“When you get to the power of voice, you have to be brave and you have to be that person that will speak up and say this isn’t right, but I want to be a part of the solution,” said Eileen Martin, the Global Director of Inclusion at EMD Serono, the U.S. division’s biopharmaceutical arm, of Merck KGaA, Darmstadt, Germany. She spoke at a recent Wilson Center event on the intersections between women’s health, leadership, and economic prosperity. This edition of Friday Podcasts is led by Sarah B. Barnes, Project Director of the Maternal Health Initiative at the Wilson Center.
Healthy Women, Healthy Economies
When women are healthy, everyone benefits. When women are supported to fully contribute to national economies, again, everyone benefits. Often, the barriers women face toward economic participation are preventable with smart policies. The Healthy Women, Healthy Economies (HWHE) toolkit provides those policies and workplace strategies for hiring entities like governments, companies, and NGOs to encourage, integrate, and retain women in the workplace.
“Policy is key”, said Martin. Merck-Brazil used the policy toolkit to find both external and internal successes around improved women’s health and participation in the workforce. Internally, Merck-Brazil increased the number of women in leadership positions from 30 percent to 43 percent over a two year period. Externally, the toolkit aided the company in their work to bring awareness to the significance of colorectal cancer and to influence government and insurance policies to include recognition of and services for colorectal cancer, where previously only breast and cervical cancer were included.
The Balancing Act and Sponsorship
“Let’s forget about 9 to 5,” said Martin. Women tend to have a double and triple burden on a day-to-day basis that inhibits a normal work schedule and has women providing unpaid work way beyond a 40 hour work week. When employers implement policies and strategies to hire, maintain, and promote women in the workforce, a woman’s juggling act of balancing career, family, and health is relieved. “Let’s leverage technology and let’s really redefine what a ‘9 to 5’ day actually looks like.”
Martin stated that there is a lack of sponsorship for women in the workforce to support their progression. “Women tend to be over-mentored and under-sponsored,” she said and went on to explain, that while a mentor can really cheer on employees and be an advocate, they don’t have the political or the social capital to pull someone forward in the organization. A sponsor has to be somebody who can “put their political and social capital on the table and pound their fists” to demand that women in the workplace are given their rightful seat at the table.
Africa in Transition, a new series hosted by the Wilson Center and the Population Institute, explores the role of population trends—migration, urbanization, fertility, maternal mortality—in shaping sub-Saharan Africa’s chances for prosperity, health, and security. In this podcast, we share highlights from the first Africa in Transition event. Parfait Eloundou-Enyegue, Professor at Cornell University, starts the conversation by reminding us that “African countries are in the middle of multiple transitions that have the potential to create opportunities for prosperity, growth, and increased human capital, but also to create greater inequality. The challenge, therefore, is to build prosperity, but to do it for all.”
Dr. Gladys Kalema-Zikusoka, the founder and CEO of Conservation Through Public Health (CTPH) said that “the solutions to our problems can only be solved by us people in Africa.” What the international donor community can do to support those efforts is provide technical assistance and training. The solution has a lot to do with empowerment, she said.
The number of women in leadership positions is on the rise in Africa, said Musimbi Kanyoro, President of the Global Fund for Women. “There are women who understand the facts […] and they are speaking up and wanting more recognition and space, wanting more resources, wanting more funding and investing in their own families and their children.” This is especially evident with women’s involvement in the workplace. However, African women do not receive equal representation in governance. “When women are in leadership positions, you see other areas impacted as well.”
“Meaningful youth engagement […] is one of the most important things that we can do” to build a prosperous and goal-oriented society, said Unami Jeremiah, founder of Mosadi Global Trust. Intergenerational dialogue and thoughtful transition plans are critical to ensuring a secure future for countries in Sub-Saharan Africa.
