional level to bring in more regional, national and grassroots voices.

Only the energy, creativity and courage of civil society will stop the trend of governments to restrict citizens’ voices and assembly. The challenges are daunting and dangerous. But CSOs are not alone in fighting against the obstacles. USAID, Sida and the global civil society sector support them.

And that’s why co-creation rocks: It enables USAID to be a more open donor, one that is not only listening to civil society, but is also encouraging it to help solve development challenges. This was USAID’s most ambitious co-creation to date. It took a lot to bring it about, but it was worth the investment if it shifted the USAID-civil society relationship a step closer to true partnership.

ABOUT THE AUTHOR

Claire Ehmann is Civil Society and Media Division Leader for USAID’s Center of Excellence on Democracy, Human Rights and Governance

A Spotlight on the World’s ‘Invisible’ Workers

Haitian construction workers in the Dominican Republic include an estimated 900,000 to 1.2 million undocumented migrants. The USAID Global Labor Program is supporting research and advocacy for international standards to protect their rights. / Ricardo Rojas

Haitian construction workers in the Dominican Republic include an estimated 900,000 to 1.2 million undocumented migrants. The USAID Global Labor Program is supporting research and advocacy for international standards to protect their rights. / Ricardo Rojas

USAID invests in people and their communities. But the people who do the most to bring wealth, infrastructure and services to a globalizing world may be those who leave their communities behind. They are construction workers, nurses, dishwashers, farm workers and maids. They are not likely to vote, or be leaders in their communities, or even lead their own households. But they do provide nearly half of all financial flows to developing country economies. They are the world’s 232 million migrant workers.

“Than,” one of many Burmese migrant worker in Thailand’s fishing industry, who face some of the worst abuse in the world.  / Jeanne Marie Hallacy, Solidarity Center

“Than,” one of many Burmese migrant worker in Thailand’s fishing industry, who face some of the worst abuse in the world. / Jeanne Marie Hallacy, Solidarity Center

“Than,” whose full name is protected for his privacy,is a 16-year-old Burmese boy who came to Thailand with his parents to find work. He works on fishing boats, earning only a little over $200 for an entire one-month boat journey. His father was arrested for not having a work permit, so now Than must provide for his two younger sisters, and earn back the money his family paid for a labor broker to bring them across the Thai border. His sisters hope to attend a school for migrants. Than only completed a sixth grade education.

Than is one of the luckier ones. Many Burmese migrant workers in Thailand’s seafood industry are little more than forced laborers. A report by the Solidarity Center found many workers were forced to work 16 to 20 hours a day and went without pay for months. Employers told workers their wages were being used to repay the labor brokers who brought them to Thailand.

Unemployment and underemployment have forced over half of Dominican Republic workers, many domestic workers from Haiti, into the precarious informal economy.  USAID’s partner Solidarity Center is supporting these workers to organize for their rights. / Solidarity Center

Unemployment and underemployment have forced over half of Dominican Republic workers, many domestic workers from Haiti, into the precarious informal economy. USAID’s partner Solidarity Center is supporting these workers to organize for their rights. / Solidarity Center

Thanks to interventions supported by USAID, some of these workers have been able to win back wages and better working conditions.

Even when migration is voluntary, life can be very difficult. Domestic workers migrating from Asia to the Middle East often lose the ability to communicate with their families or even their children; yet they keep working for wages they hope will enable those children to have a better life.

Even though migrant workers’ contributions to global financial flows are stunning (in 2014, remittances from expatriate workers were estimated to be $436 billion up from $132 billion in 2000), these workers are almost never the beneficiaries of any development program. They are largely invisible, restricted by law from participating in political or civic life in their countries of destination, and cut off from family and community ties in their countries of origin. They fall outside of human rights norms, and therefore are often victims of exploitation.

Between 2 million and 4 million migrant workers toil in Thailand as dockworkers, in seafood and domestic work. / Jeanne Marie Hallacy, Solidarity Center

Between 2 million and 4 million migrant workers toil in Thailand as dockworkers, in seafood and domestic work. / Jeanne Marie Hallacy, Solidarity Center

However, human rights advocacy organizations are beginning to advocate for the rights of these workers in new and innovative ways, and USAID is supporting a range of activities in several countries with high numbers of migrating workers.

According to the national census data in Nepal, as of 2011 over 700,000 Nepalis were recorded as working in Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates, with over a quarter of the country’s GDP coming from remittances. Unfortunately, too many Nepali workers are also exploited and trafficked as they migrate for work and in the destination country.

In Qatar, it’s been reported that more than 400 Nepali workers have already lost their lives working on World Cup construction sites. To help thwart the exploitation that may occur in the labor recruitment and migration process for foreign employment, USAID’s CTIP Project in Nepal has established 250 Safe Migration Networks to help educate community members on safe migration and monitor those who do migrate for employment. Much more needs to be done, such as ensuring ethical labor recruitment practices in countries of origin and decent working conditions in countries of destination.

The Thai fishing industry in Thailand has been described as being built on the slavery of migrant workers from Burma, Cambodia, and Laos. / Jeanne Marie Hallacy, Solidarity Center

The Thai fishing industry in Thailand has been described as being built on the slavery of migrant workers from Burma, Cambodia, and Laos. / Jeanne Marie Hallacy, Solidarity Center

USAID’s Global Labor Program has elevated the profile of some of the world’s most invisible workers: domestic workers around the world. A successful global campaign led by representatives of migrant domestic workers themselves succeeded in winning a new international convention on the rights of domestic workers, and bringing them from their homes into the world’s spotlight.

On this International Migrants Day, civil-society groups from around the world are presenting a framework for migration and development called the “Stockholm Agenda” to U.N. Secretary General Ban Ki-Moon. This initiative is a starting point for a broad and robust dialogue on how to ensure we spotlight and support the world’s migrant workers. It is our shared responsibility to ensure that “migration works for all.”

