The ongoing perils of childbirth

Published online February 1, 2012.

A problem of supply in services is limiting further improvements in maternal health

Fertility rates in Rwanda have been falling steadily over the past several years, but this year close to 400,000 Rwandan women will become pregnant and give birth. Next door in Uganda, four times as many women will become pregnant, approximately 1.5 million. If recent trends hold, nearly 10,000 of these women will lose their lives during or shortly after their pregnancy. Many of them will suffer from bleeding and infections that can be treated or prevented.

Surveys show that pregnant women in both Rwanda and Uganda seek antenatal care at very high rates. Nearly 98% of women in Rwanda and 95% in Uganda have at least one antenatal visit during their pregnancy. These women want information about their pregnancy, and seek out health services that they believe will help them have healthy babies. But often the health system fails to provide these women with the information they need to take care of themselves, and far too many mothers lose their lives because they do not receive emergency care in time. Rwanda has been showing steady progress in improving maternal health, but Uganda has faired poorly.

Both Uganda and Rwanda continue to have high levels of maternal mortality, defined as the death of a woman while pregnant, or within 42 days after the termination of pregnancy (excluding accidents). Between 1985 and 1995 in Uganda, maternal mortality was estimated at 527 deaths per 100,000 live births. The following decade, from 1996 to 2006, maternal mortality was estimated at 435 deaths.Although these figures suggest a slight decrease over the past twenty years, the margin of error around these estimates are such that we cannot say with any confidence that maternal mortality rates have changed at all between 1985 and today. Thus, it appears pregnant women in Uganda today are equally likely to die in childbirth as they were 25 years ago, when the National Resistance Movement came to power.

Meanwhile, maternal mortality in Rwanda has fallen significantly, although rates in Rwanda have for some time been higher than those in Uganda. Between 1995 and 1999, maternal mortality in Rwanda was estimated at 1071 deaths per 100,000 live births, one of the highest rates of maternal death in the world. Between 2000 and 2004, however, it had dropped to 750. The most recent estimates should be available in the next year or so, and are likely to show even further decline.

Rwanda may have made greater strides than Uganda in reducing maternal mortality in the past decade or so, but both countries face significant challenges in improving maternal health. There is a long way to go. The good news is that unlike many types of preventive health behaviors, such as getting immunizations or sleeping under a bednet, seeking help during pregnancy has become very common, even natural. In other words, the demand for health care during pregnancy appears higher than for many other health issues. Unfortunately, while demand is high, supply of care during pregnancy is weak.

Although nearly all pregnant women seek antenatal services at least once during their pregnancy, not all clinics and health facilities are equipped and ready to meet their needs. In fact, most health facilities are lacking the basics when it comes to antenatal care. The Service Provision Assessment Survey 2007 found that only 31% of health facilities in Rwanda had all the items required for infection control, including running water, soap, latex gloves, and disinfectant, and only 28% had all the essential supplies for basic antenatal care, including iron and folic acid tablets, tetanus vaccines, and equipment to measure blood pressure. A mere 11% had all the medicines required to treat pregnancy complications, including antibiotics, antimalarial drugs, and medication to treat common sexually transmitted infections.

To make matters worse, very few women were given sufficient information so that they could take good care of themselves at home during their pregnancy. Only 8% of women in Rwanda were told about signs of pregnancy complications, while only 35% of women in Uganda were informed. It is perhaps not surprising that only 35% of Rwandan women and 47% of Ugandan women attend the recommended four antenatal visits. When women arrive in clinics, often without power or water, which do not provide the necessary equipment and information to help them with their pregnancy, there may be little incentive to keep going back.

Of course, the news is not all bad. On the contrary, the improvements that have been made in maternal health, particularly in Rwanda, are extraordinarily impressive. In just five years, between 2005 and 2010, the percentage of mothers whose delivery was assisted by a trained and skilled provider increased from 39% to 69%. The percentage of mothers who delivered in a health facility jumped an equally miraculous 28% to 69%. The increase in births under the watch of a skilled provider has likely played a large role in the reduction of maternal mortality. An estimated 15% of all pregnant women will encounter life-threatening complications, and trained nurses, midwifes, and physicians can help make sure these complications do not become fatal.

