Without ownership, sustainability is a mirage

Abdulkadir leads a group of health volunteers in Nigeria, where the U.K. Department for International Development uses an innovative community-based approach to help women safely deliver their babies. Involving people at the grassroots level helps ensure that a project becomes sustainable. Photo by: Lindsay Mgbor / DfID / CC BY-NC-SA

Sustainability. We hear and use that word frequently in international development, and most of the time the word is abused. But what does it really mean?

As a Nigerian leading the Partnership for Transforming Health Systems 2, a six-year project funded by the the U.K. Department for International Development to strengthen Nigeria’s health system, I can tell you based on decades of development program implementation in Sub-Saharan Africa — and Nigeria in particular — what it means to me. I have lived it.

Grant recipients in developing countries must first understand the rationale behind the grant, the benefits to them and their role in its implementation before they will embrace it. Unless the people of a nation truly buy into the project and are passionate about its goals, it will not last. Until they own it, they cannot sustain it. Ownership precedes sustainability.

Here are three lessons I’ve learned that can help to ensure a project is sustainable:

1. Make people part of the solution

At the inception of the PATHS 2 program in 2008, Nigeria had about 2 percent of the world’s population, but contributed 10 percent of the world’s maternal deaths. To reverse this trend, the project has been supporting the government of Nigeria at the national, state and local government level, working in five states of Kano, Kaduna, Jigawa, Enugu and Lagos to improve the health of women and children, especially in rural areas.

Jigawa, Kaduna and Kano are three states in Northwest Nigeria with high rates of maternal mortality — as high as 1,100 deaths per 100,000 live births. One of the major contributors to maternal deaths is poor access to facilities. Traveling to a health facility can involve long distances, bad roads and high costs, contributing to women dying in childbirth before ever reaching help.

To improve access to facilities, save women’s lives and make the community part of the solution, we’ve established an initiative in collaboration with the State Ministry of Women’s Affairs and Social Development called the Emergency Transport Scheme. We partnered with Nigeria’s powerful and well-organized transport union to turn taxi drivers into volunteer ambulance drivers who use their own cars to get pregnant women to the hospital or clinic during obstetric emergencies. Under this program, the union drivers get training on safe driving and understanding the danger signs in pregnancy. Drivers who volunteer for this program get special privileges in their day jobs, such as being promoted to the front of taxi ranks. Since the program began in 2012, the ETS has helped more than 2,274 women receive timely medical help.

In addition, PATHS 2 has facilitated an Emergency Maternal Fund in more than 50 communities in Kaduna. This draws upon donations from community members. Very poor members of the community can borrow from it and repay later without interest to help cover the costs of caring for maternal and child health emergencies.

Without programs like these that enable communities to see their roles clearly, get involved and become active participants, sustainability is a mere illusion.

2. Listen to the community

In Nigeria, we’ve found that getting people involved at the grassroots level — and really listening and responding to their concerns, their fears and their hopes — can have a positive impact on the lives of people who need help the most.

One of PATHS 2’s key efforts has been refurbishing health facilities in an effort to get expectant mothers to use them. Many pregnant women were giving birth at home using traditional birth attendants, which increased risk of death or injury both to themselves and their baby. So it was important to understand why women were using this riskier option, instead of making our own assumptions.

What we found is that many of these facilities had fallen into disrepair, people did not feel welcomed by health care providers, and staff morale was low. Thanks to the creation of Facility Health Committees, made up of local citizens, the health centers are more accountable — and have stronger links — to the communities they serve. Today, the health centers are clean and modern. Patients say they feel welcomed. Staff, who are better trained, are able to provide around-the-clock care in emergencies. At the same time, we recognized the need to accommodate local customs, so traditional birth attendants are being trained to identify when a pregnant woman is in danger and refer them to a facility.

These activities help ensure that people have a voice in the outcome, making it more likely they will carry on with the work long after we are gone.

3. Look to the youth

Like many countries, Nigeria faced a serious problem when it came to getting trained doctors to serve in rural areas. As of 2012, there were about 18 skilled professionals (doctors, nurses, midwives) per 10,000 people, compared to the World Health Organization’s recommended ratio of almost 23 skilled health workers for every 10,000 people.

Very often, rural health facilities cannot attract doctors because of their remote locations, and because the local government authorities cannot pay for their services.

So we turned to Nigeria’s National Youth Service Corps, which runs a compulsory year-long program of national service for young people after graduation from a university or polytechnic school. We signed an agreement to send health professionals to our project sites. Some of those medical graduates who are doctors, nurses and pharmacists are now selectively posted to provide basic emergency obstetric care in rural health facilities that are supported by the PATHS 2 project. This means that the lives of mothers and children are being saved and more patients are seeking care at rural health facilities.

Involving the youth in solving a nation’s toughest challenges is a critical component of making a project sustainable.

We know that good health is essential if our families and our nation are to thrive, develop and prosper. But I also know from working on development projects throughout my career that the best intentions can fall short if we don’t involve the community and listen to their concerns and input. They must be part of the solution. Until you own it, you cannot sustain it.

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About the author

  • Mike Egboh

    Mike Egboh is national program manager for the Abt Associates-led Partnership for Transforming Health Systems 2 in Nigeria. A Harvard MBA graduate, Egboh has over 30 years of experience supporting the health system in his native Nigeria.