ABOUT THE AUTHORS

Bama Athreya is a Labor and Employment Rights Specialist
Marina Colby is a Senior Counter-Trafficking in Persons Advisor
Both work in USAID’s Center of Excellence on Democracy, Human Rights and Governance

A Look into the Hot Zone of Sierra Leone’s New Ebola Clinic

“Death is always difficult,” said Elizabeth Stevens, a nurse from Freetown, Sierra Leone.
At her new job, Stevens is forced to confront this stark reality every day, and in a way that she never has before.

“The first day, when I entered the [medical] ward, I was frightened,” said Stevens.  “But now it’s getting better.”

It’s been just a week since a new Ebola treatment unit (ETU) opened on December 1 in the town of Lunsar in Sierra Leone’s Port Loko district—an area with one of the highest rates of Ebola in the country. On its first day of operation, four patients were admitted to the facility being run by International Medical Corps (IMC) with USAID support. USAID provided more than $5 million for the staffing and management of the 50-bed ETU.

According to the ETU’s medical director, some of the facility’s 150 staff members were nervous to start caring for Ebola patients in spite of all the training they received. But by day three, things started coming together.

“For the first two days, you could see people’s anxiety…more of the fear of it being real,” said IMC medical director Vanessa Wolfman. “But we have a great psychosocial team to talk to staff about their fears.  Now we’re getting into a routine. Everyone’s much more comfortable and can rely on each other.”

This reliance and teamwork is evident even before the first patient is seen.  On one end of the medical complex, there’s a small group of people around emergency room nurse Lisa Woods, helping her get into the protective suit, gloves, apron, boots, and goggles that will keep her safe while treating Ebola patients.

“You don’t have any touch with the patients,” said Woods, her voice slightly muffled from the mask covering half her face; giant red goggles cover the other half. “I think that’s the hardest part, not being able to connect with my patients in a human way. Like right now there’s a 14-year-old in there, and boy, that’s hard.”

On the other end of the treatment complex, groups of men and women are washing hundreds of articles of clothing, boots, goggles, and gloves by hand. Right next to them, several people are hooking up a washing machine that was recently delivered—just in time to speed up the laundering process before more patients arrive and the ETU gets busier.

“We are really sympathetic with the patients,” said Idrissa Kamara, a nurse at the ETU. “These people are our people.  So we take great care of them because we don’t want to see them missing.”

Just then, the medical director announces that another ambulance is on its way with a confirmed Ebola patient. Idrissa and the other nurses walk out of the staff rest area, to suit up and take care of another one of their own.


12.4.14-IMC-Lunsar-ETU-one-of-few-places-where-food,-water-could-be-passed-from-safe-zone-to-hot-zone.-photo-Carol-Han-USAID-OFDA

A look into the hot zone: This is one of the few places where water and food could be passed from the safe zone to the patient areas. Orange fencing indicates the areas where staff must be wearing protective clothing. / Carol Han, USAID


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An ambulance brings a patient to the newly opened Ebola treatment unit (ETU) in Sierra Leone’s Port Loko district, one of the areas hardest hit by the epidemic. / Carol Han, USAID


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USAID’s Office of U.S. Foreign Disaster Assistance provided $5 million dollars to staff and manage the ETU. USAID partner International Medical Corps (IMC) is running the facility. / Carol Han, USAID


12.4.14-IMC-Dr.-Lisa-Woods-at-Lunsar-ETU-in-middle-of-6-hour-shift-Photo-Carol-Han-USAID-OFDA

Lisa Woods is an emergency room nurse from San Francisco who came to Sierra Leone to work at the USAID-supported ETU.  “To give to somebody, what greater gift is that?” said Woods. Photo credit: / Carol Han, USAID


12.4.14-IMC-Lunsar-nurse-group-hero-shot-1-Photo-Carol-Han-USAID-OFDA

Most of the 150 people working at the ETU are Sierra Leonean. “All of us are working in unity,” said nurse Elizabeth Stevens (far left). / Carol Han, USAID


12.4.14-IMC-Lunsar-ETU-laundry-area-were-goggles-are-washed-1-photo-Carol-Han-USAID-OFDA

Hundreds of articles of clothing, goggles, boots, and gloves are washed every single day by hand. A newly installed washing machine will speed up the laundering process. / Carol Han, USAID


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Dream Team: A group of nurses suit up to go into the patient ward during their six-hour shift. It takes teamwork not only to work with patients, but to get dressed for duty. “It’s really been a great experience,” said Lisa Woods (right). / Carol Han, USAID


12.4.14-IMC-Nurse-Idrissa-2-photo-Carol-Han-USAID-OFDA

“These people are our people,” said Idrissa Kamara, a nurse at the ETU. “So we take great care of them because we don’t want to see them missing.” / Carol Han, USAID

ABOUT THE AUTHORS

The Ebola Disaster Assistance Response Team (DART) is overseeing the U.S. Ebola response efforts in West Africa. The DART includes staff from across the U.S. Government, including USAID’s Office of U.S. Foreign Disaster Assistance (OFDA), the U.S. Centers for Disease Control and Prevention (CDC), and the Departments of Defense and Health and Human Services.

South Sudan’s People Deserve Peace

South Sudanese refugee girls in Gambella, Ethiopia receive assistance from International Medical Corps, funded by the United States Government / IMC Ethiopia

South Sudanese refugee girls in Gambella, Ethiopia receive assistance from International Medical Corps, funded by the United States Government / IMC Ethiopia

As leaders of United States Government humanitarian efforts, we currently contend with a long list of global disasters, conflicts and disease outbreaks. Yet none fills us with as much frustration and despair as the crisis in South Sudan. Why? Because this crisis should never have happened.