The fact that pregnant women appear to seek out services and information at high rates is a great opportunity for public health, but this opportunity is squandered if health facilities are poorly equipped to provide care. While Rwanda has made strides in improving the supply of care, there is less evidence of improvement in Uganda. The results speak for themselves.

Name your price: it’s your life

Published online January 25, 2012.

Why small increases in price can lead to a steep decline in demand for essential products

A piece of nylon netting is a useful thing. It can be cast as a fishing net, hung as a curtain, or draped over a seedbed as protective covering. Netting can make a stunningly white wedding dress, or even a make-shift chicken coop.

One can also sleep under it, of course, to keep mosquitos from biting at night. Though insecticide treated nets (ITNs) are routinely distributed in malaria endemic regions, often subsidized by major donors such as the Global Fund, many worry that such campaigns are frequently futile. Anecdotal evidence from the Kenyan shores of Lake Victoria to the alters of Ugandan churches suggest that these bednets are sometimes quite literally cast aside or otherwise misused.

While misuse is certainly problematic from the perspective of those funding mosquito net campaigns, it also raises a broader question, and one with serious implications for public policy in malaria prevention and beyond: Do people value and use things that are given to them for free?

There are two competing arguments used to answer this question. The first argument says that people value more that on which they spend their own money or resources. Furthermore, people will spend some money, when they can afford it, on those objects that they perceive to be useful. A second argument says that if an object is perceived to be useful or of value, people will use that object regardless of whether they purchased it or whether it was given to them for free. The ubiquity of incumbent presidents’ campaign t-shirts in both opposition and stronghold areas is supporting evidence for those in the latter camp.

The mosquito net-cum-wedding dress is a classic illustration of the dilemma of freebies. The protective power of mosquito nets against mosquito bites and thus, malaria, is rather less effective when the net becomes a nuptial adornment or is tossed into a river, much less left in its packaging and stashed in a corner. The creative use of nets is thus often the go-to anecdote for those in the first camp of the freebie question.

Anecdotal evidence, unfortunately, can only get us so far in adjudicating between these two perspectives. Fortunately, a number of development economists have been systematically evaluating the extent to which people use services or tools given to them for free and those provided at a cost. While there is still no definitive answer, and while context matters, much of the evidence seems to suggest that people use many free goods at high rates, and often will not purchase the same products when provided even at very low prices.

A group of researchers at the Abdul Latif Jameel Poverty Action Lab, based at the Massachusetts Institute for Technology (MIT), recently wrote a report summarizing ten studies examining the question of whether user fees and cost-sharing increase or decrease the use of health and education services and products. The majority of the studies were conducted in Kenya, although some were also conducted in Uganda, Zambia, and India. Their findings are striking, and the title of the report says it all: “The price is wrong.”

Time and again, small increases in price lead to a massive decline in demand for products including water disinfectant, deworming medicine, mosquito nets, and soap. For example, one study in Kenya found that while over 80% of people used a mosquito net if they received it for free in a prenatal clinic, only 20% would purchase the net for $.60 (approximately 50 Kenyan shillings or 360 Rwanda Francs). Similarly, another study in Kenya found that while nearly 60% of people used water disinfectant when it was given to them for free, less than 10% would use disinfectant if charged $.30 for the same product. This general pattern appears to repeat itself in different locations and with different products.

Two things are thus evident. First, people are often unwilling to purchase a number of goods and services that promote health and education even at highly subsidized rates. Second, people often use those same goods and services at high rates if they are provided for free. Clearly, receiving something for free does not preclude its use. If we think back to the wedding veil problem however, it is also clear that some products may not be used as prescribed, fee or no fee.

Why are people so sensitive to price when it comes to potentially life-saving goods and services? Individuals and families weigh the costs, monetary or otherwise, of procuring and using goods and services against the expected benefits from using those goods. Bednet wedding veils notwithstanding, in most cases it appears that families perceive some benefit from using goods like mosquito nets and soap, since rates of usage are quite high when the product is free. Some speculate that people may not physically have the cash on hand to buy even very inexpensive products, or that other inconveniences, such as the time it takes to procure a product, may affect their decision. But these are only partial explanations. It is also possible that people do not believe products will be as efficacious as researchers and policymakers think they will be in promoting their health.