To further empower women and youth, panelists highlighted the need to provide family planning and reproductive health services, and comprehensive sexuality education (CSE). In many cases, sexuality education programs are aimed solely at young people in school settings, said Jeremiah. To be effective, CSE must be shared with parents and caregivers, otherwise upon entering the home “one might as well leave their CSE at the door.” CSE is meant to teach people how to be safe and healthy, said Kanyoro, citing the influence of the Me Too movement on modern CSE. “It will make a difference in how we begin to tell the story of comprehensive sexuality education to everyone, because that is a human right.”
For more information on the Africa in Transition: Investing in Youth for Economic Prosperity event, please visit the event page.
Seeing the influx of international aid into Haiti following the 2010 earthquake, Dr. Florence Jean-Louis, Director of Human Development at Fonkoze, asked herself, “How can all this support, all this solidarity, stay in-country and have a real impact in the long-term?” She spoke at a recent Wilson Center event on the importance of community health systems to the sustainable development and stability of countries. The answer, she concluded, was to build the capacity of local organizations.
Case #1: Haiti and the Power of the Local Community
In Haiti, Fonkoze began as a small local organization with a grant from USAID. As a new organization, Fonkoze aimed to address sustainability by employing local community members, rather than professional foreign staff. “It took a lot of training, coaching, and consulting to get there,” said Dr. Jean-Louis. Using a volunteer-based strategy and grants from USAID and Advancing Partners & Communities (APC), Fonkoze has achieved a great deal of impact and positive health outcomes from nutrition, sanitation and hygiene, and other programs.
Case #2: Increasing Ebola Survivors’ Access to Care in Liberia
Liberia was one of the countries most affected by the Ebola crisis in 2014 and 2016. Those who survived the infection faced significant morbidity and challenges to their quality of life, including mental health problems and eye issues. “The focus of our work was on survivors, which including increasing access to specialty care,” said Dr. Rose Macauley, Chief of Party at APC Liberia. Funded by USAID, APC Liberia trained 60 mental health clinicians to meet the needs of Ebola survivors. Prior to this program, Liberia only had one psychiatrist for the 4.5 million people that lived there, said Macauley. Through the grant, APC also funded two faith-based institutions that care for survivors. More than 22 percent of the country’s Ebola survivors registered with them. APC also supported the development of the National Ebola Survivors’ Network of Liberia, a civil society organization that empowers survivors to recover, advocate for themselves, and integrate into their communities.
Case #3: Expanding Services for the Disabled in Laos
Millions of undetonated submunitions remain scattered throughout Laos since the Vietnam-American War. These explosives continue to be a source of danger and have caused thousands of accidental injuries and deaths since the end of the war. As a grantee of APC, World Education Laos implemented the TEAM (Training, Economic Empowerment, Assistive Devices, and Medical Rehabilitation) project, which gave out “$2.7 million dollars of grants in almost three years to 16 sub-grantees in Laos,” said James MacNeil, Vice President of World Education. These sub-grantees included the Cooperative Orthotic and Prosthetic Enterprise (COPE), as well as the Quality of Life Association (QLA), which are both local organizations dedicated to providing support and assistance to victims of unexploded ordnance (UXO) and people with disabilities to promote rehabilitation and sustainable livelihoods. As a result, these programs have made a significant impact in the disability sector in Laos.
Each speaker highlighted how partnerships between local organizations, international organizations and donors, and governments help communities respond to local challenges. These partnerships provide resources to support local organizations and solutions that build capacity to help countries become self-reliant. “Local organizations should be key actors in the work for sustainable development since they are the ones who stay, who strive, who sustain efforts with no termination date,” said Dr. Jean-Louis.
“Strengthening community health is critical to expanding voluntary family planning,” said A. Jean Affo, Chief of Party at Advancing Partners & Communities (APC) Benin at a recent Wilson Center event on the importance of community health systems to the sustainable development and stability of countries. In Benin, around half of the population lives in rural areas with a lack of access to quality healthcare services and information. Traditional attitudes and gender norms prevent women and couples from utilizing family planning methods, said Affo. Combined with early marriage, inadequate family planning leaves women and girls vulnerable to health issues associated with inadequate timing and spacing between pregnancies.