In 2011, after many years of fighting for independence, the nation of South Sudan was born. Last year, the Southern Sudanese people were on track with the work of developing their nation—development they dreamed of during decades of war. Our plan was to phase out aid to those South Sudanese who had returned from exile. Helping the new government to govern justly and serve its people was the top priority.

But on this day one year ago, fighting triggered by discord between political leaders and fueled by ethnic rivalries broke out among soldiers in Juba, which set off a wave of violence that spread to the far reaches of the country. The result was death, destruction, and, once again, innocent people on the run.

On this sad anniversary, our thoughts are with the victims of this conflict, whose hopes and aspirations have been overtaken by tragedy. Children are out of school and families have been torn apart.

Today, South Sudan is the most food insecure country in the world with parts of the country on the brink of famine. Roughly one-third of people in the Greater Upper Nile region are facing a food emergency. In areas ravaged by violence, farmers cannot harvest their crops.

When violence broke out last December, the United Nations Mission in South Sudan (UNMISS) opened the gates of their compounds to civilians desperate for a safe place to hide from the violence. Today nearly 100,000 South Sudanese are still there, crowded together in tents and facilities that were not meant to house so many families. Some venture out to check on their abandoned homes, farms or businesses, but most are too frightened to leave.

 USAID food commodities are distributed at U.N. House Protection of Civilians (POC) site in Juba, where more than 32,000 people are seeking shelter. / K. Donovan, UNICEF

USAID food commodities are distributed at U.N. House Protection of Civilians (POC) site in Juba, where more than 32,000 people are seeking shelter. / K. Donovan, UNICEF

Nearly 500,000 South Sudanese are now living as refugees in neighboring countries. These countries’ willingness to take them in has saved many lives.

Aid workers are doing all they can to help millions of people. Their efforts, supported by the U.S. Government, other governments and aid donors, have helped stave off famine, saved lives and ensured the victims of South Sudan’s violence could get food, shelter, clean drinking water, health care and psychological support. But resources are limited and many are forced to live in terrible conditions where diseases thrive and hardships multiply.

Violence, however, continues to make it dangerous, difficult and expensive to reach and protect the victims of this conflict—and South Sudan was already a very challenging place to deliver aid. In August, six humanitarian aid workers in Maban County were attacked and killed, one World Food Program staff member is missing and other aid workers have been targeted.

Aid organizations resort to exorbitantly expensive air operations to deliver food. Moving food by air can cost eight times more than delivering it by trucks. This senseless crisis is straining available resources during a time of unprecedented global need. Yet unless the fighting stops, the specter of famine will continue to loom over South Sudan and innocent men, women and children will continue to suffer.

Regional peace talks have so far been unsuccessful. It is more urgent than ever that the warring parties recommit to the ceasefire declared in January—and this time, they need to mean it. In South Sudan, political leaders and military commanders should stop the fighting and put their people first.

ABOUT THE AUTHORS

Nancy Lindborg is Assistant Administrator for USAID’s Bureau for Democracy, Conflict and Humanitarian Assistance
Anne C. Richard is Assistant Secretary for Population, Refugees and Migration at the Department of State

Delivering More Bang for Development Bucks: Cost-Benefit Analysis and Feed the Future

Ireen Mapfumo, a Zimbabwean farmer, shows off a handful of protein-rich soybeans she harvested as one of eight lead farmers contracted by a USAID project in Zimbabwe. /  Fintrac Inc.

Ireen Mapfumo, a Zimbabwean farmer, shows off a handful of protein-rich soybeans she harvested as one of eight lead farmers contracted by a USAID project in Zimbabwe. / Fintrac Inc.

Now more than ever, development professionals and policymakers ask a fundamental question: Is a project worth the investment? Many are looking to cost-benefit analysis (CBA) for an answer.

Starting in 2009, USAID re-committed to cost-benefit analysis (CBA) as a critical tool for effective decision-making, and dramatically expanded its usage and training. CBA is an economic model that weighs strengths and weaknesses to determine how to implement or modify a project. USAID uses CBA to help determine when and where to invest for maximum results.

Feed the Future, Meet Cost-Benefit Analysis

Coinciding with this renewed interest in CBA was an increase in U.S. investment in global food security. At the 2009 G8 Summit in L’Aquila, Italy, President Obama called on global leaders to reverse a three-decade decline in agriculture investment. The U.S. Government’s global hunger and food security initiative, Feed the Future, embodied the U.S. contribution to this global commitment to reduce poverty, hunger and undernutrition.

Feed the Future wasn’t just a commitment of funding. It signaled a new way of doing development, founded in support of country-led efforts, deep partnership, and a relentless focus on results. It’s fitting, then, that Feed the Future became a critical player in the renewed push for incorporating CBA into USAID’s efforts.

As the lead agency for the Feed the Future initiative, USAID determined early on that it would roll out CBA analysis to Feed the Future countries through its overseas missions. This included specialized CBA training for agricultural officers and others working on Feed the Future’s early implementation so that CBA methods could be incorporated into agricultural program design.

Cost-Benefit Analysis Explained

CBA blends smart design with evidence to figure out if a project makes sense for the people USAID serves.

Analysts examine the incentives facing multiple stakeholders, including prices, profits, and losses over a long period of time. USAID uses this information to determine who is likely to win or lose as a result of a project, and adjusts design as necessary. Once the incentives are clear, the CBA model calculates the project’s costs and benefits.

Since we live in an inherently uncertain world, CBA analysts don’t stop there. CBA has helped Feed the Future projects account for volatile changes in circumstances, such as food price fluctuations over time.

Twenty-three missions around the world have used CBA to analyze or inform Feed the Future programming. Initial results have found that Feed the Future investments will achieve a 32 percent economic rate of return on average. By comparison, long term U.S. Government bonds only yield about three percent.