Available evidence suggests that people who receive goods and services for free often do use them, although the extent to which they will use them and how they will use them is subject to some debate. Even if there are large benefits to providing free bednets, water disinfectant, soap and the like, products that often provide benefits that extend beyond the individual recipient, the question of sustainability comes to the fore. In the short term, the provision of free goods and services, particularly those that promote preventive health behaviors (like hand-washing) may have large and positive effects on the health of families and communities. But ultimately, we need to better understand why people are often so unwilling to spend even small amounts on products that have the potential to keep their families much healthier.

Rwanda’s next president

Published online January 16, 2011.

There was quite a kerfuffle following President Kagame’s last visit to Uganda in December 2011. The hoo-ha that played out over the airwaves, news pages and Twitter had nothing to do with the trip per se – relations between Presidents Kagame and Museveni have been warming over the past six months and such visits are becoming the norm – but rather with repeated questions about presidential term limits in Rwanda. Amending the constitution to lift term limits is a relatively new trick in the handbook of institutional manipulations. President Museveni, together with the Ugandan parliament, steamrolled right through term limits in 2005, paving the way for a 30-plus-year reign for the former rebel leader. By the time Uganda marks its Jubilee in October of this year, just a few months after Rwanda’s 50-year celebration, Yoweri Museveni and the National Resistance Movement will have held power for over half of the post-independence period.

Whether or not Kagame will attempt to follow in the footsteps of Museveni and lift term limits in advance of the next presidential elections in 2017 is a tired argument. Personally, I doubt that he will do so, but neither do I think it would be at all a difficult task. But that is neither here nor there. Just as there will be a South Africa without Nelson Mandela, there will be a Uganda without Museveni and a Rwanda without Kagame. Though there will undoubtedly continue to be discussion regarding Kagame’s candidacy up until 2017, ultimately the more productive debate is the extent to which promising and talented individuals have opportunities today to become tomorrow’s leaders.

I’m not going speculate who the next president will be, but I’d like to float the idea that Rwanda’s next head of state will be a woman. Rwanda has led the way in bringing women into politics and positions of power, and women around the world are making inroads every day into politics, business, academia, and beyond. As in Uganda’s National Resistance Army and Movement (NRA/M), women have held key positions in the government and party of the Rwanda Patriotic Front (RPF). The presence of women in politics has been steadily increasing since 1994, and in 2003 Rwanda joined Uganda, Namibia, Mozambique, South Africa, and several other countries in implementing a gender-based quota for legislative seats. In the 2003 election, women won nearly half of all seats in the legislature.

Women have also been well represented in other areas of government and civil society in Rwanda, and have played key roles in rebuilding society in the aftermath of the genocide. Many women have been elected gacaca judges, and women groups have worked to address a wide array of issues, from health to microfinance. As of 2008, Rwanda is home to the only majority female parliament in the world. Women today hold several key ministries, including the Ministry of Foreign Affairs (Louise Mushikiwabo) and the Ministry of Health (Agnes Binagwaho), as well as senior management positions in institutions such as the Rwanda Development Board (RDB). And regardless of your view of her, Victoire Ingabire has emerged as the figurehead of the official opposition in Rwanda.

While women representatives do not alter policy or the playing field overnight, research suggests that women’s participation in politics has the potential to affect both policy and perceptions about women’s abilities. Studies in India found that local politicians invest in public goods that are most important to their lives, and that types of investment differ by gender and location. For example, women tend to invest more in drinking water than their male counterparts. In Rwanda, women parliamentarians have been credited with pushing for the reform of laws regarding issues such as inheritance, discrimination against women and sexual assault.

In addition to the possibility of affecting policy outcomes, some research shows that the presence of women in politics helps to alter perceptions and prejudices about women’s ability to lead and govern. A group of researchers from the US and India found that where women in India held elected positions in local government, initially with the help of gender quotas for these positions, men tended to hold less negative stereotypes about the efficacy of women in positions of authority.

Additionally, exposure to female leaders tended to increase people’s perceptions of women’s abilities over time. Although community members may rate poorly the first woman elected to a position, her successor would generally be rated more favorably. Exposure to women in politics, at least in some settings, appears to reduce negative stereotypes about women’s abilities to govern, and will likely encourage more women to enter the ring.

