In the christmas spirit of excessive and unhealthy nibble grazing, I would like to take the opportunity of introducing my new favourite snack; delectable grass hoppers fried in their own belly fat . "Ensenene" as they are called in the local lingo, were in ripe and crunchy season just as I left Kampala in early December. Naturally high in protein, equally fatty, and exponentially delicious, they are dished up in small cones of newspaper reminiscent of the austerity packaging of UK fish and chips in World War II.
The ensenene season is accompanied by a 24 hour song: the jingling bells of daily sellers and the rustle of their flimsy shells being tossed around in tuppawares to attract buyers, and the nightly chorus of hundreds of thousands of grasshopper wings careering into hypnotic street lights. Leaping irratically around these lights, the small critters are collected en masse, often through innovative traps involving corrugated metal, for cooking and selling/eating.
The legs and wings are snapped off, their bodies fried, and voila: grubs up! The point at which the grasshopper dies is a flexible one around which no specific practises have been developed, in reflection of their lowly insect status. Kosher, or ethically slaughtered they are not, but free range, in demand and highly profitable they may be. One of the most expensive snacks to be bought locally, Ugandan diaspora and eccentric entomologists with cravings are also known to have paid premiums of up to $90 for an ounce. For those prepared to farm them and sell them out of season, soaring profits could be just a hop, skip and a jump away.
While academics work away, producing carefully crafted and thoroughly and systematically researched papers on current development issues, this work is failing to inform the practise of many NGOs and development projects. Overstretched and understaffed, many NGOs can be seen to operate reactively to challenges, rather than actively anticipating those challenges and taking preventative measures. However, even these reactive measures could be made more effective by drawing on the wealth of best practise knowledge available. By failing to systematically and regularly consult the advice, tools and support available, NGOs find themselves continually attacking time old, and arising issues from scratch.
I found this broken sculpture in the office. I think of it as an apt visual representation of two NGOs doing exactly the same thing, failing to collaborate, and not even having the head to notice.
It is hard to identify the exact point of disconnect. Certainly, much academic work is inaccessible to implementers organisations. This can be literally so, when access requires expensive subscriptions to academic journals and portals. Time constraints and the need for clear,concise and to the point recommendations can also rule out the helpfullness of longer, more theoretical papers. Where to begin looking for information on a particular topic is a mindfield in iteself. Clusters of small, ill coordinated and patchily informed fora and "platforms" have mushroomed up to encourage information sharing and collaboration. However, in duplicating one another they run the risk of becoming part of the problem, rather than the solution.
A quick google search identfied a Ugandan CSO forum here http://www.civilsocietyforum.org/about-portal which offers a more inclusive directory of CSOs according to thematic areas. However, the listing itself is neither exhaustive nor particularly informative. Some clarity on what a Civil Society Organisation actually is might also help matters, and work to exclude currently included international NGOs (INGOs) like ActionAid (which work with CSOS rather than being one), from the list. Hello uganda fare better in providing contact numbers and a more comprehensive listing service http://hellouganda.com/listing/index.php?id=3 but have no provision for searching under thematic areas. As a source of best practise and recent information, Eldis http://www.eldis.org/ is a pretty good bet, allowing searches by country and by thematic area. However, the search tools are basic, and can't take one into specifics beyond a broad area such as '"health" or "HIV &AIDS." There is no provision for, example, specifically searching for information on the use of SMS technology among community health workers in HIV and AIDS. You just have to scroll through the recently added articles list to see if anything comes up.
There doesn't seem to be a one stop shop for NGOs or DPs seeking development information and technical case studies and info that could be used to inform their own current and future practise. It is not just labyrinthine sources of information that foster this situation of stubborn ignorence . NGOs themselves lack a culture of consultation and exchange with others. True collaboration often excludes the competitive and is therefore unpopular among NGOs who are continually fighting to maintain a competitive edge. In the quest for income, the business of development can be an unpleasant one. What is perhaps most frustrating is that while weak businesses are weeded out by market forces, NGOs are immune to these. Lack of vigorous monitoring and evaluation of real project impact, rather than just outputs, and weak accountability requirements that are directed towards donors, rather than those they claim to serve, can lead to a proliferation of ineffective organisations that continue unchallenged.
Fortunately, relevant research does trickle down into organisations which dont have a budget for a research team, or which have a budget for an eneffective research team. This tends to come through the working groups that have been established around particular areas like HIV&AIDS and in whose meetings really valuable information and research based changes in policy changes is disseminated and shared. For those operating on the fringes of these networks howwever, or those that have no internal process for consulting, or responding to information shared, re-inventing the wheel is commonplace.
Driving down to Kabalagala from the office, a noticeably odd looking and exceptionally tall white girl gangled across the road, dressed in the classic Africa attire of sagging cargo pants, a pink, flustered face, and a droopy vest. The driver shook his head, and with an exclamation of AH ah!, turned to me and said, “you are not like these other Wazungu (basic translation: white folk): you are smart!” He proceeded to complain about how white people tramp around the city centre, as if they are on safari, and how previous volunteers had come to work dressed in the same way, taking no care over their appearance and looking unprofessional.
Generally speaking, Ugandan’s in Kampala are really quite a chic lot, coordinating their outfits with precision and care. I asked Brooke how the women sludge through the busiest bus park in Africa across the pot holed, trash strewn churned up earth, in rainy season, and still manage to look immaculate. She said a lot of it has to do with handkerchiefs. Looking down at my encrusted sandals the other day, on the way to a meeting, a NACWOLA driver indeed offered me a wet handkerchief to speedily rectify the situation.
Style is really valued here and even those with very little money invest it in keeping up appearances .I am referred to by one of our volunteers as “the designer,” which I assume is a compliment, unlike “designer lady” which actually means prostitute, or refers to those women who entertain older moneyed men for the handbag benefits. Of those women, there are two types-small c’s who are rewarded with chips, chaps (meat patties) and coca cola, and capital Cs who aim for the bigger guns of cars, cash and cell phones. My usual response to compliments on my outfit is “thanks, I got it at Owino,” which always raises a giggle. According to one of a drivers, the ability to make low cost clothing look expensive is a god-given blessing, that should be praised.