Perhaps even more important for the growth of CBA practice are the hundreds of USAID officers — including many agriculture officers — who have received training in how to incorporate CBA methods in program design. These agricultural officers will incorporate what they have learned into future projects, amplifying the effects of CBA.

USAID Cost Benefit analysis for Feed the FutureCreated by Gregory Gangelhoff

Cost-Benefit Analysis in Action

CBA is producing concrete results. In Haiti, USAID analysts conducted CBA of agricultural projects under Feed the Future West, an ongoing USAID program. Feed the Future West aims to modernize and create productive agricultural zones. Analysis determined that farmers would enjoy an internal rate of return (IRR) of 49 percent if all project targets were met. In other words, for every 1 dollar invested the host society receives an average of 49 cents in additional income over the project’s life.This result is significant: development institutions typically accept a minimum IRR of 12 percent for most projects.

Seventeen kilometers of improved roads in the Haitian mountain community of Fond-Baptiste now provide easy access to this local Monday market and larger markets on the coast. / Steve Goertz

Seventeen kilometers of improved roads in the Haitian mountain community of Fond-Baptiste now provide easy access to this local Monday market and larger markets on the coast. / Steve Goertz

USAID’s CBA analysts also examined how to remedy a shortage of rural roads in Haiti so that farmers could bring goods to market.

In Ethiopia, CBA helped guide $54 million in recent program planning. USAID estimates that these CBA-assisted programs have the potential to pull up to 400,000 people out of extreme poverty, explains Daniel Swift, an economist for USAID/Ethiopia.

In particular, USAID calculated the costs and benefits for Ethiopians of meat and dairy value chains as part of the Pastoralist Resiliency Improvement and Market Expansion (PRIME) project. The Mission’s original plan called for animal health and maintenance training, but CBA proved that the benefits of this training could not justify the investment. Instead, CBA led the mission to investments with more bang for the development buck.

This includes helping establish a meat processing plant that is expected to yield an estimated “$68 million in economic benefits for Ethiopia” in the form of a “tangible and sustainable market for poor pastoralists in the region,” according to Swift. Here and elsewhere, CBAs allowed decision makers to identify new opportunities and expand successful initiatives in the right places.

In concert with strategic analysis and a strong record of collaboration with private-sector partners, CBAs have become a part of the Feed the Future success story in this critical country.

Cost Benefit analysis in Feed the Future at USAIDCreated by Gregory Gangelhoff

CBA is more important than ever at USAID, but this work is far from complete. Tom DiVincenzo, USAID/Guatemala Mission Economist, notes that CBA analysts continue to seek new ways of explaining their work to decision-makers, who can struggle to fully understand the value of this type of analysis.

So what can the development community do to promote CBA and empower decision-makers in using it? Connect CBAs to “concrete examples” that non-economist decision-makers can understand easily, DiVincenzo notes. The results are worthwhile. When quantitative analysts work hand-in-hand with agricultural experts, their collaboration can plant the seeds for future prosperity.

ABOUT THE AUTHOR

Gregory Gangelhoff is an Economist in USAID’s Office of Economic Policy working on cost-benefit analysis, domestic resource mobilization, and growth diagnostics. Follow him @gwgangelhoff
Sally Rey is a Program Analyst in USAID’s Bureau for Food Security working on Feed the Future. Follow her @SalCary

Ending Extreme Poverty in Asia through Universal Health Coverage

A woman in the Philippines receives a tetanus shot during a pre-natal visit. / HealthPRO

A woman in the Philippines receives a tetanus shot during a pre-natal visit. / HealthPRO

The 2010 World Health Report on Health Systems Financing and the unanimous endorsement of Universal Health Coverage (UHC) by the United Nations in 2012 have paved the way for rich and poor countries alike to take a closer, more critical look at how raise resources and improve access to health services, particularly for the poor. Asia is home to 3.9 billion people and accounts for a third of the global economy. Despite the region’s robust economic growth, almost two thirds of those in extreme poverty still live in Asia.

While there are many paths that a country can choose to get out of poverty, mobilizing domestic resources towards the health sector – in the form of Universal Health Coverage policies that seek to increase access to services especially for the poor – is a sound and sustainable investment that can lead to great economic returns. These reforms that empower the poor are critical because poor health and health shocks are leading causes of chronic poverty and impoverishment.

An Indonesian patient awaits further instructions during a check-up. / USAID

An Indonesian patient awaits further instructions during a check-up. / USAID

Rapidly growing Asian countries, Bangladesh, Indonesia, Thailand, and Vietnam have shown that improving health indicators and reducing extreme poverty are clearly linked. Declines in infant and child mortality rates in these countries preceded periods of strong and sustained economic growth.

Clearly, an agenda to end extreme poverty must include UHC goals.

Ill health prevents the poor from climbing out of poverty and can impoverish the near poor. When a household member falls ill, this can mean diminished labor productivity. In addition, households often make catastrophic financial outlays paid for by selling their assets, reducing their consumption, dipping into their savings, or borrowing at high interest rates for seeking health care.

High rates of out-of-pocket spending, a highly regressive way of financing health systems, create financial barriers to accessing health care., This financing represents 36 percent and 61 percent of the total health spending in developing East Asia and Pacific and South Asia regions, respectively.

Pupils in Vietnam's Bac Giang Province take part in a USAID deworming project . /  Richard Nyberg, USAID)

Pupils in Vietnam’s Bac Giang Province take part in a USAID deworming project . / Richard Nyberg, USAID)

UHC reforms come in different shapes and sizes. Some common characteristics include improving revenue collection mechanisms so that they are fair and affordable;, helping people move away from paying for health services out of pocket and toward prepayment and risk pooling; improving value for money with strategic purchasing;, and targeting the poor through subsidies.

Many of these reforms across Asia have increased access and utilization of health care, provided financial protection, as well as improved health care outcomes.

