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Health Service Delivery in Fragile States: Lessons from the Field. Emmanuel d’Harcourt International Rescue Committee Woodrow Wilson Center for Scholars September 12, 2006. Outline. Population and fragility Fragility and health Health and fragility Missions, health, and fragility.

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Health service delivery in fragile states lessons from the field

Health Service Delivery in Fragile States:Lessons from the Field

Emmanuel d’Harcourt

International Rescue Committee

Woodrow Wilson Center for Scholars

September 12, 2006


Outline
Outline

  • Population and fragility

  • Fragility and health

  • Health and fragility

  • Missions, health, and fragility


Outline1
Outline

  • Population and fragility

  • Fragility and health

  • Health and fragility

  • Missions, health, and fragility


… The [demographic] "wolf" is present and very busy indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Maurice King, MD.

From AJPH, July 1996


Factors associated with the genocide
Factors associated with the genocide indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Related to resource scarcity

  • Not related to resource scarcity


Related to resource scarcity
Related to Resource Scarcity indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Popular discontent due to food scarcity

  • Gain from previous Tutsi “pogroms”

  • Fear of losing land to invading army

  • Joblessness


Rwanda population 1900 2000
Rwanda population, 1900-2000 indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Source: US Census Bureau


Average land holding 1960s 1990s
Average land holding 1960s-1990s indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Source: Uvin, 1996


Food production per capita 1961 1993
Food Production per Capita 1961-1993 indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Source: FAO, 1994


Over-population indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Resource scarcity

Popular discontent

Desire

Ability

Permission


Population density
Population density indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Source: PRB


Population density1
Population density indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Source: PRB


Not related to resource scarcity
Not Related to Resource Scarcity indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Falling commodity prices

  • Popular discontent due to mismanagement

  • Elite worried about losing power

  • Long tradition of social division

  • Genocidal ideology

  • Effective propaganda and media

  • Highly disciplined state machinery

  • Lack of filial bonds: state vs. tribe

  • International inaction


Coffee earnings 1985 1993
Coffee Earnings, 1985-1993 indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Source: FAO, 1994


Unfavorable terms of trade / structural adjustment indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Over-population

Arusha

Steady arms supply

Rebel attack

International Inaction

Resource scarcity

Corruption

Highly organized state

Social divisions

Popular discontent

Elite insecurity

Lack of filial bonds

Effective media

Desire

Ability

Permission


If population is so important
If population is so important indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

Source: PRB


Outline2
Outline indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Population and fragility

  • Fragility and health

  • Health and fragility

  • Missions, health, and fragility


How fragility affects health
How fragility affects health indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Security

  • Policies

  • Motivation

  • Training

  • Management

  • Sustainability

  • Communities

  • Responsibility


Children treated rwanda and sierra leone
Children treated indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…Rwanda and Sierra Leone


Amodiaquine s p
Amodiaquine + S/P indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…


Outline3
Outline indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Population and fragility

  • Fragility and health

  • Health and fragility

  • Missions, health, and fragility


How health affects fragility
How health affects fragility indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • No services is a big part of fragility


How health affects fragility1
How health affects fragility indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • No services is a big part of fragility

  • Good services legitimize governments


Cost per treatment
Cost Per Treatment indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…


How health affects fragility2
How health affects fragility indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • No services is a big part of fragility

  • Good services legitimize governments

  • Health is entry point for building systems


Safe motherhood kibungo province
Safe Motherhood, Kibungo Province indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…


Children treated south sudan and sierra leone
Children treated indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…South Sudan and Sierra Leone


Children treated south sudan and sierra leone1
Children treated indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…South Sudan and Sierra Leone


South sudan example
South Sudan example indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Good human resource management

  • Good information system

  • Simple tools

  • Scaleable

  • Adapted to local environment


How health affects fragility3
How health affects fragility indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • No services is a big part of fragility

  • Good services legitimize governments

  • Health is entry point for building systems

  • Systems may induce more responsibility


How health affects fragility4
How health affects fragility indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • No services is a big part of fragility

  • Good services legitimize governments

  • Health is entry point for building systems

  • Systems may induce more responsibility

  • Community work strengthens communities


Distributor information
Distributor Information indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…


Key quality indicators community distributors south sudan
Key quality indicators indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…Community distributors, South Sudan

n = 96 supervision reports


Can health programs help
Can Health Programs Help? indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

a

a

  • Poor information

  • Weak human resources

  • Weak absorptive capacity

  • Uncertain future

  • Unpredictable external support

  • Recidivism

  • Need to address immediate needs

  • Need to show peace dividend

a

x

x

x

a

a


Can health programs help1
Can Health Programs Help? indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Enhance stability

  • Improve security

  • Encourage reform

  • Increase capacity in key areas

  • Address sources of fragility

  • Seek short-term impact & long-term reform

  • Establish measurement systems

a

a

a

a


Institutional indicators from health
Institutional Indicators from Health indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Utilization rate

  • Reported supervisions / health area / month

  • % community workers reporting

  • % stock out for key drugs


Outline4
Outline indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Population and fragility

  • Fragility and health

  • Health and fragility

  • Missions, health, and fragility


Health fragility and missions
Health, Fragility, and Missions indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Missions are concerned about fragility

  • Missions care about health status

  • What do missions do that helps?

  • What do missions do that doesn’t help?


Health fragility and ngos
Health, Fragility, and NGOs indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Field-based

  • Innovative

  • Collaborative

  • Coordinated

  • Think of scale-up

  • Expensive

  • Short term

  • Small scale

  • Not audited


Things that don t help
Things that don’t help indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Frequent strategic redesign

  • Process of strategic redesign

  • Little field presence

  • Concentrating resources

  • Lack of DC – Mission coordination

  • Some regulations – drugs, salaries

  • Short-term funding


Things that do help
Things that do help indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Ambitious programs designed for scale

  • Coordination of grantees

  • Coordinating with other donors

  • Grantee – Government mediation

  • Inter-sector synergy

  • Willingness to support systems

  • Long-term funding


Who has the answer
Who has the answer? indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

USAID DC

USAID Mission

iNGOs HQ staff

iNGOs local staff

Beneficiaries

National officials

Local officials

Local NGOs


Top 5 recommendations
Top 5 recommendations indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Think big, think national

  • Focus on coordination and systems

  • Rethink drug procurement limits

  • Rethink salary support limits

  • Rethink strategic planning process

    • Less large shifts, more small adjustments

    • More participation


Ofda recommendations
OFDA Recommendations indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Switch to long-term funding ASAP

  • Increase monitoring of costs, results

  • Continue focus on inputs


Bottom line
Bottom Line indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned…

  • Fragility affects health – a lot

  • Health programs can reduce fragility – some

    • Systems

    • Measurement

  • Health programs can reduce suffering – a lot

  • Missions help, could help even more

    • Stable strategy, stable funding

    • Coordinate


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