One of the great privileges of working at BRAC is the occasional opportunity to hear our founder, Fazle Hasan Abed, speak. Last Wednesday, we congratulated our first cadre of international Young Professionals on the completion of their training period in Bangladesh, and he offered some comments.
I've heard him speak several times about BRAC's experience in the 1980s with the Oral Therapy Extension Program (OTEP) (succinctly summarized in the New Yorker and more richly described in A Simple Solution, a must-read for any public health practitioner). But today he offered some details that were new to me.
In brief, brief detail: the OTEP program was an effort to ameliorate the massive death toll of children from diarrheal disease --it claimed almost 1 in 5 kids before their fifth birthday. Once scientists realized that you could prevent death from diarrheal disease through an IV (that essentially replenished fluids and electrolytes), the logical next realization was that by drinking a mixture of water, salt, and sugar, you could do the same thing. Given the dearth of health facilities in Bangladesh, and the challenges of transporting ready-made oral rehydration solution (ORS) all over the country, BRAC chose the strategy of teaching moms how to make it at home.
The story gets really interesting when the monitoring team goes out to evaluate the program after it reached its first 30,000 households--it found that while many mothers could make the solution, only a handful (~6%) actually USED it when their children had diarrhea. Upon a bit more investigation, they found that the field workers, who were teaching mothers about the solution, didn't actually use it in their own homes! So BRAC brought the field workers in, gave them a tour of the Cholera Hospital where many were being treated with the solution, and also gave a scientific explanation of how the solution worked. Satisfied that the workers now had "drank the koolaid" (or at least the ORS!!), they asked them to go door-to-door for another 30,000 households and teach them about it.
Usage went up, but was still only about 20%. The monitoring team at this point brought in an anthropologist (see! that degree does have applications!) to see what was going on in households where mothers knew how to prepare the solution, had children who had experienced diarrhea, but had not treated them with it. The anthropologist came back and said--the problem is that the men in the household don't trust it and won't let mothers use it.
BRAC now set about adding new components to the program--discussions at mosques, in the market, tea stalls, and other places in communities where men congregated. Slowly but surely, the monitoring team found a rising usage rate.
Only then did the program start to really think about scaling up--and eventually reached over 12 million households in Bangladesh!!
There are many, many lessons from the OTEP experience, but the two I want to highlight are:
1. Good monitoring is fairly simple to implement, but often marginalized. Especially at the beginning of projects, you can learn a great deal, especially if you build in a combination of quantitative and qualitative elements to get at the "whys" as well as the "what's." It doesn't have to be overly scientific and rigorous; better to go with something less formal and quicker that can lead to immediate tweaks.
2. You are only as good as your frontline workers. Organizations often spend a lot of time on technical training, but less on values, vision, and other "soft topics." But particularly for something as challenging as behavior change, if those tasked with converting others aren't true believers themselves, it's unlikely to be effective. If possible, recruit people who have drunk the koolaid, and in any case reinforce their beliefs vigorously before moving to the technical details. Atul Gawande, who wrote the New Yorker piece, got it right on the money when summarizing the magic of OTEP: "People talking to people is still how the world’s standards change."
I've heard him speak several times about BRAC's experience in the 1980s with the Oral Therapy Extension Program (OTEP) (succinctly summarized in the New Yorker and more richly described in A Simple Solution, a must-read for any public health practitioner). But today he offered some details that were new to me.
In brief, brief detail: the OTEP program was an effort to ameliorate the massive death toll of children from diarrheal disease --it claimed almost 1 in 5 kids before their fifth birthday. Once scientists realized that you could prevent death from diarrheal disease through an IV (that essentially replenished fluids and electrolytes), the logical next realization was that by drinking a mixture of water, salt, and sugar, you could do the same thing. Given the dearth of health facilities in Bangladesh, and the challenges of transporting ready-made oral rehydration solution (ORS) all over the country, BRAC chose the strategy of teaching moms how to make it at home.
The story gets really interesting when the monitoring team goes out to evaluate the program after it reached its first 30,000 households--it found that while many mothers could make the solution, only a handful (~6%) actually USED it when their children had diarrhea. Upon a bit more investigation, they found that the field workers, who were teaching mothers about the solution, didn't actually use it in their own homes! So BRAC brought the field workers in, gave them a tour of the Cholera Hospital where many were being treated with the solution, and also gave a scientific explanation of how the solution worked. Satisfied that the workers now had "drank the koolaid" (or at least the ORS!!), they asked them to go door-to-door for another 30,000 households and teach them about it.
Usage went up, but was still only about 20%. The monitoring team at this point brought in an anthropologist (see! that degree does have applications!) to see what was going on in households where mothers knew how to prepare the solution, had children who had experienced diarrhea, but had not treated them with it. The anthropologist came back and said--the problem is that the men in the household don't trust it and won't let mothers use it.
BRAC now set about adding new components to the program--discussions at mosques, in the market, tea stalls, and other places in communities where men congregated. Slowly but surely, the monitoring team found a rising usage rate.
Only then did the program start to really think about scaling up--and eventually reached over 12 million households in Bangladesh!!
There are many, many lessons from the OTEP experience, but the two I want to highlight are:
1. Good monitoring is fairly simple to implement, but often marginalized. Especially at the beginning of projects, you can learn a great deal, especially if you build in a combination of quantitative and qualitative elements to get at the "whys" as well as the "what's." It doesn't have to be overly scientific and rigorous; better to go with something less formal and quicker that can lead to immediate tweaks.
2. You are only as good as your frontline workers. Organizations often spend a lot of time on technical training, but less on values, vision, and other "soft topics." But particularly for something as challenging as behavior change, if those tasked with converting others aren't true believers themselves, it's unlikely to be effective. If possible, recruit people who have drunk the koolaid, and in any case reinforce their beliefs vigorously before moving to the technical details. Atul Gawande, who wrote the New Yorker piece, got it right on the money when summarizing the magic of OTEP: "People talking to people is still how the world’s standards change."
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