Owino market in old Kampala is the place to go to sort through the bales of second hand clothing that get delivered to Africa as the last stop on their retail journey. Some of the clothing here has made its journey via Eastern Eurpean scam agencies who collect the clothes under the guises of charity, and sell them on at a profit (or even steal sacks for other charities: see here). Other clothes are apparently imported mainly by Indian businessmen. It isn’t exactly a relaxing place to shop, particularly due to the apparently east African custom of sharply shoving those who are in your way, out of your way. Bales are delivered on Monday and Thursday mornings, when shopkeepers arrive around 5.30 am to get first picking of the goods to take back to their stores and sell at a mark-up of up to 500%. Sharp elbows are required.
If you can artfully avoid the clothing stands near the chicken coops (smell coups), the experience is vastly improved. Clothes pulled from the bales coming in are sorted into categories of first, second and third, which refer not to first or second hand (new and old), but rather the quality of the goods. Items are usually shipped with others of their kind, so each vendor will have a different speciality-shirts, trousers, skirts etc. To select clothes, you can choose a vendor, who will lift up their pile of stock and start throwing the items at you one by one to “sort”, or alternatively start tossing the clothes up in the air with the energy of a kid at a ball park. If the vendors had even the slightest idea of what you might like (ie, probably not a polyster catsuit, with cockroach snacked holes in the crotch, or a pair of curtains fashioned into equally grotesque trousers), it would really be shopping heaven.
Wandering through the labyrinthine paths, there is absolute vintage gold to be found. 80s wedding meringue dresses hang ghoulish from the rafters and many of the stands display what I can only describe as 90s floral curtain cladding to swaddle middle aged women. Admittedly, as much of the stock is 90s stuff it isn’t quite old enough to be considered vintage. However, 50s tea dresses emerge from the churning piles of clothes, as do 60s shifts, the odd Yves Saint Laurent skirt and other designer items. These items nestle among a host of stuff from Primark, Next and other British high street stores.
These newer items often come complete with charity shop and value village tags, which state an amount in dollars which is often less than what they retail at in the African market. Second hand clothes from UK, Europe and the US are often referred to collectively as clothes from “that place,” “your place,” or simply, “there.” The clothes from “there” are valued much more than the new clothes exported from China for reasons of quality,style and durability. This is reflected in the price.
The surprising thing about about Owino is how people emerge from its chaos with the most excellent outfits. Aaron and Christmas cardigans are bought and worn by boda boda drivers, teamed with helmets and wrap around shades for added street cred. Men wander around in ankle skimming turn ups, deck shoes, 1980s adidas tracksuit jackets and glasses frames from the 50s. The market has produced a city of accidental hipsters who wouldn’t look an inch out of place in Dalston. Wazungu meanwhile continue to walk around in clothes that no discerning Ugandan (with the money to choose) would be seen dead in.
Three weeks ago was my first day at the NACWOLA office where, if all goes well and I secure funding, I will continue to work for the next six months. The office is based on a leafy compound, serene and quiet but for the ibis’ deafening shrieks that invariably start up as soon as something important is being discussed. The office is based far from a main road, down a long and tumbling dirt track. Boda boda riders (motorbike taxis) bump up and down the road, dodging potholes and long horned cattle. Meetings are held outsider under a thatched roof in the compound, and the atmosphere is generally relaxed. NACWOLA members and small crowds of children stop by to speak to Judia, one of our lovely volunteers, who offers psychosocial support and does a bit of washing up. Peter, another volunteer, takes on the duties of compound keeper. Both volunteers receive a pitiful remuneration for their efforts which doesn’t even cover their lunch. Unless someone buys them lunch, they don’t eat it. Resources are scarce at NACWOLA. Salaries are low to the point where many staff see the work they do as partly a charitable contribution. The staff are skilled and professional people who could get far better paid jobs elsewhere, but they choose to work with NACWOLA because of what Judia calls “the NACWOLA heart.” This heart is an attitude of professional and personal motivation to make a difference and is borne of peoples own experience of living with HIV&AIDS among themselves, their families and their communities.
NACWOLA HQ, Kampala
While we thrilled to have secured funding from major development partners, it comes as project funding, rather than core funding. Current conditions are resource scarce; there is chronic toilet paper and soap insecurity. There is one towel, so on the day it is washed, there is no towel. There are no provisions for staff tea and coffee. Drivers stash their sugar pots in secret cubby holes and accuse each other frequently of helping themselves to one anothers supply. I bring in tea and sugar for the volunteers and have had to have words with a particular M&E person who has been ordering the volunteers to fetch him that tea, which he then slurps, blissfully. I had no idea hot drinks could be so political. Lunch was being bought for staff at one point, but that was stopped, presumably because of tight finances. There is no mineral water to drink-instead chlorine tablets are put in big tankards of tap water. The tap water is so full of heavy minerals that I now have rust stains on my clothes. I have heard there is a lot of lead in the water. We don’t have a hired cleaner-that is left to Judia, the volunteer on ART therapy who walks miles to the nearest taxi/matatu stand to come to work for no salary, and is given no soap to clean with.
Spot the sugar...
Extreme measures: A driver mixes salt into his sugar to give any potential thieves a fright. He doesn't mind it himself.
The office spaces are lively; people buzz in and out of each others rooms sharing updates, documents, and jokes, while mice run frantic relays behind the desks. An open door policy allows for free and easy exchange , and working relationships are presented more in terms of team work, than subordinate and supervisor hierarchies. The office with the heaviest traffic is that belonging to the finance, HR and admint co-ordinator, unsurprisingly as cash flow is the life blood of any NGO. Unfortunately this seems to have dried up even more during the last week. The director of the organisation is currently on leave in the US, but due to bureacratic challenges, the transfer of financial control to the acting director was not completed successfully. While attempts are being made to rectify this untenable situation, permission continues to come from the US, as and when the director has a chance to check emails and process requests. However, as the director is on sabattical this must be extremely invonvenient for her, and so isnt really happening in the most timely and coordianted manner. This has led to the recent absence of soap in the toilets and the fuelless vehicles sitting paralysed in the compound. Senior management are having to lend staff money to top up the phone and to refuel the vehicles, at a time when fuel prices have increased sharrply to UGX 3500 per litre (£0.98). We finished a big proposal for project funding which needed to handed in as a hard copy to an office out of town. Without fuel in the vehicle this meant lending money to one of the drivers to take more than a days worth of time, a bus, a taxi and a boda boda to get there...and the same back.
My desk in the resource centre, complete with miscellaneous unclaimed files, and a tupperware of fried crickets.
