Runa Khan • Friendship
Founded by Runa Khan, Friendship began its activities in 2002 with a floating-hospital to ensure access to health care for ultra-poor communities in Bangladesh. Since then, Friendship has extended its intervention to create what is a fully integrated development model and an innovative development model that is geared to engaging communities, and strengthening their resilience and dignity. Today it is developing its network internationally through entities established in Europe. Its approach is observed with curiosity and interest by other development actors.
Bangladesh is one of the most fertile countries in the world, but also one of the most vulnerable. The country is indeed literally stuck between the Himalayas and its melting glaciers, and with its 600 rivers, it makes it the second biggest delta in the world. This makes it the most exposed region to rising seas. Nearly a third of the country is susceptible to tidal inundation and 70% is flooded every year during heavy monsoons. This situation strongly affects the ecosystems and the exploitation of the already restricted natural resources.
It is also one of the poorest countries in the world and, with a population of 160 million, the most densely populated (it is one fourth of France in size, with more than three times the population of this country). Therefore, the question of resilience of the communities becomes crucial. According to the Government of Bangladesh, 20 million people may be displaced by 2050 because of climate change. Many of them are already migrating: 500,000 migrants are arriving every year in Dhaka, the already over-crowded capital which is home to more than 18 million people.
The Friendship’s journey
In 2002, the NGO Friendship created a floating hospital: the Lifebuoy Friendship Hospital. Thus began Friendship’s journey towards reaching what seemed to many an insurmountable goal: carrying healthcare in the most remote and difficult-to-reach areas of Bangladesh, the so-called Chars, which are shifting islands that thread the northern reaches of the Brahmaputra River and where 4 million people live.  
Since then, Friendship has progressively developed a healthcare system to provide comprehensive quality health and information to the remote river-based communities of northern and southern Bangladesh. Two more floating hospitals were introduced: the Emirates Friendship Hospital in 2008 with the sponsorship of the Emirates Airline Foundation and the Rongdhonu Friendship Hospital, formerly Greenpeace’s Rainbow Warrior II, in 2012.
Starting from 2005, a system of mobile Satellite Clinics was set up, complemented by health workers to serve communities at the grassroots level. Presently, each month, approximately 250,000 persons are treated thanks to Friendship’s health program.From healthcare to an innovative and integrated approach to development
Recognising that the broader goal – enabling marginalized communities to improve their living conditions and gain control over their lives – requires more than healthcare support alone, Friendship has progressively built an integrated community development model. It includes education, disaster management and infrastructure development, good governance, sustainable economic development, and cultural preservation.
For the last 15 years Friendship has been working on the basis that the ultra-poor are entitled to the same quality of service, care, and opportunity than any-body else. This has given Friendship the strength to overcome the challenges that it faces daily.
Friendship is a needs-based organisation, principled on a bottom-up approach, strongly rooted in the community level: it bases its work on the evolving needs of beneficiaries. Since its beginnings, the organisation is working in close collaboration with local communities to understand their needs, which enables it to develop an integrated development approach. This promotes ownership by the local communities and facilitates effective collaboration to deliver services. It ensures efficient use of resources and long-term sustainability.
|Nurturing dignity: the strongest change-maker
The genuine community involvement is probably what impressed me the most when I joined the Friendship family. All programs are systematically shaped involving communities in the governance of all projects in order to imbue self-respect to the beneficiaries with whom Friendship is working.
This model is shaped with the belief that we need to ensure that our giving preserves and nurtures dignity. Otherwise we take away more than what we give to the beneficiaries; for then we take away their power to survive. Acknowledging that the first and most powerful change-maker is actually the beneficiaries themselves and the best thing we, as NGOs can – or even should – do is to facilitate the growth of their self-confidence, is a lesson in humility. It is probably also the only way for a really sustained approach to development.