Countries such as China and Bangladesh successfully piloted schemes. In Bangladesh, the pilot voucher program to improve maternal and child health successfully increased pre-and post-natal care and facility-based deliveries, while reducing out-of-pocket spending and the costs of these services, and decreasing neonatal mortality rates by a third to almost half in home-based interventions. Bangladesh has adopted UHC as a national policy goal and USAID is providing assistance to support implementation of their health financing strategy.

Vietnam and Indonesia have reached partial coverage of their populations by around two thirds, and have recently taken additional steps to expand their coverage.

Analysis of various UHC schemes in Vietnam (public voluntary health insurance, social insurance and the health care fund for the poor) showed that they had improved financial protection – significantly decreasing spending for the beneficiary insured and providing evidence of positive impacts on their nutrition indicators. And in January of this year, Indonesia set out on the path towards UHC with the goal of covering its entire population of 250 million people by 2019.

The dynamic economic environment in fast-growing Asia means that the role of donors like USAID and the development assistance architecture will need to evolve as well.

Individual countries and the region at large will need to grapple with growing migrant populations and the need for portable schemes that ensure access for migrant labor populations across porous borders. A large and growing informal sector, individuals not covered by the labor and social security provisions, will continue to test how countries communicate expanded coverage to remote and often marginalized communities. Equally as important will be the question of how to finance and address the changing mix of population health needs arising from demographic trends and the emergence of non-communicable diseases.

As many of the developing countries in Asia continue to grow, they will have sufficient resources to afford a basic package of health services for their entire population; however, governments tend to under-invest in their health sector relative to their economic potential.

As a result, oftentimes as countries grow wealthier, public health systems fall further behind.

In Asia and globally, growing domestic resources represent a critical window of opportunity where countries must have the vision and courage to strategically direct this increased wealth towards the health sector so that development dollars are crowded out.

By financing policies that focus on increasing equity and access to quality essential health services – the aim of universal health coverage – countries will be taking concrete steps towards the bold vision of ending extreme poverty.

ABOUT THE AUTHOR

Kristina Yarrow is a Senior Health Technical Specialist in the Asia Bureau, backstopping technical areas specific to health systems strengthening and research such as health financing, UHC, and implementation research.

Caroline Ly is a Health Economist in the Bureau for Global Health’s Office of Health Systems.

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Breaking Invisible Barriers in the West Bank and Gaza

USAID supports girls’ education in the West Bank. The Agency built the new Nahalin Secondary Girls' School in the Bethlehem Governorate  / Credit Alaa Badarneh

USAID supports girls’ education in the West Bank. The Agency built the new Nahalin Secondary Girls’ School in the Bethlehem Governorate / Alaa Badarneh

It’s nearly impossible to watch the news or read a newspaper without hearing about the West Bank and Gaza. It seems every week there’s a breaking story of violence and destruction. And yet when I visited USAID’s West Bank and Gaza Mission in November, the message I consistently heard was one of hope.

I went to see first-hand how USAID’s diverse programs are helping to ensure women and girls have the tools and capacity to realize their rights. From the justice system to small business, it was inspiring to witness the positive impact of USAID’s work.

The trip was also a powerful reminder that gender relations in the West Bank and Gaza are unique and complex but also obscured by the ongoing conflict. The main challenge Palestinians face is occupation, being both physically and socially restricted in everyday life that we take for granted.

Susan Markham meets with USAID staff, beneficiaries, and partners to promote the importance of gender equitable structures, institutions, and infrastructure in Palestinian society. USAID/West Bank/Gaza

Susan Markham meets with USAID staff, beneficiaries, and partners to promote the importance of gender equitable structures, institutions, and infrastructure in Palestinian society. / USAID/West Bank/Gaza

While the physical roadblocks inhibit movement, there are also invisible barriers that Palestinian women face. Despite a commitment to girl’s education, and a long tradition of women’s engagement in political life, separate social structures and a male dominated culture endure. However, instead of being demoralized, what really shone through was the enthusiasm and determination of both women and men to fully engage on equal terms.

I was energized to meet Maysa, a 26-year-old entrepreneur breaking ground within the tourism industry. By organizing photography tours throughout the West Bank, running her own YouTube channel, and designing original souvenirs, she is staying at the forefront of tourism and opening doors to women who wish to work in the industry.

I spoke with inspiring women entrepreneurs who are breaking barriers within their communities and launching successful businesses in information and communication technology (ICT), marketing, tourism and international training and certification. Thanks to assistance from USAID, many of these women are already planning to start a second business.

Through USAID’s Local Government and Infrastructure Program, I was able to hear from young women participating in and leading Youth Local Councils across the West Bank where women and men work together to advance community driven ideas around education, health, infrastructure and governance.

Perhaps nowhere was progress in gender equality so evident than at the Youth Development and Resource Center in Hebron. There I met Omar whose parents forbid him to go to the center as a boy because there would be girls there. Today, he runs the center, providing skills training, work experience, and a dynamic example of what’s possible when men and women work together.

From the teachers fighting for improved training for their students to the women working in cutting edge technology fields, there was optimism for a brighter future and a fierce resolve to get there.Vera Baboun, the mayor of Bethlehem, summed up the experience best when she quoted poet Mohja Kahf to me:

All women speak two languages:
the language of men
and the language of silent suffering.
Some women speak a third,
the language of queens.
They are marvelous
and they are my friends.

 

ABOUT THE AUTHOR

Susan Markham is the USAID Senior Coordinator for Gender Equality & Women’s Empowerment. Follow her @msmarkham

South Sudan: The Threat of Worsening Hunger

Residents of Bor County receive sorghum, oil, and lentils in exchange for road construction work they completed as part of the Catholic Relief Services led Jonglei Food Security Program, in Jonglei, South Sudan.  / CRS

Residents of Bor County receive sorghum, oil, and lentils in exchange for road construction work they completed as part of the Catholic Relief Services led Jonglei Food Security Program, in Jonglei, South Sudan. / CRS

A few weeks ago, my office instructed a vessel carrying 21,000 tons of American-grown sorghum destined to serve hungry people in South Sudan to divert from its Djibouti destination and discharge its cargo in Port Sudan instead. That vessel arrived and offloaded last week.