The NACWOLA heart is not a pampered one, and is not incentivised by the comparitively lavish salaries, buffet lunches and biscuit breaks provided by many international NGOs. But as the electricity in the office cuts out, the phone and internet dies and salaries are delayed due to cash flow blockages, the NACWOLA heart beats fiercely on.
Saturday was moving day. Had a lie in, a leisurely breakfast, and some time to reflect on the news Brooke had told me the former evening; that she had been offered a job with another agency, to do the research project I was developing with NACWOLA, but for Marie Stopes. (MSU) So, while I had been away on the field trip, discussing the research ideas that we had presented on the last day of the workshop (to do a situational analysis of the use of community health workers in Uganda, to identify opportunities for collaboration and strengthening of community systems), this agency had been thinking along similar lines. What baffled me was the apparent decison to duplicate this research without officially informing, or discussing this with the NACWOLA team. This was a confusion shared by Brooke. I was unsure whether to take my exclusion from this advancement and the possibility of funding to do the research as a personal slight, as a symptom of some kind of NGO rivalry, as a result of having so clearly aligned myself with NACWOLA through the course of the workshop. I hoped it was the latter.
Talking about the isse later, the CD agreed it made sense to collaborate, but I was unsure of how this collaboration would work if one party were getting paid to do it as a full time job, while the other was doing it on a voluntary basis, and alongside other projects. I had already considered concedeing defeat and handing over my purpose for being in Ugandas to Brooke, as she had already secured the fubnding to do what I had planned to do. I felt pretty disheartened and confused by the conversation. However, it later transpired of course, that I had put 2 and 2 together and gotten 20, envisioning that both research projects would evaluate the system nationally. In reality the respective projects, for NACWOLA and for MSU would be a first step towards this, by evaluating each NGO system respectively. Possibilities for collaboration and further research would perhaps arise after this first step. I had lept from stage 1 to stage 10 in my thinking, and so got my wires crossed unecessarily.
We packed up and at around 4, the country director of Marie Stopes came and picked us up. We have the good luck of being able to live there for the next 6 weeks or so as house sitters and dog feeders. On top of this, the CD was good enough to pick us up in the car, and to swing by the supermarket on the way home. The supermarket was full of local produce that was impossible to find in Ghana and most of West africa-there was fresh milk, cheese, flavoured and plain yoghurt and west nile honey. The vegetables were good, varied and cheap. The highly inflated costs of imported food like pasta and rice that I was used from Ghana (where you paid at least double what you would in the UK) were non existent here. There was even dairy milk chocolate! I got quite excited that I wasnt going to be reduced to a diet of beans and matooke on my shoestring budget. Brooke and I stocked up and clambered back into the car which chuffed around and up the very steep hill to the house.
Cranking open the gate we were met by Bobo and daisy, the two guard dogs, who were clearly interested but unsure of us at first. As the CD had described, Bobo is a big baby who jumps at you and wants his tummy rubbed whereas Daisy is smarter but with yellow eyes and with a flash of wolf in her that snarls from time to time. They had a good sniff as we unpacked warily.We met the friendly guy who looks after the compound and does the gardening etc. He was pleasant, but for a marked body odour issue. The house was beautiful-like a bug Scandinavian summer house, but decked with rich teak floors; a veritable colonial palace. Brooke and I had a room each, and adjacent bathroom. Living here would be far from slumming it. and we were both delighted. We deposited our bags, the CD shackled the dogs up to their leads, and with one in each sturdy hand led the way for a walk around the hill.
Canine tryptich, part 1: tension mounts
Part 2: Bobo attempts to mount, tension is released
Part 3: all is calm
The path was rough, and the slope from the house down onto it even more precarious, the loose stones on the surface sliding underfoot like on a spree slope. We picked our way down gingerly, relieved that we weren’t the ones holding the dogs. The view was, like from the house, utterly brilliant, and as we walked round we could trace the humped backs of the surrounding hills gently undulating on the leafy horizon. The area was beautiful, serenely quiet, but pretty far from town; the Kampala equivalent of Chislehurst. Transport, particularly at night, was going to be an issue.
We arrived home a bit sticky. Brooke and I set about making pesto and pasta, with fresh basil from the garden while the CD packed. Over dinner we discussed the logistics of the house, how to deal with inevitable water and power cuts, the location of the key, noisy neighbours, organisational politics and the trials and tribulations of being an expat. Later we headed out to a party I had been invited to nearby, arriving to find the LGBT community letting loose in the safety of the compound belonging to the self names "fag-hag of Kampala." A dapper guy in a tilted flat cap started a conversation with me about vaginal douching while his friend in a skin-tight wastecoat, flared jeans and stacked mules, puffed out his chest and danced /pranced circles around himself to lady gaga. He had been bold enough to leave the house dressed like that despite the homophobia here that recently made the headlines due to Uganda's proposed anti-homosexuality bill. If passed this would have criminalised homosexuality and made it punishable by death. Read more about it here: http://www.gayrightsuganda.org/ The guy finished the conversation with a "toodleoo, must dash dahling..." , and accompanied jazz hands. Rather than asking for each others numbers (so last year), the question was always "what's your facebook?" Fabulous people, fantastic party.
The country director invited us for a late lunch; a kind offer that was much appreciated by all. Arriving at a restaurant we agreed after some time to each order a plate of chicken stew with the standard collection of carbohydrates. We made polite conversation until the food came: plain boiled chicken, plain boiled rice, plain boiled sweet potato and matooke (a type of savoury banana/plantain that is steamed for hours in leaves). As I have discovered, Ugandan food is often a neutral palette of cream, beige, mustard yellow and off white, occasionally brightened by a splash of miscellaneous "greens", and tomato. Flavours are equally neutral, with Ugandans tending to eschew any use of spices and seasoning beyond salt, in favour of unadulterated blandness. The waiter brought us each a small bowl of salty vegetable broth of the type my great grand mother used to prepare. "Is this chicken stew?" I asked, wanting to know so I could avoid ordering it again. The driver laughed, and said she was happy because she didn't like stew anyway-too spicy. The CD was back to business of one of his three mobile phones (It is not uncommon to have multiple phones here, with a sim for a different network in each phone to reduce call charges) . We finished up and travelled to the district health office to try and gather some more information on infection rates in the area.