In the Agago District of Uganda, family planning is further complicated by the destabilizing effects of conflict in nearby Sudan. Frederick Mubiru, Chief of Party at APC Uganda, discussed the value of fertility hotspot mapping, an epidemiological analysis which identifies areas where fertility rates are highest. Mapping these “hotspots” allows organizations to dig deeper into community-specific behaviors and create tailored interventions, said Mubiru. For example, APC Uganda specifically mapped areas where adolescent pregnancy is particularly prevalent and aimed to determine which socio-cultural factors contributed to these rates.
Panelists agreed that practicing cultural sensitivity and a community-based approach are key when promoting uptake of family planning in various communities. This means getting not only women but also men, teachers, religious leaders, and other community leaders involved. In Agago, APC implemented an intervention called “Emanzi,” which means male role model. “It’s an approach that takes [men] through a nine-week curriculum that addresses gender issues but also teaches couples communication and joint decision-making,” said Mubiru.
A community-based approach to promoting family planning must reflect a strong understanding of the area population, said Susan Otchere, Senior Technical Advisor of Family Planning and Reproductive Health, Birth Spacing and Advocacy at World Vision, who has worked on family planning and maternal and child health. In Garba Tula, Kenya, she said, communities tend to be nomadic pastoralists who are predominantly Muslim.
With that knowledge, World Vision realized that the community responded more positively to the terminology “birth spacing” than “family planning,” because it was more closely aligned with the Quran’s teachings to keep women healthy by spacing births and allowing for breastfeeding, said Otchere. Sensitivity to these nuances, she said, allowed the team to gain the trust of the community.
Moving forward, countries that wish to develop sustainably must make strengthening community health systems a priority. Increasing local financing will be crucial to sustaining community health programs, said Affo. But the next call to action, said Otchere, is to integrate food security with health programs. “I see this as a community’s journey to self-reliance,” she said.
The overarching goal of the U.S. Global Water Strategy is to create a more water secure world, said Ambassador Marcia Bernicat, Principal Deputy Assistant Secretary for the Bureau of Oceans, and International Environmental and Scientific Affairs at the U.S. Department of State at a recent Wilson Center event. “Simply put,” she said, “a world where people have the water they need, where they need it, when they need it, without living in fear of floods or droughts.”
In honor of World Water Day 2019, Ambassador Bernicat took a look back at the challenges and objectives included in the U.S. Global Water Strategy, which was released in November 2017.
Three Main Challenges
“We addressed three major challenges in that strategy,” said Ambassador Bernicat. The first challenge is that a significant portion of the population in many countries still lacks access to safe drinking water and sanitation, she said. Nearly two billion people worldwide lack access to safe drinking water and nearly four billion lack access to safely managed sanitation services. “This is not only a threat to human health,” she said, “but a factor in migration, civil unrest, and terrorist recruitment.”
Second, the U.S. Global Water Strategy sets out to tackle rising levels of water insecurity around the globe. By 2030, according to projections, more than half of the world’s population will be living in water stressed conditions. “Many countries will not have enough water to meet domestic, industrial, and environmental water needs,” said Ambassador Bernicat. “These countries are fundamentally water insecure and risk increased fragility or failure.”
The third challenge concerns the possibility of conflict over water. “More than 270 water basins worldwide are shared by two or more countries,” said Ambassador Bernicat. “As water resources become scarce and variable, tensions over shared waters are likely to grow, increasing the potential for conflict at the local and regional level.”
Four Strategic Objectives
To answer these challenges, the U.S. Global Water Strategy provides four strategic objectives:
1) to promote sustainable access to safe drinking water and sanitation services along with the adoption of key hygiene behaviors,
2) to encourage the sound management and protection of freshwater resources,
3) to reduce conflict by promoting cooperation on shared waters, and
4) to strengthen water sector governance, finance, and institutions.
