All posts in Failure

Failure

Sometimes, even when we know the right thing to do, we fail to do it. We do this with seatbelts, diets, speeding, and love, and as it turns out, we sometimes do this with PEPY programs too.

Recently one of our programs faced a failure which should have been avoidable but which will hopefully help us set better systems in place to avoid similar problems in the future.

You might have read about our “Saw Aw Saw” program, the arm of PEPY which partners with communities to help them create and implement plans to improve their government primary schools.

To build more long-term sustainability into the program (learn how we define “sustainability” at PEPY), SAS includes a small business development component. The idea is that if schools are able to generate additional income on their own, they can use this income to further develop their school beyond what the government or other fundraising efforts provide.

Last year one of the SAS partner schools decided to start a small mushroom growing business. It did quite well, as there was no other local supplier of these nutritious mushrooms, and their first rounds of sales went very well. Eventually, it became too difficult to source mushroom spores and the program stopped.

This year, two schools decided to start a spore-growing program, as spores typically generate a high net profit and in this way they could support local families in improving their nutrient intake by affordably growing their own mushrooms at home. This sounded like a great plan!

BUT we rushed into this program to try to get it started before the end of the school year. We didn’t do enough research, or support the communities with the tools and networks to do this themselves and we also didn’t have the in-house technical expertise to understand the threats to this agriculture program.

Part of the SAS model provides support for the one-off training costs which go into business development. We sent representatives from both schools to a course on mushroom growing. In addition to poor research, we made another big mistake, which goes against the lessons we have learned:

We paid for this in full. The school support committees did not have to invest funding into this project, only their time. As such, if there was a financial waste, they had very little incentive to point it out or prevent it.

We didn’t send any PEPY staff to the training, which would have helped us to understand the program into the future and might have also prevented us from wasting funds on unnecessary equipment. You see, the key to growing spores, it turns out, is a sterile working environment. We had researched this enough to know the very basics, but when signing community members up for the course, we failed to research what technical tools, apart from the training component, would be required for the success of the program. When the community came to us with a proposal to go to a nearby training on spore growing, we accepted the proposal without doing enough research on how the training would work.

It turns out that part of the training included how to use one of the key tools in spore growing. This sterilization device is, you guessed it, electricity-powered. We had sent two people who live in remote communities with no electricity to a training about how to use an electronic instrument, just because they had asked.

Big oversight.

Failure

Médecins Sans Frontières (MSF) is an organization that thrives on critical debate. Across the five MSF operational centres, we readily point out each others’ errors and shortcomings. When this dynamic is kept within the range of “healthy tension,” it serves the operational teams and the patients we treat. Everyone has to defend or adjust their actions in response to the criticism of colleagues. This pushes program quality to the forefront and reinforces accountability.

Added to this, MSF headquarters staff regularly visit field teams to ensure that our medical action adheres to the standards and goals of the organization. We also do formal evaluations, particularly after major emergencies. Some within MSF will say we don’t do enough evaluations. Having been with the organization for almost 20 years, I believe that we tend toward the opposite.

We do so many evaluations, alongside the regular supervisory visits, that our teams tend to be swamped with recommendations that risk being lost over time. Trying to prioritize and follow through on the multitude of well-intentioned insights can be overwhelming.

Learning lessons in MSF is not a problem. We learn lessons easily. Unfortunately, the same lessons are sometimes learned by different teams at different times. Our challenge is to swiftly integrate what we have learned across the vast MSF movement – more than 27,000 MSF aid workers served patients in over 60 countries in 2010.

As an organization that works largely in sub-Saharan Africa, historically we have focused on treating people with infectious diseases found in low-resource settings. This was reflected both in our clinical guidelines, and in our emergency medical supply kits containing standard drugs and medical supplies for the most common diseases.

In 2003, I was supervising MSF operations in Iraq. There, many of the illnesses people suffered were non-communicable, like heart disease and diabetes. In the aftermath of the U.S. invasion, our teams quickly positioned themselves with the usual emergency medical supply kits. Armed with malaria drugs and antibiotics, teams were not well prepared to encounter the kinds of health needs associated with middle-income countries, namely non-communicable diseases.

It was a frustrating situation. Not only were we unprepared, but our teams struggled with the change in focus. We needed substantial additional supplies to make our medical action fit the main needs. Even more frustrating was when we realized that an evaluation of our previous work in Kosovo had already highlighted the importance of being ready to treat chronic, non-communicable diseases in middle-income settings.

But still we failed to learn our lesson, and repeated the same mistakes after the 2010 earthquake in Haiti. From “Haiti One Year After” (2011), the report on our response:

“Furthermore MSF did not have the appropriate medicines on hand in the emergency phase to care for patients suffering from non-communicable conditions such as hypertension, diabetes, and epilepsy. Of 850 patients treated in one location between March and September, there were 72 cases of hypertension. Recognizing this shortfall in the package of available care in some MSF medical structures, the organization is already evaluating the feasibility of including chronic disease kits in the emergency preparedness stocks it maintains in different countries.”