Uganda: The Health of the Nation

Published online Nov. 4, 2012 in The Independent.

The Health of the Nation
By Melina Platas Izama

Since Uganda hit 50 recently, it seems as good a time as any to check its vitals. There is the heartbeat of the economy and the temperature of the masses, the pressure of the politics and the weight of history. The health of this nation in one word? Resilient.

The Jubilee celebration was not made up of unfettered jubilation, as one might expect at 50 years of independence, but instead doused with a heavy coat of introspection.

The pristine Kampala Road, captured in black and white photos, is hardly recognisable today – a bustling, grating and downright stressful stretch of earth.  Cynics wandered and wondered aloud, are we better off now than we were a half-century ago? Teachers are striking, projects stalling, health clinics leaking staff, money, and drugs. This version of events is familiar. We listen to it every morning and read it every day. Frankly, it’s exhausting.

The health of the nation is in part a function of the health of its people. And here we have some great stories to tell. The greatest story of all is the about the survival of children. In the last fifteen years, death in infants and young children has fallen by nearly 40%. The drop in child deaths was faster in the past five years than it has been in decades.  This is fantastic news.

When Uganda raised her flag for the first time, mothers across the newly birthed state could expect more than one in five of their children to perish before age five and 13% of newborns would not survive their first year. This year, as the flag was raised once more, the death of a child is not foreign, as it should be, but neither does it go hand in hand with motherhood.

The results of the most recent round of the Demographic and Health Surveys (DHS), which have been instrumental in documenting these trends, have just been released for Uganda. Conducted across the country in more than ten thousand households, the DHS has been conducted in 1988, 1995, 2000, 2006 and 2011. While there are a number of improvements to report, the story of child survival, particularly in the last decade, stands out. It is perhaps the greatest achievement of the new millennium in Uganda. Continue reading “Uganda: The Health of the Nation”

Our biggest development challenge

Published online April 11, 2012

Why solving inequality is a must for Africa’s development

In the morning young children brush their teeth outside makeshift houses as a snaking line of Range Rovers crawls by.  In the afternoon, businessmen fill cafes while street vendors peddle their goods in a sea of commuters inching towards home. In the evening, toddlers sit transfixed by flat-screen TVs while their neighbors sit playing by candlelight. We are living in a world where shopping malls are popping up alongside young boys herding cattle – a clash of peoples occupying the same space but living lives that bear no resemblance to one another.

Rarely in history have such extremes coexisted. The yawning chasm between rich and poor is palpable but not physical – lives but not livelihoods overlap. In some ways, disparities in wealth are inevitable. Countries whose average annual income is in the hundreds of dollars but whose annual economic growth soars at rates of 5% and beyond are bound to experience uneven transitions to prosperity. Access to opportunities, education, even liquidity is not even or equitable. We can’t wish away these disparities, but sooner or later, we will have to address them.

This was also the message of a keynote address by John Githongo, Kenya’s famous whistleblower, at a conference on innovations in governance a month ago at Stanford. I had heard a lot about Mr. Githongo and read Michela Wrong’s popular book, It’s Our Turn to Eat, which documented his time fighting corruption in the administration of Kenyan President Mwai Kibaki. Nevertheless, I wasn’t sure what to expect from him. I had heard so few critical words about the man that I began to become suspicious – surely he could not be as saintly as depicted! Like all of us, Mr. Githongo surely has his flaws, but I have none to report. His speech was simply exceptional.

The message? Inequality is the primary development challenge of the next few decades – inequality of outcomes and opportunities, of expectations and aspirations. Inequality is not only morally repugnant but also easy to politicize, ethnicize, and militarize in Africa, he argued.

Herein lies the real threat to development  — a new round of conflict and instability triggered by inequalities that are the product of the very economic transitions for which we strive.

Githongo likened our current state of affairs to a meeting of old and new technology. We have often been successful in getting right the hardware of the state – infrastructure, education, health – or at least making noticeable progress in these areas. However, the software, made up of political rights and freedoms, is outdated. Combining old software with new hardware is like buying a brand-new Dell laptop and loading it with Windows ’95 – it will have a blue-screen! And what follows is not pretty.

Where political opposition and mass protests have been successful at toppling regimes, there has frequently been a political hangover. After the euphoric triumph of the many over the few comes the realization that updating the software of political freedoms and institutions does not happen overnight. The end of dictatorship does not call for champagne. The inequalities that prompt regime collapse do not disappear with the despot.

The challenge of political instability provoked by inequality is particularly acute in urban areas. There are vast disparities between rural and urban populations, but it is the inequality within urban areas that seems to drive most conflict. Revolutions rarely begin in the countryside.

The hopefulness of the Arab Spring just one year ago has given way to the realization that we do not know how to cope with the mobilization of society based on inequalities, whether economic or political. Sitting governments often retaliate violently, exacerbating societal tensions that are already on the verge of a breaking point. Ordinary citizens do not know whether to join the masses in protest, run for their lives, or sit tight and wait for calm. The dominant actors on the world stage shout past each other, often rendering impotent international institutions like the United Nations.

The good news that in many places, the software is being updated, albeit in fits and starts. Coups and election violence notwithstanding, there have been gains in political freedoms across the continent. The development of the media, slow strengthening of parliaments, widespread acceptance of elections, and multitude of multiparty elections that have increasingly resulted in regime transitions are all evidence that political freedoms are far from stagnant.

Of course, just as with a computer, it is frustrating when the machinery of politics and society temporarily freezes or crashes. You lose your work, and you lose time. But if we are discouraged at the pace of progress, we have not only to look at ruling parties but also at the would-be political and social entrepreneurs who have not always put pressure on the powers that be or provided a viable political alternative. Inequality has allowed political opposition to mobilize the masses, but what comes next? Without organizational or institutional infrastructure, opposition parties and coalitions are unlikely to prove any better than the regimes they oppose.

Watching cities like Kigali or Kampala increase in size and wealth is inspiring, but the gap between the “haves” and “have nots” is also larger than ever before. Inequality will not vanish as countries grow, and may eventually impede or even threaten further progress. For this reason Githongo’s case is a strong one: inequality will be one of the greatest development challenges of this generation. I think we have the tools to avoid a meltdown. Everyone knows what Windows ’95 is a dinosaur. The question is, who is in charge of the update?

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.

inspiration: Kennedy and Maathai

As I finished reading Ted Kennedy‘s True Compass in the early hours of the morning, I also poured over the hundreds of tweets and articles about the passing of the Kenyan environmentalist and Nobel Peace Prize winner, Wangari Maathai. Both battled cancer, and both, through their life’s work and struggle, have provided inspiration to millions. As a new day, a new week, and a new quarter begins, I want to keep in mind some of the lessons, hopes, and challenges they have shared.

This is the greatest lesson a child can learn. It is the greatest lesson anyone can learn. It is the greatest lesson I have learned: if you persevere, stick with it, work at it, you have a real opportunity to achieve something. Sure, there will be storms along the way. And you might not reach your goal right away. But if you do your best and keep a true compass, you’ll get there.

Edward M. Kennedy, True Compass


The revolution I propose requires the development of policies that work for the benefit of all citizens rather than the advantage of a few. It necessitates standing up to international interests that seek access to the considerable natural resources with which Africa is blessed for less than their fair market value. It entails implementing decisions that encourage the dynamism and entrepreneurship of African peoples, protecting them from unfair competition, and nurturing economies that add value to the commodities that the rest of the world desires so much…Perhaps the most important quality that the African leadership needs to embrace, and which is desperately lacking across the continent, is a sense of service to their people.

Wangari Maathai, The Challenge for Africa