“To achieve these objectives, the United States is building capacity, investing in infrastructure, promoting science, technology, innovation and information, mobilizing financial resources, engaging diplomatically, and strengthening partnerships, intergovernmental organizations, and the international community,” said Ambassador Bernicat.
The Importance of Interagency Cooperation
The U.S. Global Water Strategy relies heavily on an interagency approach to address these global water challenges. More than 20 U.S. government agencies work on water in more than 60 countries. “This is not a problem that the United States will solve alone. It is through partnerships where we can leverage our respective strengths where we will be most successful,” she said. “And that is the message for today.”
Because the problems matter, they are worth tackling head on, said Ambassador Bernicat. “I am convinced that working together, we can achieve a more water secure future.”
Three big trends are coming, said Ken Conca, Professor at American University’s School for International Service at a recent Wilson Center event that explored the future of water. “We’ll be storing a lot more water,” he said. “We’ll be recycling a lot more water. And we’ll be thinking much more systematically and foundationally about flood risk.”
To meet the water challenges of the next 30 to 50 years, water storage will become increasingly important to smooth out extremes, to buffer against shortages, and to replace natural storage that we’re losing as snowpack and ice melt begin to vanish in a greenhouse world, he said. Water recycling will become a tool to enhance the water supply and reduce the energy and conservation costs of our current inefficient water system.
Inefficient Use of Water
For example, Conca said that we clean water to world class drinking standards and use a large amount of energy to pump it to your toilet. If your toilet is more than 20 years old, with two flushes of that to make a few ounces of urine go away, you have just flushed away what the World Health Organization says is the daily survivable minimum of water for immediate personal use. “That is not a smart system, and that is going to start to change,” he added.
Conca also predicted that more attention will go to combatting flood risk, particularly the “double-exposure” that coastal communities face. On the one hand, they’re exposed not only to intensifying storms from the sea and higher sea levels. On the other, they are vulnerable to the danger of flash flooding from heavy rains, like those from Hurricane Harvey that stalled over and inundated Houston.
While climate change is obviously one of the drivers behind these adaptation trends, it isn’t the only one, he said. Other drivers include the shifting dynamics of water economics and a variety of new actors, such as the Department of Defense, which are taking actions to manage their exposure to risk and making much needed updates to existing water infrastructure. “That’s one of the really key points,” he said. “We have to get the infrastructure decisions right.” Longevity poses a planning challenge, given that new water infrastructure may need to survive more than a hundred years.
Unintended social and ecological consequences of infrastructure decisions could also have a large effect on “the peace and conflict dimensions that we will have to pay attention to as well,” he said. Disputes may arise when big dam projects do not consider environmental or human rights consequences, when livelihoods and profits are altered by the use of recycled water, and when flood protection affects property values and the way of life in historic neighborhoods and communities.
While in aggregate, the big trends may look like positive adaptations that will increase resilience and further risk management, Conca pointed to a downside. They are laden with tremendous potential for injustice, for inequality, for contentiousness, and for conflict, violent or otherwise. “I’d like to stress that it’s not enough to capture the macro-benefits to society of these broad adjustments that we know are coming and that we know make sense writ large,” he said. “We have to manage the micro-considerations. Who wins? Who loses? Whose voice? How do we spot the unintended consequences? How do we spot the second-order effects?”
Water Project Micro-effects
For many people, the second-order and unintended effects are the real story, Conca says. “As we get climate smart, we also have to get conflict smart and equity smart.” To do so competitively, we must put more time into decision-making and consider the micro-effects of water infrastructure projects. If these effects are over-looked, production based on the principles of economies of scale appears to be the most cost effective strategy in designing water infrastructure.
For example, building one big pile of concrete and generating 1,000 megawatts in one project is much more efficient than 10 projects generating 100 megawatts each or 1,000 projects that produce one megawatt each. However, with factors such as changing land and water prices, updated environmental regulations, and a variety of social considerations, economies of scale eventually may turn into “diseconomies” of scale.