I asked the CD if the information was collected centrally by a demographic health survey (DHS) and accessible from Kampala. He explained that invariably one would be passed from office to office on a wild goose chase and that the breakdown per district would not be available. He noted that the last DHS had been conducted in 2005, and at last I understood his eagerness to get at least an idea of what the current infection rate stood at. As the others disappeared into an office to hunt for numbers, I stayed outside, and introduced myself to the team from JSI who had just pulled up. JSI are NACWOLAs donors on the STAR EC project-strengthening HIV&AIDS and TB response in central/eastern Uganda. JSI themselves received funding from USAID and then subcontracted the actual implementation to local partners like NACWOLA. Ideally NACWOLA should be able to attract large grants directly, but they currently lack the M&E systems and management capacity to make this happen. I introduced the possibility of working with NACWOLA to develop an M&E strategy, and the specialist from JSI said he would be glad to offer technical assistance to the process.
I relaxed a few moments on the step, in the sun, before the others emerged and we set of back to Kampala at around 4.30pm. We tucked into the bananas given to us by the psychosocial support group leader. Irene made the (subconscious) connection between our visit and that of politicians, saying that when she travelled as a journalist on a political campaign, villagers would present far more than they could possibly afford to politicians in the hope of increased support. The politicians would return to Kampala with goats, chickens and great sacks of maize, only to deliver nothing. We all agreed that a bunch of bananas was probably acceptable, but that when people offered more, clever ways of turning the offer down without out rightly refusing needed to be exercised. Suggestions for such excuses included being unable to strap the goat to a bicycle that you intend to travel part of the way home on.
We passed the time in the traffic home, discussing the universal challenge of encouraging men to access health care services in general, and not just for HIV&AIDS. Irene spoke of how you could treat woman for a sexually transmitted infected but that unless her male partner was treated too, she would repeatedly reinfect herself and return for services indefinitely. We identified the need to reach out to more men, and to target men more with sensitisation. We discussed the big cultural ceremonies at which community sensitisation, for men in particular, could be conducted. Irene talked of the male circumsision season in western uganda, where almost everyday you could see small boys getting their foreskins "chopped" in full view of the audience gathered. Sensitisation and HIV education activities had at least already increased the use of a fresh blade for each boys procedure. We spoke of the silent HIV epidemic in Iganga, and the practises among most at risk populations, including plantation workers, long distance drivers, sex workers, men who have sex with men.
We talked about the problems of polygamy for HIV prevention, and how the taboo nature of talking about sex that makes discussion of HIV&AIDS transmission& prevention and family planning an extra sensitive issue. We talked about the possibility of streamlining family planning into the information and support provided by community support agents. We talked of better partnerships between organisations working with community health workers and village health teams, and the serious need to identify opportunities for collaboration, to reduce overlap, and to fill in gaps. Irene and I discussed that I (NACWOLA) and possiibly Marie Stopes could at least look at the other organisations and government involved in Iganga district. We saw a great need for these organisations to partner up, to try and streamline activities and resources, and to provide better, fully co-ordinated outreach services to the poor. A national strategy for the use of community health workers loomed as a gaping gap that we began discussing how best to fill.
We dropped the CD at home with a big thankyou and a vigorous wave. It was brilliant that he had come, and that he was genuinely interested in engaging more with the realities of what was going on at the community level. His interest and genuine offer of support will no doubt be of great help to NACWOLA in the coming months. As we wound up and down and across the hills of Kampala, to the other side of town, the dusk quickly tuurned to darkness. Each black mound was sporadically illuminated with the warm glow of houses and the snaking lights of heavy traffic. The driver dropped us at the hotel, Irene drove home, and I settled happily onto the veranda of the hotel with Brooke, the fellow anthropologist, and a beer.
We left the hospital for our next engagement: a psychosocial support group meeting being held under the canopy shade of a wide flat tree. As we drove up, excitement ruffled through the group, and a crowd of school children in yellow and brown uniforms scampered around the car. We introduced ourselves, took a seat on a wooden bench that had been set out for us, and rather than sitting in and observing a psychosocial support group, the ceremonials began. We sat in a row as an audience to their full attention, and listened to a welcome and background story given by a male community support agent (CSA). Much of what was said was lost to lack of translation but some prize bits of information were relayed to me in English. The groups name translated as “People living with HIV take care of ourselves.” A truly voluntary group, unsupported by lunch provision and transport allowances, this group formed to offer one another psycho social support and to conduct income generating activities. As they have no land they pool their resources collectively to hire the land which they now farm on. They also do bricklaying to earn money for the group. International HIV/ Alliance presented the group with a cow last year to use for ploughing the land. That cow has since given birth and they are training the calf to plough too so that they can lease the wee beast to others.
The CSA explained that they provide nutrition advice, follow up those who have not been attending the services they referred them for, support anti retro viral therapy adherence and refer pregnant mothers to prevention of mother-to-child transmission services etc. He also mentioned that he teaches against witchcraft as a cause of illness. At that point however he also mentioned the importance of believing in God. As far as I know missionary services are, like reproductive health services, yet to be streamlined into the community support agent model. The latter is something I hope to work on over the next 6 months. The CSA repeated the phrase “a tug of war” in relation to getting men to join groups and access services. One of the reasons he attributed this hesitance to was the self stigma that men with HIV attach to themselves. This particular psychosocial support group tries to set an example to others by revealing their HIV status and showing others how to live positively. It was all very positive.
We asked how the group thought men could be encouraged to access services. An old woman suggested that women should not be treated unless their husbands come to the clinic with them. In response to this it was noted that this approach had been tried and that it failed miserably, resulting in far fewer women being treated, and no more men. No more suggestions were offered. I asked how the group was started and was told that it was thanks to a nurse who had put three HIV positive people in contact with one another, and supported them to begin a group in absence of formalized services.. She arranged for them to attend CSA training with NACWOLA. While NACWOLA aims to bridge the gap from the community to the health service provider by starting at the community, many persons at health service providers have begun bridging the gap from the opposite side, as the nurse did here.
On asking the group how being part of this group made them feel , some bold and confident women stood up to share their answers. Their answers attributed this new found confidence to psychosocial support which offered them feelings of unity, a new life, shared experience and knowledge, joy away from the stigma of HIV and empowerment through realising that the power to prevent the spread of infection begins with themselves. We thanked the group for their time, and turned to leave, but not before being presented with a fanned out hand of miniature bananas. The CD handed over UGX 20,000 (about £6). I wasn't sure which was worse; to reinforce the stereotype of "donors" arriving in white 4 by 4s,spending a pitiful amount of time before handing over cash and disappearing for ever more, OR to challenge those expectations and break the stereotype by not giving any much needed and well received petty cash. It had been a private donation borne of the generosity of the Country Director, but arriving in the branded vehicle that Irene had (fortunately) arranged to use through hr own agency, changes the context of everything you do.