Coming from an entrepreneurial and change-management business background, this idea was very powerful for me. It literally changed the presumptive knowledge I had on the NGO world that seemed to me at the time very complicated, political and short-term in vision. As Runa often says, in order for dignity to be preserved, we must ensure that the right support is given at the right time and in the right way; and that it meets a true need of the recipient. It contrasts with the “donor-driven” approach, whereby activities are undertaken based upon the agenda of available donors and in compliance with such donor’s defined use of funds, which in-fine creates a negative chain of money flowing in and out, without achieving much sustainable impact.
Not only did I find Runa’s and Friendship’s views to disrupt and challenge those ideas and practices, but in it was also the power to effectively bring change with a bottom-up and hands on approach. It is not about talking but about doing and making effective changes happen. I found out that some decision requires quite a dose of courage, and I understood that the model was heavily inspired by an entrepreneurial mind set. It is a model that has space to say no; no to a donor that is only willing to pay for low cost latrines because they will not last in the extreme weather conditions. Since the donor is not beneficiary driven, not ready to pay for higher quality latrines that will last longer, create a social statute and therefore really change the habits, then you better say no to save your time and other people’s money.
Over the years of servicing the ultra-poor and climate change impacted communities, we have learned that the poor cannot afford poor solutions. Poor solutions mean defective service delivery, and the premise behind giving itself being poor. It is only where the mind-set of the giver is based on truth and respect that recipients respond equally, building on the support they receive. There can be no sustainable development without mutual respect and therefore dignity.
It is based on these principles that we have set up Friendship France. Alike all other Friendship constituencies set up outside Bangladesh, Friendship France’s is committed to the mobilisation of financial and other resources in order to support the operations of Friendship Bangladesh. In view thereof Friendship France aims at developing long-term cooperation with partners that are looking for sustainable impact. Sustainable meaning that they under-stand the importance of communities’ involvement and the power of self-respect and dignity, as well as Friendship’s determination to be guided by the communities needs and abilities in all circumstances. Friendship France has been lucky in getting together a well experienced board with members with both private and NGOs background, enabling a fruitful cooperation.
One of Friendship France’s priorities today is to develop partnerships to fund Friendship’ first land based hospital currently under construction in the coastal area of Bangladesh and which will mark a further milestone on the organisation’s journey in setting up a comprehensive and effective health system, thus showcasing, including to the public authorities, that delivery of quality healthcare is possible in remote areas.
William Lebedel • Chairman, Friendship France
Friendship recognizes that problems are multi-faceted and interlinked. For the organisation it is clear that economic welfare interventions can be effective only for a community who has access to healthcare and education; successful healthcare relies upon knowledge of basic hygiene and a sanitation infrastructure; education cannot be promoted successfully where students suffer from hunger; and improvements cannot be sustained if the results of people’s efforts are regularly wiped out by natural disasters. This model today interlinks six programs.
Friendship has developed an innovative and highly recognized 3-Tier healthcare system. At its core are three hospital ships (Tier 1), supported by strong field level static and satellite clinics (Tier 2) and Friendship community medic-aides or FCMs (Tier 3). The FCMs are micro social entrepreneurs, whose services fill a vacuum in the community in which they live and enable them to earn a reasonable income. With this reliable and replicable system, Friendship presently serves approximately 3 million patients per year. Significant portions of the beneficiaries receive secondary level care in the hospital ships, and the static clinics.
The ships serve as primary care and secondary care centres. They are fully operational as hospitals providing care on average to 175 persons per ship per day. They serve as referral centres for the second and third tiers. Each ship is equipped with doctor services, gynaecological services – including treatment of first level cervical cancer –, path labs, Xrays, and two operations theatres performing surgical interventions for cataract extractions, orthopaedic corrections, reconstructions and fistulas repairs. Except for a nominal token amount, the services are provided free of charge including operations and medicines. 
The satellite clinics are mainly for primary health care, follow ups and prevention. These are mobile teams manned by paramedics with very strict protocols. From prevention to awareness and direct service delivery, the satellite clinics also identify community needs for health and refer patients to our hospitals. The services provided are teaching and training communities for better health, total package of services for M&C (Mother and Child), EPI (Extended Immunisation Program), Nutrition and medicine dispersion as needed.