Economies of Flexibility
“We don’t know what the future is going to entail,” Conca said. “There is a value that we can price in delaying a decision until you have more information,” he said, and in the ability to change your mind. These advantages form a cost efficient “economy of flexibility” by adapting and adjusting water infrastructure decisions to a variety of ever-changing challenges. These “economies of flexibility” eventually outweigh economies of scale in the long-term future of water infrastructure.
“One of the interesting things about dealing with water and sanitation issues is that in many ways it’s a crosscutting issue,” said Sam Huston, Chief of Party at Tetra Tech’s USAID-supported Water Supply, Sanitation, and Hygiene Financing (WASH-FIN) Project. Practitioners often must deal with multiple challenges that are usually much broader than their specific focus, he noted during an interview for this week’s Water Stories podcast.
Over the past two decades, Huston has engaged with local communities on water utility reform programming in low-intensity post-conflict and potentially new conflict environments. For much of 10 years, Huston worked in and out of South Sudan and for 4 of those years worked on a water peacebuilding program, The Water for Recovery and Peace Program.
The challenges one faces when trying to jump-start a water utility in a post-conflict environment can be considerable. A country may have no power grid. Or the supply chains for diesel fuel needed to run backup or primary generators do not exist. “You’re soon involved in not just jump-starting a utility,” said Huston, “but all kinds of logistical challenges around securing what would be readily available on the market in a fully functioning economy.”
To move a water utility toward autonomy, practical interventions may be needed to get it fully operational. This might involve changes in a water utility’s record keeping systems. Is the accounting system computerized? Is the customer database up to date? Are utility managers thinking about how they can improve collection from customers? How transparent are accounting and billing systems? Non-flashy interventions related to core systems can collectively move the utility to a position where it is able to cover more and more of their operational costs, said Huston, “so that they can operate in an autonomous way.”
To stabilize a utility, it is critical to figure out how “to ring fence these utilities after the capital investments have been made so that they’re able to operate on a sustainable basis and they’re not directly dependent on the political cycle for funding to maintain operations,” Huston said. Water utilities are not going to perform consistently if they rely on external financing to cover day-to-day operations. If you need to knock on the door of the Ministry of Finance every other day to fill up your generators and to run your water pumps, you’re not going to be providing water on a very reliable basis, he said.
The pathway out of fragility for a utility is ultimately a transition plan from being dependent on the public purse for operations to moving to a situation where you depend only on customer fees and user tariffs to fund day-to-day operations, Huston said. Water utilities need to come up with a viable business plan and work within their systems to recover costs so they can become operational. “It sounds easy,” he said, “but it’s a really long hard slog.”
“The Jordan River has been the lifeblood of the Levant,” says Gidon Bromberg, the Israeli co-director of EcoPeace Middle East, in this week’s Water Stories podcast. The river’s importance offers a unique platform for multi-level conflict resolution and environmental conservation efforts
in a region wracked by conflict.
Following the 1993 Oslo Accords, “there was a sense of euphoria; we all thought that peace was about to break out completely,” says Bromberg, who helped found EcoPeace Middle East in 1994. “And the goal for creating the organization was the fear that the environment was not on the peace agenda, that fear that peace was going to lead to unsustainable development.”
When violence broke out once again, the bonds between the Jordanian, Israeli, and Palestinian members kept EcoPeace together. “We came to see…the model we had created in how to work together was actually a model for peace,” says Bromberg.
EcoPeace’s Good Water Neighbors program brings together residents of Palestinian, Israeli, and Jordanian communities to focus on their shared water sources, such as the heavily polluted Jordan River. “Communities came to see…that the only way to promote economic development in my community was to work with the other side, to develop relations and to move forward on a common agenda,” says Bromberg.
“We’ve found that youth are often braver than any other level of community interaction. From their perspective, if we need to work with the other side in order to solve this problem, then why aren’t we doing that?” he asks. For example, city mayors were persuaded to engage in water clean-up projects only after students requested it.