We piled back in the car and set off down a rough dirt track, flanked by lushly planted fields sprouting avocado, jack fruit, maize and cassava among other crops. The CD requested to be dropped en route so that he could pray in the mosque. We arrived at the site of a home visit that the CSA with us was due to make, and followed him into the house. We greeted the young girl (maybe 14), her tiny baby and her grandmother who lived there, accompanied by 5 other aids orphans. Once seated on the sofas, a rakishly elegant man stooped down and up into the house through the low entrance. Dressed in a long flowing white tunic and an islamic cap, he bent to shake the hands of all of us in the room, greeting people in the local language, before reaching me. At that point, he took a dramatic pause before exclaiming 'Good Morning!' in a comical voice that induced a long laugh from the room.
The CSA looked to us for guidance as to what to do next. I suggested that he continue to do as he would if we weren't there, if that was ok, and that we would just observe quietly and conspicuously. We learnt that the CSA had been passing through the village when he saw that the girls baby had been looking ill. He had taken a measurement of her upper arm and referred her to the clinic. It was unknown whether the baby had been ill from HIV, poor nutrition, or more likely, a combination of the two. The girl had run away to "the island" and returned pregnant. It was therefore suspected that the father was a member of a fishing community who characteristically have very high HIV infection rates. After receiving treatment and services the baby was in visibly better health. As we sat talking, the driver rang Irene's mobile repeatedly. She was hungry and the CD had finished praying. That was our summons to leave. I avoided being completely rushed though, and dawdled a few extra precious mins to talk with the women and take photos.
Travelling back in the car we passed the absurd site of a man sitting on a low stool in the middle of a field in a smart suit and tie. It was the country director. We reversed, picked him up and all had a good laugh.
As I noted in my previous post, much to the frustration of NACWOLA staff, the USAID funded programme called STAR EC had excluded the use of condoms from its prevention programme. This was despite Obama lifting the gag rule on his second day in office. This meant that no longer would 40% PEPFAR funding have to go to faith based organisations that were inevitably anti-abortion, anti condom and anti-homosexual. The issue was raised by lone NACWOLA staff member who spoke out at the last meeting with STAR EC, on 15th sept. She was shot down by the other participants.
A letter from STAR EC today however, confirms that, having finally read the new PEPFAR priorities for prevention, they will now be looking at a more comprehensive ABC (Abstinance Be faithful and Condoms approach). They will also now be looking at extending and target services to MSMs (men who have sex with men.
It may have been at the end of the workshop, but we got to Iganga in the end. And not only Irene and I, but the country director (CD) of a high profile development agency who had also come along for the ride. He had cancelled his attendance at a presentation, justifying his actions by explaining that while his job requires his to make mission statement after mission statement he has nothing to state because he never gets let out of the office to see anything. His mission that day was clearly stated then: to get out into the field and try and see first hand what the HIV situation was out there. Irene and I were visiting to observe what NACWOLA does, to see some psycho social support groups, a community sensitisation activity and to shadow a community support agent doing his rounds in a village.
We arrived 3 hours or so after leaving Kampala, driven there by a female driver from Irene's agency, in traditional attire which for Uganda was pretty unusual on both accounts. The driver explained that she liked her job as a driver because it was low pressure, mentally unchallenging and physically easy. Having spent most time in Ghana where driving to the end of the road is made out to be a big job, this easy honesty was also extremely refreshing. After going around in a few too many circles following Esther’s confusing directions, we managed to find her and she hopped in the with a shy smile. We first went to the NACWOLA office: two rooms, two computers, two volunteers and a store room stacked with condoms.
While Obama changed the US HIV/AIDS prevention policy of Abstinence and Be faithful to finally include C for condoms, the USAID Star EC project was still only, by policy, offering condoms to HIV positive people as part of positive prevention. While funded by STAR EC, NACWOLA however are able to distribute condoms regardless of HIV status, by other means. I asked how often they got deliveries and if there were enough condoms to go around. Esther explained that because the area was predominantly Muslim men tended to have more than one wife. She said, with a giggle, that it wasn’t uncommon for a man to require 3 condoms a day in order to practise safe sex with his three wives.
After picking up copies of the data collection forms and being introduced quickly to the monitoring and evaluation procedure for the project we piled back into the car, ready to visit the community sensitisation activity. However, much to my initial dismay, the CD hijacked the agenda somewhat, initiating instead that we visit the district hospital. So we missed the community sensitisation and went straight there. The hospital was crumbly and ramshackle but quiet, as Fridays apparently tend to be. I saw no men, but rather lots of women; women clustered outside on the grass, eating and talking, old women heaped up on wooden waiting benches and corridors of young mothers and babies lining the walls.
I lingered behind to take photographs while the others wove through the corridors to reach an office or other, which was locked. The person Esther had advised to the CD would not be there, was indeed, not there. We wandered on through, past a lady whose crossed legs blossomed into what looked like huge fungi where one expected feet. A vintage ambulance rusted, neglected into the earth while a shiny new one pulled up alongside it. Passing into a new block which was undergoing a shambolic reorganisation we were ushered into an office space where a nurse sat down to answer our unexpected questions.
The CD asked the nurse whether or not she thought HIV infection rates had increased or decreased. The nurse was unsure how to answer and I was unsure as to whether or not this was the CDs method of trying to find out the actual answer or just to gauge peoples perceptions. The CD thanked the nurse for her time when he was satisfied and rose to leave. I added that, actually, I also had a couple of questions and proceeded to learn from the nurse that HIV Alliance had first put community health workers in the facility, that the same people have been coming over the years but that their names have changed...from village health teams to community support agents etc. She perceived them to be doing a good job without treading on hospital staff toes.
The nurse explained too that the structure of HIV testing had changed and was now being offered across all the wards. This was news to the CD who became genuinely excited and exclaimed "this is brilliant, this should be rolled out all over the country." Irene later confirmed that this was already national policy.I asked if this had impacted on the ability of the already overstretcheed staff to offer pre and post testing counselling to everyone but she seemed not to think so.