In Rwanda, many women have had opportunities to develop the skills and experience to lead. While the debate on term limits rages on, it is important to think beyond personalities—however formative or influential—and focus on the processes through which leadership is reproduced. Rwanda’s political system, its many flaws notwithstanding, has allowed women to participate in government and policymaking to a greater extent than in many other countries. These opportunities for leadership will help shape the next generation and next era of Rwanda’s history. It would not be surprising, therefore, if Rwanda’s next president comes out of this network of powerful and promising women leaders.

Women’s leadership in Rwanda has evolved alongside the innovative approaches the country has tested in its recovery from conflict. Like other challenges Rwanda faces, both general and gender-specific, from poverty to maternal mortality, it is to processes and not individuals that attention should be paid.  Despite urgent challenges, real opportunities exist for ordinary citizens, men and women alike, to grow up in good health with a good education. The impact of public health and education policies on Rwanda’s political development may not be obvious now, but will eventually become evident. The democratic space in Rwanda is still being tested and shaped, discussed and critiqued, pushed and pulled. Ultimately the future lies not with an individual, but with a system that allows the next generation of leaders to emerge.

Explaining health behavior

Pascaline Dupas has an excellent paper in the Annual Review of Economics: Health Behavior in Developing Countries. It’s well worth reading. Conclusion below:

Good health is both an input into one’s ability to generate income and an end in itself. As such, it is not surprising that a relatively vast literature is devoted to understanding the determinants of health behaviors. This literature has recently expanded to the study of health behaviors in low-income settings, for which good data are becoming increasingly available. This review is too short to be exhaustive, but it tries to present the most compelling evidence to date on this issue. The important thing to take away from this review is that when it comes to health behavior in developing countries, there are a substantial number of deviations from the neoclassical model. First of all, people seem to lack basic information, and sometimes have limited ability to process information, because of low education levels. Second, there are market imperfections and frictions, especially credit constraints, affecting people’s ability to invest in health. Finally, there seem to be some deviations from the rational model, with, as has been widely shown in developed countries, a nontrivial share of people exhibiting time-inconsistent preferences as well as myopia.
Overall, this suggests an important role for public policy when it comes to health. Above we identify four important demand-side policy tools: information, mandates, price subsidies, and financial incentives. All appear to have the potential to increase the sustained adoption of preventive behavior. But the success of these demand-side strategies is contingent on the supply side being adequate: on health services and products being available, with delivery and/or enforcement institutions that are effective. The issue of how to improve service delivery in health is outside the scope of this review, but it has been the focus of a number of recent and ongoing studies that will soon need a review of their own.

Gender and Development

A topic worth exploring. From the 2012 World Development Report, Gender Equality and Development:

The lives of girls and women have changed dramatically over the past quarter century. Today, more girls and women are literate than ever before, and in a third of developing countries, there are more girls in school than boys. Women now make up over 40 percent of the global labor force. Moreover, women live longer than men in all regions of the world. The pace of change has been astonishing—indeed, in many developing countries, they have been faster than the equivalent changes in developed countries: What took the United States 40 years to achieve in increasing girls’ school enrollment has taken Morocco just a decade.

In some areas, however, progress toward gender equality has been limited—even in developed countries. Girls and women who are poor, live in remote areas, are disabled, or belong to minority groups continue to lag behind. Too many girls and women are still dying in childhood and in the reproductive ages. Women still fall behind in earnings and productivity, and in the strength of their voices in society. In some areas, such as education, there is now a gender gap to the disadvantage of men and boys.

The main message of this year’s World Development Report: Gender Equality and Development is that these patterns of progress and persistence in gender equality matter, both for development outcomes and policy making.

Analyzing Africa: The Audacity of Despair

A new, defiant image

Published online at The Independent, Rwanda Edition, December 17, 2011

In 2000, the cover of The Economist pictured a boy wielding an AK47 inside the outline of the African continent, surrounded by black. “The hopeless continent,” the cover ominously read. At the time a combination of factors led the magazine and a whole host of bystanders to throw up their hands in despair, and mentally close the door to hope for the future of “Africa.” A decade later, The Economist, whose cover this week reads, “Africa rising” and many others, are waking up, wide-eyed, to realize the tremendous growth and progress that has been taking place on the continent all along. Progress has not been even, or without crushing reversals along the way. But given the history of development across the globe, it is entirely unclear why we should have anticipated linear progress, or lament its absence. Political, social, and economic development will carry on with or without handwringing at one extreme, or ululations at the other.