While the food was originally destined to travel for weeks by road from Djibouti to Gambella, Ethiopia, and then be airlifted or air-dropped into remote areas of South Sudan, a recent agreement between Sudan and South Sudan brings the possibility of a more hopeful scenario.

After almost a year of negotiation, the U.N. World Food Program secured agreement from both governments, as well as opposition groups in South Sudan, to facilitate safe passage of this grain to hungry people in South Sudan.  Saving both time and expense, it will be trucked or shipped by barge across the border from Sudan to South Sudan to meet immediate food needs and be pre-positioned in remote areas for use in the coming months.  If the two governments follow through on their commitments, the opening of this corridor will help to stave off hunger in a new country, whose hopes for growth and prosperity were dashed by ruinous fighting between the government and armed opposition groups one year ago.

Mary Ngok, 31, a farmer in Bor County receives sorghum, oil, and lentils in exchange for road construction work they completed as part of the Catholic Relief Services led Jonglei Food Security Program, JFSP, in Jonglei, South Sudan. / Sara A. Fajardo/Catholic Relief Services

Mary Ngok, 31, a farmer in Bor County receives sorghum, oil, and lentils in exchange for road construction work they completed as part of the Catholic Relief Services led Jonglei Food Security Program, JFSP, in Jonglei, South Sudan. / Sara A. Fajardo/Catholic Relief Services

South Sudan is the most food-insecure place in the world. Six months ago, after visiting, I laid out five key actions that USAID was taking to avert hunger and famine in South Sudan. One of them was to draw on the Bill Emerson Humanitarian Trust (BEHT), a seldom-used fund that USAID taps when unanticipated global needs outstrip food aid budgets, to procure additional food for South Sudan. Thanks to this trust, 50,000 tons of U.S. food – including the 21,000 tons recently offloaded in Port Sudan, are being used to respond to the hunger crisis in South Sudan.

The scale-up has enabled emergency care for more than 76,000 children suffering from severe acute malnutrition, and humanitarian workers have reached roughly 3.5 million vulnerable and displaced people with aid since January. Throughout 2014, conflict and bad weather forced the international community to rely on expensive airlift operations to move food and other supplies into remote areas of the country – operations that are roughly 8 times more costly than serving people by road. While extraordinarily costly in terms of expense, lifesaving aid has helped avert famine – for now.

The question is, what happens next?

Will the United States’ BEHT food make it safely to its intended destination, as planned? Will people already worn down by a year of war be reached with lifesaving aid and recovery support? Or will renewed fighting move South Sudan into a deeper downward spiral?

Sadly, the dry season, which typically lasts from December to April, is not only a time for recovery but has in past years also been a time for renewed conflict. Already we have reports that fighting has begun anew, adding to the suffering experienced by the nearly 1.9 million displaced people.

The international community is already overstretched due to the scale and gravity of the crisis and other humanitarian emergencies worldwide. The United States has provided more than $720 million in response to the crisis, including more than $339 million for food and nutrition assistance alone.

The future of South Sudan is in the hands of the combatants. This humanitarian crisis is man-made, as will be its resolution. The best way to avert a future famine is for the combatants to stop fighting, so that ordinary South Sudanese people can plant crops, markets can reopen and communities can begin to recover.

ABOUT THE AUTHOR

Dina Esposito is the Director of USAID’s Office of Food for Peace

A ‘Daily’ Struggle for Human Rights

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Today, in honor of International Human Rights Day and the 66th anniversary of the Universal Declaration of Human Rights, USAID joins the world  in standing with all those who struggle for the realization and protection of their human rights. We believe that promoting human rights is closely linked to advancing long-term, sustainable development, and that these rights are instrumental to attaining other goals such as economic growth and democracy and addressing underlying grievances that cause instability and conflict.

While USAID’s global mission is to end extreme poverty and promote resilient, democratic societies, inextricably linked to this mission, is the protection and promotion of universally accepted human rights for all persons where we work.

Following the Rwanda genocide in 1994, issues of reconciliation remain a concern for maintaining peace into the future. USAID's Reconciliation and Reintegration programs provided trauma counseling and space for dialogue that allowed Elaine to forgive Alexis (both pictured) for killing her family members. They now have rebuilt their lives in the same community.  / Carol Storey

Following the Rwanda genocide in 1994, issues of reconciliation remain a concern for maintaining peace into the future. USAID’s Reconciliation and Reintegration programs provided trauma counseling and space for dialogue that allowed Elaine to forgive Alexis (both pictured) for killing her family members. They now have rebuilt their lives in the same community. / Carol Storey

Ending poverty is not feasible if people are denied the right to work, or are not paid fairly for their labor or are unable to secure housing, land, and property or lack access to health care.  Building well-functioning democratic societies requires respect for fundamental rights and freedoms of assembly, association, expression, information, political participation, and a fair trial.

Everyone should have the right to non-discrimination and protection against arbitrary arrest and detention, torture and inhumane treatment, and forced labor and slavery.