We then paid a visit to the ante natal unit to look at PMTCT care (prevention of mother to child transmission). A couple of CSAs from mother2mother, our main competitor in the business model, were there. I took the opportunity to stop for a chat and to find out that mother2monther approach NACWOLA for staff recommendations and that NACWOLA had recommended and pretty much handed the lady over to mother2mother to take on. Rather than feeling that the mother2mother contract was a short term offer (1 year) with limited opportunities for skills learning, as NACWOLA staff believed, she thought that her contract would be renewed because of good performance and she noted receiving higher skills training and that she was now even taking blood for testing.
We sat down with another nurse, this time with a brilliantly twee uniform and a couple of dolls in her office (one black and one white). A scrawled note to “always ask for information on family planning” was, like the other posters, fixed clumsily with brown tape to the wall.The CD proceeded to ask questions about drug and testing kit availability and HIV infection rates. This time he was able to do spot checks in the nurses records to see how many mothers out of ten had tested positive. I asked about the counselling offered to discordant couples and men, and she said that while it was “a tug of war" to get men into the hospital for HIV services at all, they had received 3 couples that week.The CD continued with spot checks for a further ten minutes or so. He was optimistic that these promisingly low infection rates could be indicative of a regional trend, despite them reflecting a group of women that were already accessing treatment and services, in a fairly low risk community compared to the fishing villages, plantation workers and truck stop over sites further out. The CD was charming, and offered his card to the nurse, saying "if you ever come to Kampala we will take you for lunch...call if you need anything." The nurse looked at the card, confused, and checked: "I can call you if we have a problem here?" Irene stepped in to clarify that he would be more likely to put her in contact with the relvant service rather than offer direct assistance. We thanked the nurse for her time and left, but not before I got a picture of their wonderful hats.
Today my group had halved its numbers. By midday we lost Ismael to visa bureaucracy and by mid-afternoon I was a one woman band. However, progress was made, and was probably made quicker by the reduction in numbers of people whose opinions and input had to be solicited, and whose ownership had to be encouraged and assured. This could potentially cause more problems in the long term however.
In the morning we openly discussed the challenges that we would face in the coming months, with Harry asking what would be the most difficult-the beginning, the middle, or the end? Some optimistic people shouted “the beginning!” but the more realistic among us answered “the middle” and Julie took her cue to relate to us some of the challenges that been faced with the India programme and the challenges of long-distance (business) relationships between two cultures. Lack of (reliable and regular) communication from the NGO side was a central challenge, and Julie tried to manage our expectations about what we should consider to be reasonable . For the main part this would require a reduction in expectation from the corporate side, and for the NGO staff the advice was given that if you don’t have time to respond, at least communicate that you have no time, and reschedule tele-conferences etc, rather than just not tuning in for them, as had commonly been the case.
Late morning and early afternoon was spent in our teams (or in our case-pair), working on the final business model to be presented that afternoon. Irene and I laid out our PESTEL analysis and later, alone, I consolidated all our existing work into one vivid green and yellow power point presentation. It was nice at least to take a break from the role of trainer that I had been required to adopt over the previous days, to ensure that the group made progress. At 2pm the groups dribbled slowly back into the room and the presentations began, kicking off with an extremely professional presentation from the PACE SMS project. Presentations were meant to last for 20 mins, followed by 10 mins question time from the group who would role play as the senior management team. In practise the presentations lasted up to 40 mins and questioning veered off onto tangential topics that would have been better addressed in the breaks, eg. Right before moving on to the next presentation a non Ugandan participant asked “what is the situation of malaria in the country? I really feel this needs to be discussed now.” Fortunately a Ugandan participant gave an unusually concise, well structured and highly informed answer. Harry certainly had a tough time with the timekeeping.
Many of the groups had developed impressive and promising business models through the course of the workshop, although it was often unclear as to who exactly would be doing what exactly over the next 6 months. This was concerning as without allocating tasks and persons responsible it is likely that nothing will happen, or that lots of activity will occur in an unstructured and ineffective way as often happens on development projects. One group was at least clear in what their proposed activities were: to follow the 6 steps to putting together a business model. This however had been the entire purpose of the workshop and I wondered what they had been doing instead. The time for questions was extremely helpful and the senior management team played its part gently, offering helpful insights, suggestions and constructive criticism.
Last but not least, I presented the NACWOLA Community Systems Strengthening model. This was very well received and attracted many compliments afterwards on the work and progress that we had made. I presented our intentions to research and review other models of using community health workers including our own. This would include looking at the other agencies using CSA/CHWs and village health teams (essentially different names for the same group of people in practise doing very similar things but for different donors/gov.) Rather than suggesting that NACWOLA should do this to avoid duplication and overlap, Jon CD of Marie Stopes said that we should be looking to maximise the benefit of this overlap and work in collaboration with one another. Streamlining the use of CHWs is clearly a crucial step that needs to be taken nationally, and the workshop process had helped this issue to be identified and brought to the fore. More on this later
The end of presentations was met with a feeling of relief for many, and had re-enthused others to continue work on their model and to plan out, step by step how things could be taken forward. A round of thanks was dedicated to Harry and Julie for their hard work. I felt embarrassed and upset that we hadn't arranged for a thank you gift to be presented to Julie who has dedicated her professional life to the Pepal mission, and whose vision, energy and dedication and good humour had made the whole thing possible. Beers and chatter followed and I was delighted to be introduced to Maya, the acting country director of NACWOLANACWOLA and Pepal while in country. Having reached the point where I really felt like I was beginning to get to know the other participants, and having shared so much in so little time, it seemed sad to say our goodbyes.
When discussing the value proposition for our respective business models, a Ugandan participant offered the following story as food for thought.
...On visiting a rural village in Uganda, the world bank saw that women were having to walk 2 miles each way everyday just to fetch water. Seeking to lessen their work burden, the world bank built a bore hole for the women to access water from the convenience of their village. Returning some months later they were astounded to see the bore hole relatively unused, and the women still walking to fetch water. What they hadn't realised was that the 2 mile walk filled a function above and beyond the collection of water; it provided valued time in which women could talk freely, outside the confines of their huts and away from men.