The FCMs are trained between three to five years in medical service delivery for over the counter medicines and for ensuring that primary medical services are available for the community even when the Friendship satellite clinics and hospital ships are not there. They are also the link with the government systems and thus ensures continuity of services in the communities they work in. 
This healthcare system is presently being further strengthened through the introduction of an in-house developed, smart-phone based, m-Health software enhancing the ability of the Friendship Community Medic Aides to diagnose, treat and, if need be, refer patients to another tier of the system. A satellite based telemedicine platform initiated by the Luxembourg Government in cooperation with SES, a leading satellite company, will allow Friendship to be linked with its remote working areas, enabling it to, among others, interconnect its different hospitals, and initiate remote consultations and training programs.
These technology jumps and the potential they offer stand for Friendship’s belief that “the poor cannot afford poor solutions”. Technology in and by itself will rarely provide sustainable solutions for the poor but when it is combined with strongly rooted work for strengthening communities, then it is capable of making the work much more effective and scalable. Friendship experiences the same leverage effect its Education program, where solar and IT technologies enable it to introduce secondary education in extremely remote areas.
More than 5,000 children, who would otherwise not have access to any sort of schools, attend our primary schools. The children not only follow the national curriculum syllabus, but also receive lessons on ethical standards or citizens’ rights, preparing them to be responsible citizens in future. Children from Friendship schools achieve well above average results in national exams.
In 2015, Friendship has started secondary education in 5 “chars” as a pilot model. Children from our schools who have taken the national primary examinations and passed the exams, are mostly unable to go for secondary level schooling outside their community. With the help of (in house) pre-recording of lessons by teachers of very good private schools, solar panels and computers, the Friendship secondary education is a remote educational concept to reach migratory and out of main stream students.
In addition, 1,500 adolescents and adults attend Functional Literacy classes in Friendship’s 74 schools and education centres.
Disaster Management and Infrastructural Development (DMID)
Bangladesh is on the forefront of climate change whilst being one of the least equipped to deal with it. Among the communities we serve, some people are aware about the impact of climate change while others just see changes in their lives, affecting their livelihoods in inexplicable ways. People are facing unpredictability in all aspects of their lives. We help them to face this.
For these people Climate change is not a reality of tomorrow, but of today. Floods used to come every ten years, now they come twice or thrice a year. In the coastal belt, the cyclones are now totally unpredictable. Increased salinity is negatively affecting the quality of the land. People lose their home, their land, their lives, and livelihoods. Unlike the developed world, the effects of climate change here is an everyday reality, especially in ultra-poor communities.
The DMID program works to increase disaster management capacity of remote and particularly disaster exposed populations. It trains approximately 5.000 direct beneficiaries every year on Community Managed Disaster Risk Reduction. Post disaster relief including housing and sanitation, and flood shelters are part of the programme. Additionally, 6 desalination plants have been established in salinity prone areas which can provide access to fresh drinking water to 80.000 people.
Climate change impact is far beyond just rising sea levels. For Bangladesh, it dramatically impacts the lives of more than 160 million people of a country that has an average elevation of six meters above the sea level, and where 30% of its total area is covered by rivers. Rising sea levels will mean population displacement on a mass level, thus, making the human and social impact of climate change tremendous. However, resilience and dignity is what keeps people going, and we bank on these when we go to communities with our services. We assist marginalized populations to mitigate the effects of poverty, natural disasters, and climate change through healthcare, trainings, saving plans, education, and disaster preparedness. We do not just say “do this or do that”, we actually provide direct service delivery to them to strengthen them. As our work is with migratory people thus the model is built on mobility for people who need to survive. 
Sustainable Economic Development (SED)
Friendship has created an innovative system to enable ultra-poor access finance, through a model based on risk-sharing, interlinked with leasing for capital goods, cash, clearance of debts to middlemen, training, savings, and insurances against natural calamities. It endeavours to bring in a sustainable positive change for communities by providing training, identifying employment opportunities, and creating market linkages. Through its SED program 5,700 poor farmers and fishermen are currently helped and over 1.000 Solar Home Systems (SHS) have been installed (on a leasing basis) in very poor households. Finally vocational training centres for weaving, dyeing and tailoring train over 130 women per year while currently 140 women are directly employed in those centres.