There have been at least two common mistakes in assessing progress (or the lack thereof) in “Africa,” which together have made for some rather wrongheaded analyses. First, there is a danger in conflating levels of development with development itself. It is obvious to all that levels of per capita income, education, and mortality, for example are lower on average in Africa than anywhere else. The issue of levels, however, is entirely different from change over time. Contrary to popular belief, improvement in both human and economic development was occurring in Africa before the dawn of the new millennium, just not everywhere. This leads me to the second analytic pitfall – the “Africa is a country” problem.

It is obvious to all that Africa is not a country but a continent, but analysis nonetheless often treats Africa as if it were one political, economic, or social unit. It is not. There is tremendous variation across the continent in both levels of development and rates of improvement over time. A failure to acknowledge the divergent paths countries have taken leads to the kind of essentialisation one tends to regret.

It is all too easy to essentialize. The mind recalls the most extreme cases, and remembers those that support prior beliefs. So in 2000, near the height of the HIV/AIDS epidemic, with flooding, drought, the Second Congo War, political crisis in Sierra Leone and a waffling UN Security Council, it was easy to create an image of Africa that was tearing itself to pieces. “Africa was weak before the Europeans touched its coasts. Nature is not kind to it,” wrote The Economist. “This may be the birthplace of mankind, but it is hardly surprising that humans sought other continents to live in.” Ouch.

As noted, it is true that levels of development, that is, income per capita, literacy, infant mortality, and many other measures of development, are comparatively far lower in sub-Saharan Africa, but all of this ignores the changes that have been taking place. In the 1990s, for instance, despite much pessimism, a number of countries held multi-party elections, a wave that started with Benin in 1991. While these countries would not become flourishing liberal democracies overnight, the 1990s would mark the beginning of the end of dictatorship as we know it.

There was also an effort to improve access to education, and the percentage of children completing primary school grew in a number of countries, including Benin, Burkina Faso, Cape Verde, The Gambia, Guinea, Guinea-Bissau, Liberia, Mali, Malawi, Togo, and Uganda, albeit occasionally starting at very low levels. Gains in education were not achieved everywhere, and schooling declined in some countries, but this fact only further demonstrates the variation in performance across African countries.

The best news is that although improvement in education varied, improvements in health over the past several decades have been nearly universal. Since 1960, child mortality has fallen in every single African country for which there is data, with the possible exception of Somalia. Even in a country like the Central African Republic (CAR), notorious for its poor governance, under-5 mortality fell by half over the past fifty years, from 300 to just over 150 deaths per 1000 births. In 1960, just over one in three children born in CAR would not live to see their fifth birthday; today six out of seven will survive childhood. Moreover, in spite of the devastating HIV/AIDS pandemic, which has claimed millions of lives, the hardest hit African countries are rebounding, and child and maternal mortality rates are again declining in countries like Botswana, Namibia, South Africa, and Zimbabwe.

Economically, the performance of African countries has been diverse for decades, with some countries consistently growing and others wallowing in economic misery. A number of African countries experienced periods of negative economic growth throughout the 1970s, 1980s, and into the 1990s, which, along with population growth throughout, meant that several had the same or even lower levels of per capita income in the 1990s than they had at independence.

Still, many countries began to see positive economic growth in the 1990s or earlier, including countries as diverse as Angola, Burkina Faso, Cameroon, Congo (Brazzaville), Ethiopia, Ghana, Guinea, Mali, Mozambique, Rwanda, Senegal, Uganda, and Zambia. Some of these economies are reliant on commodities such as oil and minerals, but service and other sectors comprise an increasing share of the economy in many countries, and regional trade has grown as well.

Average levels of development give Africa a bad name, but initial conditions were different from most of the rest of the world, and rates of improvement have often equaled or exceeded those in the developed world. As interest in Africa is piqued by double-digit economic growth figures and opportunities for investment, we will continue to see discussion of a part of the world most people inadvertently essentialize. Fortunately, I think the audacity of despair that has pervaded western thinking on Africa has left little in its wake other than egg on some faces. The audacity of hope has now come to the fore.