USAID’s human rights programming is grounded not only in core democratic principles and values of the United States of America, including the four freedoms articulated by President Franklin D. Roosevelt in 1941 (of speech, of worship, from want, and from fear), but also in the clear and timeless framework of the United Nations Declaration of Human Rights.   This includes:

  • Article 2.  Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.  In countries and regions such as Cameroon, Nicaragua, Bosnia, South East Asia, Kazakhstan, Vietnam, Zambia, and Jordan, USAID is supporting the education, advocacy and sensitization work of local activists and human rights organizations who are breaking down the barriers of many forms of discrimination. USAID’s recently launched Lesbian, Gay, Bisexual, and Transgender (LGBT) Vision for Action specifically highlights our commitment to promoting and protecting the rights of sexual and gender minorities.
Training of Human Rights Monitors, part of USAID’s Human Rights in Action Program, Chernihiv, Ukraine. / USAID/Ukraine

Training of Human Rights Monitors, part of USAID’s Human Rights in Action Program, Chernihiv, Ukraine. / USAID/Ukraine

  • Article 3. Everyone has the right to life, liberty and security of person.  USAID is assisting human rights defenders and national human rights institutions in Ukraine, Burundi, Zimbabwe, and Mali, among many other countries, to document, investigate, and report on the severest forms of violations of this internationally enshrined right to life. USAID also supports the protection of human rights defenders  and the victims and survivors of human rights violations.
Youth from the municipality of Caucasia (Bajo Cauca Antioqueño), Colombia, participating in the first intercollegiate human rights competition “Human Rights: A Strategy to Educate.” This initiative, carried out by Corporación Jurídica Colombia Humana with USAID’s Human Rights Program support, sought to promote a human rights culture at schools through a human rights competition that evaluates knowledge acquired during the project duration. Photo Credit: Jairo  Martínez, Corporación para el Desarrollo Social del Bajo Cauca, partner with USAID’s Human Rights Program

Youth from the municipality of Caucasia (Bajo Cauca Antioqueño), Colombia, participating in the first intercollegiate human rights competition “Human Rights: A Strategy to Educate.” This initiative, carried out by Corporación Jurídica Colombia Humana with USAID’s Human Rights Program support, sought to promote a human rights culture at schools through a human rights competition that evaluates knowledge acquired during the project duration. / Jairo Martínez, Corporación para el Desarrollo Social del Bajo Cauca, partner with USAID’s Human Rights Program

  • Article 4. No one shall be held in slavery or servitude; slavery and the slave trade shall be prohibited in all their forms. As millions of people around the world continue to be exploited in the modern day slave trade or human trafficking, USAID set forth a new vision to counter-trafficking in persons (C-TIP) through an agency-wide C-TIP Policy with key programming objectives that include integrating C-TIP activities in development projects across sectors from health to economic growth.  USAID is responding to human trafficking trends in Bangladesh, Cambodia, and Nepal by supporting programs that foster legal labor recruitment practices and safe migration. We also work to ensure that its own employees, partners, and procurement practices are not in any way facilitating human trafficking, by diligently enforcing the agency’s C-TIP Code of Conduct. New partnerships are being cultivated with the private sector since ending human trafficking is everyone’s business.
Nusrat Bibi, an acid burn survivor, takes photographs during a field trip for the photography workshop in Pakistan. Nusrat received photography training from Acid Survivors Foundation (ASF) under the USAID Gender Equity Program, which supports women’s rights as human rights and works to empower women, especially those who are survivors of gender-based violence. As part of a rehabilitation process that includes developing new skills, ASF trained nine acid attack survivors. The photographic work of these survivors was featured in three different exhibitions in Islamabad. / Diego Sanchez.

Nusrat Bibi, an acid burn survivor, takes photographs during a field trip for the photography workshop in Pakistan. Nusrat received photography training from Acid Survivors Foundation (ASF) under the USAID Gender Equity Program, which supports women’s rights as human rights and works to empower women, especially those who are survivors of gender-based violence. As part of a rehabilitation process that includes developing new skills, ASF trained nine acid attack survivors. The photographic work of these survivors was featured in three different exhibitions in Islamabad. / Diego Sanchez.

  • Article 10.  Everyone is entitled in full equality to a fair and public hearing by an independent and impartial tribunal in the determination of his [or her] rights and obligations and of any criminal charge against him [or her]. USAID provides Rule of Law assistance to more than 40 countries around the world, including Bosnia, Burma, Cote d’Ivoire, and Indonesia in order to strengthen the administration of justice and promote independent, accountable, and efficient judicial systems.
Vu Lieu, LGBT Advocate, participated in the Vietnam National Dialogue as part of the “Being LGBT in Asia” Initiative.  The dialogue convened LGBT persons from around Vietnam to share lived experiences and discuss legal and socio-economical challenges they face and propose solutions. / Information Communication and Sharing, Vietnam

Vu Lieu, LGBT Advocate, participated in the Vietnam National Dialogue as part of the “Being LGBT in Asia” Initiative. The dialogue convened LGBT persons from around Vietnam to share lived experiences and discuss legal and socio-economical challenges they face and propose solutions. / Information Communication and Sharing, Vietnam

  • Article 19. Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers. In Central African Republic, USAID is supporting local journalists, radio and press outlets to ensure critical and accurate information and peacebuilding programming is reaching those communities severely affected by the crisis.
  • Article 25.1. Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.  In Angola, USAID has empowered communities affected and threatened by forced evictions and demolitions through capacity strengthening activities and legal assistance and assisting the government in compiling a database of those in need of housing.

Today, we support the global efforts to expand human rights and the fundamental liberties contained in the Universal Declaration of Human Rights, which reminds us that “the inherent dignity and…the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.” It is equally a foundation of development.