Our Good Governance program endeavours to make underprivileged beneficiaries aware of their citizens’ rights and offer them access to justice and legal services. The rapidly growing programme is presently implemented in 35 islands through its Friendship Civil Society Groups, its trained paralegals and Friendship Community Good Governance Aides. Roles and responsibilities of the local government bodies are taught and interactions between them and beneficiaries are organized.
It is worth stressing that it is only after a certain number of years of delivering effective services in the communities that Friendship initiated this program. The latter indeed strongly builds on the trust created in the communities and the demonstration, including to-wards the public authorities, that, even in remote and difficult to reach areas, effective health, educational and income generating services can be rendered in a dependable manner and with a high level of quality.
Friendship indeed doubts that advocacy and awareness raising activities alone can achieve much, where they are not combined with the promotion and implementation of effective development solutions.
In an attempt to preserve the oldest heritage of Bengal, passed down through over 5000 years of oral history, Friendship strives to save the skills of the builders of the traditional wooden boats of Bangladesh, whose craft is rapidly dying out with the onset of new technology. Our team has thus discovered and built replicas of 85 almost extinct boats, using its building techniques, and has arranged 11 national and international exhibitions to date.
The effects of the Friendship’s approach
Our programmes interconnect with each other to support an integrated approach to development. This stems from the understanding that no program can sustainably continue by trying to solve secondary needs before addressing primary ones.
Once the “step-by-step” approach was developed, it allowed the organisation to develop positive synergies in its day-to-day journey, and most importantly helped to adapt its programs to identified needs. For instance, teachers from our education system facilitate the identification of children suffering from diseases and inform the doctors.
Through the sustainable economic development program, households are able to access solar panels that allow the children to study after sunset thus, to obtain better results.
Otherwise and though, initially, Friendship was primarily a service delivery organisation, it is fully aware that governments have a prime responsibility for their citizens and that it is not for NGOs to substitute them or release them from their responsibilities. Friendship’s Good Governance program is a direct manifestation of this realisation. It remains that, for various reasons, being not always neglect, but ability, geographical or financial restraints, government services are not, at a given point of time, reaching out to certain communities. It is then for civil society organisations such as Friendship to fill the gaps till public authorities notice the conditions and are led to take over.
But for this constant interaction with public authorities is required. Close cooperation between Friendship and public authorities thus exists on many programs, such as EPI (Extended Program for Immunisation), family planning, cervical cancer prevention and treatment, introduction of the Friendship Code of ethics and child rights in government schools, linkages for governance matters, shelter guideline development, etc. Friendship’s relations with public authorities are not confrontational; nor are they complacent. They build on the belief that only cooperation and complementarity can bring matters forward for the greater benefit of the most underprivileged.
What about tomorrow?
After developing a functional, replicable model of integrated interventions, we are looking ahead to expanding our outreach. Without compromising on the quality and the essentials of our work and approach, we are looking at reaching others who need us, but we are also setting perimeters for expansion, bearing ethical values as the foremost guiding factor. We are also focusing on growth management, as our organisation has grown rapidly over the last few years. In order to manage this growth, we are now further strengthening our relationships with our stakeholders, strengthening our methodologies for replication and helping, guiding and building the ability of our institution and people across all disciplines.
|The Friendship International network: an inspiration?
In January 2006, Runa Khan took the initiative to establish “Friendship International” in Luxembourg. Whereas the choice of Luxembourg was rather circumstantial, the decision to establish a Friendship entity in Europe was a very deliberate one, taken after thorough and careful consideration. For the founder of Friendship in Bangladesh, it was about establishing a platform in Europe in order to get as close as possible to her donors and other supporters, and thereby avoid long chains of partnerships which too often dilute relationships and the related projects. Since then, Friendship International has developed into a network with local constituencies in 5 European countries (France, Germany, Luxembourg, Netherlands and United Kingdom) and regular contacts beyond.