HIV in colonial Africa

Online this week in The Independent (Rwanda Edition): How public health efforts likely contributed to the early spread of HIV.

The Tragic Amplifier

Published online December 8, 2011.

This year marks the 90th anniversary, approximately, of the introduction of human immunodeficiency virus (HIV) into the human population. It also marks thirty years since HIV was first scientifically recognized in 1981. Since the 1920s, this virus has spread across the globe and become the HIV/AIDS pandemic we are all too familiar with today. Most people consider the 1980s to be the beginning of the HIV/AIDS pandemic, but the virus had been prevalent in populations living in parts of central Africa for decades before it became a global nightmare.

New evidence from epidemiologist and international health expert Jacques Pepin suggests that human efforts to improve public health in central Africa were critical in facilitating the early spread of HIV, which has since claimed nearly 30 million lives. In the past two decades, massive coordination, mobilization, innovation, and investment have managed to slow the epidemic and save millions. As we mark World AIDS Day on December 1, 2011, HIV/AIDS is a reminder to us all of the tremendous power of human folly, but also of human triumph.

The Origins of AIDS, by Pepin, is a remarkable new book that pieces together the emergence of HIV in the human population, and its subsequent spread across the globe. HIV is the human version of simian immunodeficiency virus (SIV), which has been present in chimpanzee populations of central Africa for hundreds of years. Human contact with chimpanzees led to at least one transmission of SIV to HIV in a human in the early 1920s, most likely a hunter or a cook living in central Africa, where the majority of SIV-carrying chimpanzees live. This transmission alone was extremely unlikely to have triggered an HIV epidemic, and indeed chimpanzee-to-human transmission could have occurred on separate occasions prior to the 1920s, but would not have spread far. An infected hunter may have passed HIV to his family members, but in all likelihood, the virus would have stopped there. Why did HIV begin to spread beyond a few infected individuals in the early 1920s?

Pepin argues that heterosexual transmission, which is the predominant mode of transmission of HIV today, could not alone have led to an outbreak of HIV on a scale that would trigger a pandemic. Thus, there must have been some kind of “amplifier” that allowed for very rapid transmission of HIV to many people at a time. And what was the mostly likely initial culprit in the amplification of the virus? Colonial public health campaigns involving widespread use of unsterilized syringes and needles.

In the 1930s and 1940s, colonial administrations in French Cameroon, the Belgian Congo, and elsewhere began massive public health campaigns to treat various infectious diseases, including yaws, syphilis, malaria, leprosy, and sleeping sickness, using syringes and needles which were not sterilized regularly, if at all (oral tablet versions of treatments were not available for these diseases at the time). Although there are no blood samples from this time period still in existence (the oldest blood sample in which HIV has been detected dates back to 1959, taken from a man living in Leopoldville, Congo, now known as Kinshasa), it is well documented that other less lethal viruses, like Hepatitis C, were transmitted via syringes in Cameroon, Gabon, and the Belgian Congo, among other colonies. It is not difficult to imagine that HIV could have been passed quickly through a population via syringe as well.

One clinic to treat sexually transmitted diseases (STDs) in Leopoldville treated up to 1000 patients a day by the mid-1950s, with documented evidence that medical equipment was not sterilized between patients. To make matters worse, HIV was likely introduced into Leopoldville/Kinshasa at a time when there was a dramatic gender imbalance due to colonial policies. Urban areas like Leopoldville were often the equivalent of “work camps” in which wives and children were not welcome, which resulted in widespread prostitution, further facilitating the spread of HIV through heterosexual transmission.

HIV, which first spread through non-sterile syringes, often in clinics aimed at treating sexually transmitted diseases among men and sex workers in urban areas, kept at a steady prevalence through heterosexual transmission among the same population. In the colonial period, female sex workers, or “free women”, had only a few regular clients each year, but by the time of independence, female prostitutes would often see up to 1000 clients per year. This new type of prostitution greatly facilitated the transmission of HIV to populations beyond urban areas, and spread along major trades routes and cities in central and eastern Africa, including Kigali.