ABOUT THE AUTHOR

Nicole Widdersheim is Human Rights Advisor for USAID’s Center for Democracy, Human Rights and Governance

The Intersection of HIV/AIDS and Gender-Based Violence: A Critical Connection

A mother plays with her child while waiting for services at Jose Maria Cabral y Baez Hospital in Santiago, Dominican Republic. Health workers and supervisors from this hospital participated in a workshop and supportive site supervision system designed and delivered by the Directorate of STI/HIV/AIDS (DIGECITSS), the health services network (REDES), and CapacityPlus to improve the quality of services to eliminate mother-to-child transmission of HIV and congenital syphilis. / Wendy Tactuk, courtesy of CapacityPlus and IntraHealth International

A mother plays with her child while waiting for services at Jose Maria Cabral y Baez Hospital in Santiago, Dominican Republic. Health workers and supervisors from this hospital participated in a workshop to improve the quality of services to eliminate mother-to-child transmission of HIV. / Wendy Tactuk, courtesy of CapacityPlus and IntraHealth International

This week we mark World AIDS Day. Appropriately, it occurs during the Sixteen Days of Activism Against Gender-Based Violence. Why so appropriate? Because we know that gender-based violence (GBV) prevention and response are critical to effectively treating and reducing the spread of HIV. Though not always self-evident, the connection is clear.

For me, the linkages were driven home during recent conversations I had with health experts in Ghana. While discussing our health programs, I casually asked how important attention to GBV was within efforts to treat and stem the spread of the HIV.  As soon as I asked the question, the room’s atmosphere changed palpably. Everyone sat up and leaned in. People began speaking all at once, tripping over one another to respond. The passion was tangible and the analysis compelling. It was all the more persuasive because it is backed up by research.

In Ghana, the HIV rate is low and declining, though the rate is 15 – 20 times higher for key populations at risk of contracting HIV, which include female sex workers (FSWs) and men who have sex with men.

GBV is particularly common among female sex workers (FSWs), 24 – 37 percent of whom are HIV-positive. How do GBV and HIV rates correlate and relate, and how do we bear that in mind in our work to prevent and treat the infected?

A traditional leader discusses multiple concurrent partnerships, a key driver of HIV in Zambia, during a November 2013 training on HIV/AIDS leadership messaging in Kanyembo Chiefdom in Luapula Province / JSI/SHARe II

A traditional leader discusses multiple concurrent partnerships, a key driver of HIV in Zambia, during a November 2013 training on HIV/AIDS leadership messaging in Kanyembo Chiefdom, Luapula Province. / JSI/SHARe II

Many of my conversations in Accra focused on how to help people change behavior to decrease the risk of transmitting the virus and to increase the likelihood of seeking testing and treatment. The experts discussed how much more difficult it is for a woman or a man to negotiate condom use with an abusive partner.

The victim is less likely to try to persuade the abuser to use protection. The perpetrator is less likely to listen. The practitioners also talked about how victims of gender-based violence have less self-esteem and a lowered sense of self-worth. As a result, victims of abuse don’t believe they have the “right” to receive health services. It is much harder to coax people who face GBV or who fear violence or abandonment to seek services, test for HIV, or to successfully access or adhere to treatment.

A 2010 study of FSWs in Karnataka state, south India, confirmed what the Ghanaians explained to me; fear of partner violence prevented women and girls from seeking health services and from asking their partners to use condoms. The study found that condom use was some 20 percent lower those who had been beaten or raped within the last year compared with those who had not faced such violence.

The experts I spoke with also mentioned how gender-based violence cements relationships in which one partner is clearly dominant; they discussed how that feeling of dominance can give the abusive partner a sense of invincibility, reducing his or her willingness to practice prevention.

If you don’t believe you are vulnerable to harm or disease, there is no need to protect yourself. A 2014 study in South Africa supported this contention. The study, which considered women and girls attending four health centers in Soweto, found that abusive relationships with high levels of male control were “associated with HIV seropositivity.” In relationships where men had a great deal of power or where violence was frequent, researchers found that females were less likely to request condom use and had about a 12 percent greater likelihood of being HIV-positive.

Sometimes, the statistics were actually pretty astonishing.  A 2012 study in Moscow, Russia found that FSWs were more than 20 percent more likely to be HIV-positive or to carry a sexually transmitted infection (STI) if they experienced client violence. In addition, over forty percent of FSWs who were coerced into sex with the police were STI/HIV infected. Researchers concluded that reducing the risk of infection would require decreasing client, pimp and police abuse and coercive behavior.

A 2013 WHO systematic global review and analysis of studies across different HIV epidemic settings underscored the association between GBV and HIV, finding that intimate partner violence increases the risk for HIV infection among women and girls by more than 50 percent, and in some instances up to four-fold.

There are two bottom lines to the research and experiential data. First, reducing and responding to gender-based violence should be a key tool in efforts to prevent the spread of HIV. Second, additional research is needed to understand those violence-reducing interventions that best reinforce HIV prevention and treatment.

USAID has seen important dividends from integrating GBV prevention and response into HIV and AIDS programs in collaboration with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). In Tanzania, USAID has supported development of National Management Guidelines for Health Response and Prevention to GBV, which provide a framework to guide comprehensive management of GBV survivors.

The Guidelines have led to training of health care providers and roll-out of a GBV register at health facilities across the country. In Zambia, USAID with PEPFAR funding, is collaborating with the British Department for International Development (DFID) and six government ministries to strengthen the response to GBV; this includes doubling the number of one-stop centers in several provinces, reaching 5 million adults and children with preventive messages, assisting 47,000 survivors, and training 200 police and justice sector personnel through 2018.

All told, USAID has contributed significantly to important results under PEPFAR; in FY2013, 2.5 million people in 12 countries were reached by efforts to address GBV and coercion, and an additional 800 health facilities began offering GBV screening, assessment and/or referrals to service providers.

The connection between gender-based violence and HIV infection is unambiguous. The data combined with the experience and perspectives of field experts make it clear. As we renew our commitments this week both to combat the spread of AIDS and to prevent GBV, let’s recognize and ensure that programs address the intersection. It could make the difference between the success and failure of efforts around the world.

ABOUT THE AUTHOR

Carla Koppell is USAID’s Chief Strategy Officer. She was formerly the Agency’s Senior Coordinator for Gender Equality and Women’s Empowerment. You can follow her @CarlaKoppell

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