While this story acted as a vivid warning against making rash assumptions, the development of each groups value proposal was based on assumed value factors that we had essentially plucked from the air by brainstorming. While local NGO partners formed the majority of each teams it would be incorrect to assume that they completely understand and can represent the values of the users and end-users of their product. Admittedly they stand a better chance than the world bank employees who made a quick day trip from Kampala in a white 4 wheel drive, but the local knowledge of an NGO worker is full of its own assumptions, and biases and is not infallible.
While our group had come up with some suggested value factors for the purpose of this workshop, a business model that based itself on these without verifying them first would be absurd. However, identifying the value factors of a group of people in the limited time the pepal groups were allocated (e.g 2 days) poses a great challenge. I warned the group about taking peoples answers at face value to, noting that answers change according to who is asking the questions. As recipients of aid have learned to frame their needs and desires in alignment with what an NGO or donor like the world bank is offering, it takes time and effort to get beyond those answers and to identify peoples actual priorities. However, it is also problematic to assume that these are somehow completely different and independent of the development projects and BCC campaigns that have come before.
Short of spending 6 months conducting ethnographic research to identify actual value factors, a pragmatic compromise might be to use tools like the participatory consensus workshop method taught by the Institute of Cultural Affairs. The beauty of this method is that it enables a group to reach consensus on an issue, whilst facilitating input from everyone present, regardless of the power hierarchies at play.
"The method involves a five-step process that guides people from generating and collecting ideas, through organising those ideas into meaningful groups, to reaching agreement on the question they are facing and identifying some next steps to move forward.The method generates new creative ideas, incorporates both rational and intuitive approaches to problem solving, and builds team spirit and consensus."
I was awarded a scholarship to attend the basic training in this method before I came to Uganda and feel that it will serve me very well here. I intend to run workshops with CSAs and PLWHAs to identify actual value indicators. This however, will require some creative thinking around how to adapt the tools to suit an illiterate group who speak another language. No doubt pictorial representations and a translator will be my best friends.
With a later start time of 9.30, many groups mixed business with breakfast, meeting early to get a head start on their projects. Today was a more theoretically orientated day, which unfortunately meant even less time dedicated to group work. We had 5 steps to take that day, and a lot of theory and powerpoint slides to get through first. Harry outlines the order of the day: 1)establish a new revenue model, 2) Design the new organization 3) discuss what could be outsourced 4) How to make space for Open Innovation and 6) to determine how much value is created for stakeholders.
Admittedly, much of what was covered that day, from micro-franchising to open innovation was lost on my team at least. A quick glance around showed them dis-engaged with the business concepts being presented and engaged in answering the work emails that streamed in on their laptops. For the other NACWOLA team who were creating a model for an agricultural co-operative through which WLHIVs could sell peanuts, how to add value was a very quantitative exercise; figuring out how to sell peanuts for more than peanuts involves looking at the price of transport, key farming inputs etc. However, for our team the value proposal was qualitative, looking at how to improve the experience of the end users and users according to qualitative indicators like ‘a sensitive approach.
When the time for group work began and we set to work on the value proposal for users (CSAs) it was extremely hard for the group to see the other organisations that NACWOLA trained women could work for as competition. Other NGOs target and recruit NACWOLA CSAs to work for their own organisation because of the critical skill set they have already developed through NACWOLA support. In business terms such organisations needed to be presented as competitors, but are seen by the NACWOLA staff as complimentary. This is because they offer good salaries and opportunities for the very women NACWOLA is trying to support-WLHIV.
Much work with other organisations is also part time and so leads to no clash in time commitments. CSAs also learn new skills from both agencies, adding value to their work with both. However, with some organisations like Mother2mother recruiting/poaching CSAs for full-time work, NACWOLA is left to fill their gap by training a replacement. Essentially NACWOLA find themselves draining their own resources to provide skilled and knowledgeable staff to other organisations. Our value proposal for users then, was designed to try and retain NACWOLA volunteers by offering them a competitive package of benefits. Alternatively we noted that NACWOLA needs to negotiate a better deal for itself when government and other donors decided to recruit its volunteers, rather than handing them gladly over.
In our group work at the end of the day, time pressure was really beginning to be felt and the teams worked doggedly until 6pm when we were invited back into the conference room to listen to a talk by an intern at the Acumen fund Kenya, who had flown over especially for the occasion. The Acumen fund offers capital patient loans to social enterprises, meaning they don’t mind waiting years and years for a small return on their investment because what they invest in are enterprises that are socially as well as financially profitable. We listened attentively to the eligibility criteria which unfortunately excluded most of our enterprises in the short term, but did offer a possible source of capital for the medium term.
After sifting through some of the NACWOLA and Global fund documents I joined the others for the BBQ, buffet and beers outside and listened to the live music courtesy of KampalaMusicSchool. Singing a mixture of local songs and more western ones - sometimes in tune, sometimes completely out - they were entertaining and were, in our new language, a great value proposition to the evening, offering a new dimension and richness of experience. I particularly liked the Rwandan style of dance where the dancers crouched low to the ground and pushed their hands out and up with palms to the sky and all the while with small pots balanced on their heads. Impressive. The BBQ social also provided the opportunity for me to introduce Brooke, the fellow anthropologist and the work she was doing to Jon, whose house I would be spending the next few weeks in. To my relief it was agreed that she could stay too, meaning I would have some company in the big house on the top of the hill. As I went to bed I passed the usual crowd gathered at the Wi-Fi hot spot of the restaurant balcony, furiously trying to connect with their lives back home.
The workshop kicked off shortly after 9am, with the participants making their way into the conference room of the hotel. A U-shaped seating plan had been set up, complete with stationary for each of the participants, a projector and Harry at the front to introduce the programme. After Julie facilitated personal introductions Harry outlined the shape and purpose of the programme. The purpose was twofold: 1) To develop and document a new or existing business model that would provide a solution to a problem at hand, e.g. an income generating social enterprise for economically and socially excluded WLHA (new), or the Marie Stopes’ health voucher scheme (existing). Documentation of this model could then serve as the basis of a funding proposal. 2) To increase participants capacity to innovate future BMs in their own context and work. The programme would consist of 6 steps which we would complete over three days.