Of course, “independent fundraising” through the network has been of major importance. Combined with strong leadership guided by a clear vision, it has strengthened Friendship’s ability to act according to its own values, principles and objectives, relying upon intermediary organisations only when there is a close match of goals and agendas. Not being “donor-driven” (while nevertheless being attentive to donor’s needs and expertise) permits Friendship to develop its programmes directly according to the needs of the communities it serves and has worked with for 15 years.
But Friendship’s international network is not only a source of financial resources. The opportunity to enter into direct relationships with a diversified range of partners, including foundations, corporates, NGOs, development agencies and private individuals, has led to organic growth of an unique platform for exchanging skills and ideas. This, in turn, has allowed the organisation to be regularly recognised as being exemplary in many respects.
Of course, having set up a network of its own, does not prevent or dispense Friendship from seeking and entering into partnerships with other organisations, including international NGOs. On the contrary, Friendship is very keen to do so where the agendas match, where partnership is intended to be more than just a word, and where there is a genuine inclination towards mutual understanding and learning. Experience shows that so-called “implementing organisations” are not always looked upon as equals in partnership and that while their familiarity with the local context and needs is often praised towards donors and funding agencies, it is not always well respected and built upon in practice. Having a certain amount of strength and independence is of major value in these circumstances. The capacity to say No where one feels that an intervention is not the right one, in the right place and at the right time, or that it is not conducted with the right mind-set, is invaluable. It also prevents damage to the organisation’s particular strength, which is the trust it has built up in the communities it serves through years of patient work.
In the preparation for the World Humanitarian Summit there is much discussion around the concept of “localisation”. An NGO from the South working directly in the field at grass roots level in particularly remote areas, it is typically classified as an “implementing NGO”. Indeed it is while at the same time, but it is much more than just that. Friendship of course very much welcomes this call for more localisation and advocates that it should be turned into reality to the largest extent possible.
This the more so because more localisation would naturally help bridge the gap that still exists between humanitarian interventions and development programmes, as local actors would deliver both humanitarian aid and development interventions in the communities with which they are involved.
It is desirable that international NGOs look beyond their short-term organisational interest and, in the light of their ultimate mandate for the benefit of those in need, express support for more direct funding of front-line NGOs of the South.
Although the Friendship model of an NGO from the South setting up its own network in the North may not be unprecedented, there do not seem to be many similar structures. The Friendship model might therefore well serve as an inspiration to others. That is not to say that this should be the only model to prevail in the future; nor that each and every organisation from the South should and could aim at setting up a network in the North. But more diversity and rather less one-way North-South intermediation with its related costs – both from a strictly financial point of view and in terms of relevance and quality of interventions – would certainly be desirable in making the sector less monolithic.
Additionally, while the call for more localisation seems to be heard with sympathy by a growing number of representatives of public development agencies, it does not at all reflect the current trend in the way the money actually flows when it comes to private and, particularly, corporate funding. There are indeed a number of factors that cause global corporates to seek global partnerships with NGOs which tend to be as global as themselves.
For organisations like Friendship, which work in a single country because they experience that this is the most efficient way of delivering effective development solutions, this comes as a real challenge. This is also because decisions on whom and what to support tend to be made further and further away from where solutions will, at the end of the day, have to be implemented.
Marc Elvinger • Chairman Friendship-Luxembourg, Co-Chairman Friendship International
It has never been my intention to build a big organisation and by no means would I like Friendship to grow for growths sake. In order to gain credibility as a model that might inspire others, a critical mass of operations is required though. Running one school is different in essence from running a hundred of them; serving 250.000 beneficiaries in healthcare a month implies a system that is working whereas bringing healthcare to 100 people a month may well be just a good deed.
With our operations having reached this “critical mass” it is certainly part of our ambitions to make the system better known within the wider development community and to have others get inspired by it, always of course subject to such adaptations as circumstances and needs may require. Flexibility, close observation of the beneficiaries changing needs as well as deep community involvement are key to the success of the model: thus, by definition, it cannot be implemented in all places and at all times in a monolithic manner. The approach, the way of doing and the mind-set behind it are the shaping factors and these are worth being adopted by others, rather than the strictly operational components.
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