By 1984-85, Kigali, which at the time had a high ratio of males to females, and thriving prostitution, had the highest recorded HIV prevalence in the world, with 80 percent of prostitutes, 50 percent of STD patients, and 15-20 percent of blood donors, factory workers, and hospital employees testing positive for HIV. By 1987, HIV prevalence was at 17.8 percent in urban areas and jumped to 27 percent in urban areas by 1996.

From central Africa, HIV soon spread to Haiti, before being transmitted via multiple routes to the United States and beyond. Today, 34 million people are living with HIV/AIDS, and another 29 million have perished. That the spread of this virus was likely facilitated, and perhaps only possible, with the help of human technology and early public health campaigns should give us pause, and remind us of the terrifying potential for destruction due to human folly. As Pepin writes, “When humans manipulate nature in a way that they do not fully understand, there is always a possibility that something unpredictable will occur.”

Turning the tide on the spread of HIV/AIDS has taken decades, and millions have tragically lost their lives in the process. But the HIV/AIDS epidemic also demonstrates the amazing power of human innovation and cooperation that can take place on a global scale. Today, there are 6.6 million people receiving life-saving antiretroviral treatment, and both AIDS-related deaths and new HIV infections are declining in most parts of the world. The time, research, energy and money that have gone into tackling HIV has been phenomenal. If anything, we are now in danger of devoting too few resources to other health challenges that must also vie for the attention of the global health community and domestic health budgets.

HIV/AIDS is an extraordinarily painful reminder of the good intentions that can pave the road to hell, and of the unique capability of humans to create as well as destroy.

Beyond the State: Letters from Gulu

Apologies for the extremely sparse posting of late. I have just returned from a trip to Central America, including Belize, Honduras, and Mexico, which I’ll post more about soon. In the meantime, I’d like to share the first edition of a weekly column I began writing for the Independent (Rwanda edition) three weeks ago. I’ll be posting these weekly after they are published online. I look forward to your comments and feedback.

Beyond the state: letters from Gulu

Published online November 23, 2011

Health care, education, basic infrastructure, and security are some of the services the modern state seeks to provide. The success of states in delivering these goods to their far-flung populations, especially in the midst of conflict or under severe resource constraints, is quite variable. In recent years, for example, Rwanda has been lauded for implementing a health insurance scheme that covers all Rwandans and offers them a range of health services, while the reach of the state in countries like the Democratic Republic of Congo or South Sudan is much more limited. While there are important lessons to be learned from the success of the Rwandan state, which has proven itself unusually efficacious in a number of sectors, it is all too easy to overlook the ways in which information and innovation flow alongside the state, and often in spite of state failures. Tremendous opportunity lies beyond the state.

I recently unearthed letters given to me in mid-2005 by a group of primary school students in Gulu, northern Uganda’s largest city, illustrating this point. At the time, to cross Karuma Falls, where the Nile cuts the land like a scythe, was to enter a world far removed from political drama unfolding in Kampala. While Ugandan President Museveni was jostling for the removal of term limits in the capital, the terror of the Lord’s Resistance Army (LRA) in northern Uganda was still unfolding, though nearing its final days. The river dividing north from south might as well have been an ocean.

The reach and strength of the state was limited. Getting to Gulu from the capital carried its risks – tarmac fell away at the edges of the road much of the way from Kampala to Karuma, rebels lingered somewhere north of the Nile, and reaching the environs beyond Gulu was an even greater challenge. The state could not guarantee security, much less provide quality public services. Then Prime Minister, Apolo Nsibambi, in charge of public sector management, did not even set foot in the north until the mid 2000s, more than five years into his term.

When I first received the letters, I was struck by the violent images many of the children in Gulu could portray with a couple of pens and a piece of paper. Looking back, however, more striking than these images are what these youngsters wrote. “Too many children one after the other”, wrote a young boy named Geoffrey. “If a woman is not allowed to rest between children, her reproductive system can be harmfully affected, and her children will not be properly cared for”. Another, Solomon, carefully printed Ghanaian Nobel laureate Raphael Armattoe’s poem, “The Lonely Soul”, word for word. Others wrote about the effect of AIDS on their community, and a young boy named Kenneth drew a picture of “Cent 50”, the American rapper.