“I don’t want to paint a rosy picture: there is a lot of work still to do. But we have 100 years of conflict, and in just 10 focused years of peacebuilding [and] of advocacy, we’ve been able, through this multi-level intervention, change mindsets. Ministers and authorities that just several years ago were continuing to tell us that we’re dreamers, that we’re naive, that we’re wasting our time—today, some of them are the biggest advocates.”
“Almost everyone of reproductive age—about 4.3 billion people—will not have access to at least one essential or reproductive health intervention over the course of their lives,” said Patricia Da Silva, Associate Director, International Planned Parenthood Federation United Nations Liaison Office. She spoke at a recent Wilson Center event showcasing recommendations from the Guttmacher-Lancet Commission report, “Accelerate progress--sexual and reproductive health and rights for all,” on how to advance sexual and reproductive health from a human rights perspective.
The Commission presents a “comprehensive, evidence-based, and integrated vision of sexual and reproductive health and rights (SRHR) that recognizes that improving health depends on rights,” said Da Silva. Guaranteeing that all people, regardless of who they are or where they live, have access to “affordable, essential, and attainable” sexual and reproductive health services is a core pillar of the Commission.
Countries tend to focus on certain components of SRHR, such as improving access to contraception, HIV prevention, and maternal and newborn health services, but the Commission includes often neglected components of sexual and reproductive health, such as “abortion, infertility treatment, LGBTQI friendly services, youth friendly services, comprehensive sexuality education, as well as the prevention, detection, and management of gender-based violence,” said Da Silva.
Some key recommendations from the Commission include providing access to safe abortion services for all women, supporting changes in policies that enable all people to understand, protect, and fulfill their sexual and reproductive health and rights, ensuring universal access to an integrated package of sexual and reproductive health services, with a particular focus on reaching vulnerable populations, and finally, addressing sexual and gender-based violence through policy changes and prevention programs.
Existing gaps in access to sexual and reproductive health can create consequences not only for individuals and communities, but also for national economies around the world, said Da Silva. Investing in and ensuring access to reproductive services for all, primarily contraception, and high-quality maternal and newborn health services would result in a net savings of 6.9 billion dollars. “Spending money now, making corrective policy actions now, can save huge economic benefits for the future,” said Da Silva.
“The rights-based roadmap approach proposed by the Commission…it is the way to accelerate progress for SRHR. It is the way to achieve sustainable and equal development for all. And ladies and gentlemen, colleagues, the time is now.”
“When we start talking about water in the context of security, we’re immediately drawn to a conversation about conflict. And that’s often framed in terms of scarcity of water and a real zero-sum game around water, where scarcity begets grievances, which beget instability and conflict,” says Ken Conca, Professor at American University’s School of International Service, in this week’s Water Stories podcast. Of the world’s 276 transboundary water basins, fewer than half are governed by an agreement or accord that allocates use of the shared water between countries—and less than a quarter of these accords include all the riparian states in a basin.
“But when we step back, I think the larger frame is really one of uncertainty and of managing risks, and in that context, I think the good news is that there are a lot of cooperative opportunities,” says Conca.
Today, “we have a very weakly developed and patchwork body of international law. When you look at the content of that international law, we find that most of those agreements are actually fairly static, inflexible water-sharing agreements,” he says.
Conca points to some potential models for cooperation and collaboration: For example, the 1997 United Nations Watercourses Convention codifies several key principles that basin agreements should include to be equitable and effective: environmental protection, information sharing, and notice of infrastructure development, among others. “On one level it provides a very good framework,” he says, but “it doesn’t deal with a lot of the challenges of adaptation and resilience we face. So the challenge in international water law is really to create more flexible accords first.”
“We need to start doing the kinds of climate vulnerability assessments that the Paris Accords envisioned at the basin level,” he says, pointing out that national-level adaptation assessments don’t address shared water courses or dynamic flows across borders. “It’s critically important we start doing that sort of analysis.”
“We need to think less about allocating a fixed pie of water and more about expanding that pie through sensible and cooperative management,” says Conca.