Today, the first day, was dedicated to the first step of each team articulating a defined product, a solution to a problem at hand, and an experience that the product was offering. This new BM outline would include a Value Proposition (VP) to demonstrate how it adds value and justify itself. After an introduction to key concepts and steps towards BM innovation, Harry encouraged us to step outside of the box with our thinking and to conduct a PESTEL analysis in our groups for inspiration. We broke away then to identify and discuss enabling factors in the political, economic, social, technological, environmental and legal context. I had been told the day before by Sandra that my team might be unable to make it, which would have meant the project being scrapped and me joining forces with the other NACWOLA project- a peanut cooperative for WLHA. However, I was delighted that overnight my group numbers had not dwindled but rather increased to 6. New additions included Jacqui, the regional director of NACWOLA for eastern region, Esther, a project coordinator in Iganga and Ismael who is based at the head office in Kampala.
Our group discussion was therefore very fruitful, with lots of input from everybody on the team. We were able to identify key opportunities, one of which was the provision of solar powered mobiles to CSAs to allow timely transfer of data through SMS messaging & to send messages on safe sex practises, and health facility appointments. Joining the main group again, we reported back on enabling factors in the format of a group discussion. Harry then took us through the process of articulating a Product, Solution and Experience and identifying its users and end users. In our break away groups then we put ourselves into the place of users/end users to brainstorm on value factors (what they valued in the product) and to identify where we could add value. The time allocated for break away time was on the slim side. There was little sense of urgency among the Ugandan NGO staff and exiting/ entering the room and sitiing at a different table took considerably longer than Harry had probably anticipated, shaving off about 15 mins of working time.
By moving at a motivated pace however, our team managed to articulate a product, solution and experience, and to outline possible value factors for end users, the PLWHAs. Where CSAs were performing poorly, we discussed how to add value. Taking confidentiality as a value factor then, Sandra explained how frequent visits from a CSA can act as almost a default disclosure, and that on top of that, some CSAs were indiscrete and disclosed the HIV status of their clients. Community sensitisation on the role of the CSA as a general health worker was suggested as a way to reduce rumour, and continuous appraisal of CSA performance, including spot checks with clients, was suggested as a way of increasing CSA discretion. These ideas were then included in our VP and we mapped this out visually using the strategy canvas format suggested.
Back in the main group, Irene presented our strategy canvas and VP for PLWHHAs with humour and energy, and Harry offered valuable feedback. On the basis of this feedback we changed our product from ‘an empowering and supportive community to increase the demand, quality and uptake of HIV and wrap around services’ to the more concrete and project specific product of ‘training workshops for CSAs.’ Harry also noted that we still needed to produce one for the CSAs, the users, which would include an evaluation of the performance of competitors ie. Other organisations that community members could choose to work for. In reporting back, the workshops process of taking small steps to innovating a BM with potentially life saving impact was captured perfectly by one of the participants. He said, simply and succinctly, “think big, start small, act now.”
While some groups did struggle to articulate their product, solution and experience, and chose to follow their own alternative format, most made excellent progress and had established the core of their BM. Having completed these first and most difficult steps, morale was high and team members seemed to have bonded really well. Despite the intensity of the day and a late finish of 6pm, many NGO staff stayed for dinner, to talk further with their teammates and other participants. There was a buzz in the air, and many teams stayed together, working well beyond the delicious buffet dinner, and into the night.
I woke up to the alarm I had set for 6.30, giving me half an hour to get ready for sunrise and our planned departure to Iganga. Shared a sleepy cup of tea with Julie before she revealed that there had been a change of plan late last night and that we were now due to leave at 9am. I sloped back to bed and then met Sandra, from NACWOLA when she arrived on time, but unfortunately without the vehicle to leave in. Plan A of a UNAIDS car had, despite assurances, not materialised, so we reverted to Plan B which was to travel in the NACWOLA vehicle. However, this had already been booked so we resorted to Plan C which was to stay in the hotel and work from there to get an idea of the project. This actually worked out for the best, allowing us time to ask questions and for me to get a clear enough picture to put together the 1500 word initial project outline that (Prof) Harry had assigned to be completed and submitted by that evening (!!!).
Joined by Irene, a former journalist and current fellow in the communications dept at UNAIDS, Sandra began to guide us through NACWOLAs activities and multiple projects across Uganda. NACWOLA is unique in that it is the only national NGO for women living with HIV/AIDS (WLHA) that is also predominantly staffed by them. Sandra, a project officer in Iganga, was able to outline the impact of NACWOLA by tracing her own experience with the organisation, first as a member of the network and beneficiary of services and psychosocial support, through to her current of offering those services and support as a NACWOLA employee. Sandra showed how, in no exaggerated terms she owed her life to the NACWOLA. By encouraging her to be tested and providing support through the whole process as well as follow up, she was tested, began ARV therapy, was empowered and enabled to live positively. She now has two of her own children, a husband and an adopted HIV orphan in her family.
NACWOLA offer holistic support for PLWHAs. They recognise that women’s wellbeing is inseparable from that of their immediate families, and that care goes beyond facilitating ARV treatment to include psychosocial support, access to information and legal services, community sensitisation and assistance with income generating activities and nutritional support. At the heart of their work are Community Support Agents. These are PLWHAs themselves who NACWOLA recruits and trains to mobilise community members to get tested and access treatment and wrap around services. Community based CSAs do door-to-door visits to recruit new members into the network and refer them for testing and other health services. They also continue to support existing members. Facility based CSAs meet NACWOLA members who have been referred for testing and treatment at the health facility, and guide and support them through the process, offering pre and post testing counselling. These CSAs form a bridge between community members and health service providers, to increase demand, uptake and the quality of HIV/AIDS and wrap around services.
For a break for the groups working at the hotel, lunch was had in the beautiful Speke resort. The ambling walk there and back allowed plenty of time for chit chat and inter-group introductions and mingling, I sat with Irene and Sandra, hoping to get to know them a little better and move beyond the wall of politeness that had been established. However, they soon slipped into Luganda, their shared local dialect while I sat lemon-like. I interjected at a couple of points to ask what they were speaking, and which language would be best to learn. As they returned to Luganda after answering I realised that, should I be posted to Iganga for 6 months I was going to be completely isolated unless I learnt the lingo.
At 7pm those remaining the hotel (mainly the private sector folk who had flown in from the US and Europe) were all officially welcomed into the programme by Julie, the CEO and founder of Pepal. A huge buffet and relaxed seating arrangements gave us all a chance to relax, mingle and get to know one another and the different projects/business models that were going to be developed in the coming days. While those who were new to Africa appeared shocked by the poverty they had seen, the field trip experiences had been "powerful" (as Bonnie said) and provided the motivation needed to really work hard to develop the business models that could make a positive impact.