These letters illustrate not the failure of the Ugandan state in the north, which had evidently been unwilling or unable to stop the marauding LRA for nearly twenty years, but rather the porous nature of society, and the tremendous opportunities that lie outside the state. These students demonstrate not the dismal quality of Uganda’s educational system in an insecure region, but rather their ability to utilize the resources at their young fingertips. At ages seven to ten, they shared information about child spacing, antenatal care, infertility, the spread of infectious disease, poetry, and American pop culture. Through what channels did they initially access this information? Through school and formal state structures? Possibly, though these are likely to be only part of the story. How can we use these channels, whatever they may be, to further promote innovation and the spread of information?

Our approaches to improving public health and education have often focused on things we can touch and see – a health center, a new classroom, an operating table, a chalkboard – but ignored the social networks and flow of information that do not respect administrative boundaries and are not tied to specific politicians and policies. This bias is in part due to the fact that physical infrastructure is highly visible, and as such, plays an important role in politics. It is much harder to see the networks of common knowledge than it is to see the building of walls. It is easy to undervalue and difficult to use that which we cannot see, at least politically. We tend to privilege infrastructure over information.

How do we take advantage of the vibrant flow of information today? How can we better understand the channels through which it flows – through communities, families, churches, mosques, media, and even music? The state is not the only, or even primary, conduit of knowledge with the potential to improve health, for example. The formal structures of the state and public service provision often seem to fail us – absenteeism among civil servants, rampant corruption, poor policy implementation – but the social structures that connect society have the potential to fill in the gaps.

What is remarkable is not how far we have to go in ensuring a minimum standard of living, which can seem like a daunting journey, but how far we have come, even in the midst of conflict and severe resource constraints. The state can and should play an important and perhaps guiding role in providing public services, but we should also try to understand and take advantage of the opportunities to improve health, education, and other social services already at our fingertips.

Does results-based financing in health work?

I’ve been reading “An overview of research on the effects of results-based financing,” published by the Norwegian Knowledge Centre for Health Services, which discusses ten reviews of RBF schemes in low and middle-income countries (LMIC). What did they find?

  • “Conditional cash transfer (CCT) programmes have been found to be effective at increasing the uptake of some preventive services which were already free.”
  • “The success of CCT depends on the existence of effective primary health services and local infrastructures.”
  • “Although financial incentives are considered to be an important element of strategies to change professional practice, there are relatively few well-designed studies and overall the evidence is weak.
  • “A small number of more rigorous evaluations have examined relatively simple preventive interventions, such as the impact on rates of immunizations and screenings, as opposed to more complex interventions. The success of a financial incentive is likely to be inversely related to the complexity of the tasks it seeks to motivate.”

Overall, it appears the quality of evaluation of RBF schemes has been relatively poor. The available evidence suggests we need to look more carefully at the (perhaps very specific) conditions under which RBF can work. I’m afraid RBF might not work well in the public sector in the absence of fairly strong government support and political commitment to the project. But that is something to be explored…

Uganda’s entrepreneurs

In Uganda it seems like everyone and their mother (I do mean that literally) has their own business. In fact, the 2010 Global Entrepreneurship Monitor Report on Uganda finds that 31 of every 100 working age Ugandans are involved in some kind of entrepreneurial activity, making Uganda the 6th highest in terms of entrepreneurship out of the 59 countries surveyed.

Interestingly, there appears to be a strong relationship between GDP per capita and entrepreneurial activity, as can be seen below.

Source: 2010 GEM Uganda report, page 32. Download here.

So what does this mean?

High TEAs [Early Stage Entrepreneurial Activity] are mainly registered in developing countries. And there’s a group of scholars that have argued that the greater the poverty, the higher the TEA of the country concerned. GEM Uganda team does not wholly agree with these scholars as its number of entrepreneurs motivated by opportunity is also high and so is that of Ghana, Zambia and Angola.

Although the team believes that necessity is a factor in Uganda’s high TEA, some entrepreneurs are keen to pursue business opportunities in the country. The positive relationship between economic growth and entrepreneurship is unquestioned; it is the causality, the measures used, and the role of the state that need to be explored further.

I’m curious about the relationship between the Doing Business scores and entrepreneurship as well. I would imagine that while it may be difficult to set up a business formally (i.e. following all the rules/wading through bureaucracy) in countries like Uganda, the relative lack of regulation encourages entrepreneurs to try their luck in business, especially in the informal sector.

Your thoughts?

%d bloggers like this: