Tag: Rwanda

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The King and Queen-makers

Published online February 28, 2011

Driving through the countryside or city streets in Uganda or Rwanda, one is greeted by the same sight over and again – children. Youngsters in colourful uniforms fill the sidewalks and paths every morning and afternoon as they trek to and from school.

Jogging in the early morning down Kigali streets I have more than once been embarrassingly out-run by little girls in dress shoes and backpacks, screeching gleefully as they dash past. Meanwhile, the smaller children toddle curiously around the home, and babies find themselves securely strapped to the backs of their busy moms. You don’t have to look up demographic figures to know that one word characterizes the population: young.

In a region long defined by civil war, violence and dictatorship, youth is the new and hopeful quality permeating society. The wars that wracked the region for the past several decades have drawn to a close, one by one – the Ugandan civil wars of the 1970s and 1980s, the 20-year terror of the Lord’s Resistance Army in Northern Uganda, the Rwanda genocide of 1994, and the Congo wars that followed. As the worst episodes of violence recede, how will newfound security affect the political, social, and economic opportunities and beliefs of the new generation? How will the youth relate to the decisions of leaders whose lived experiences are increasingly distant from their own?

The children and young adults of today will live profoundly different lives than those of their parents and grandparents. While conflict continues in eastern Congo, a peace and cautious hope has come to most of the region. Nearly half of Rwanda’s population today was born after 1994. 52% of Rwandans and 61% of Ugandans are less than 20 years old. Nearly three quarters of all Ugandans have lived under President Yoweri Museveni for their entire lives.

Most Ugandans and Rwandans, therefore, know only stories of the terrible wars that once ravaged society. The scars, visible or not, are everywhere, but the memory is increasingly derived from history passed down by those who lived through it. As these children come of age, they face very different challenges than their parents before them. The vast majority will attended primary school, and will read and write in English. Many will graduate from secondary school, and an increasing number will obtain a university degree. Unlike their parents, most will not fear for their lives, but for their livelihoods.

Yet for now, those who govern the countries in which these children grow up – individuals who were intimately involved in the conflicts of the past several decades – continue to make calculations, judgments, and risk assessments based on the experiences through which they have survived, as have done leaders before them. National security is at the top of the agenda for every government, but the price one is willing to pay for security is shaped by experience. For the older generation, there may be no price too high. For the younger generation, the choices may not be so clear-cut.

It is difficult to assess the extent of the divide between today’s youngsters and the generation that preceded them. Often votes are a good indication of political and policy preferences, but the post-conflict generation is only just coming of age. Surveys too can help, but ultimately we are left to some speculation.

Recent surveys in Rwanda show that both the young and old continue to place a high value on national security. Overall, 44% of Rwandans said that “strong defence forces” should be the top national priority, with a similar percentage across all age groups, according to the World Values Survey. In the U.S., by contrast, while 38% of all Americans surveyed believe strong defence forces is the most important national priority, only 20% of those under 30 list national defence as the top priority. The vastly different security challenges facing each country have surely shaped these preferences.

In Rwanda, an extraordinarily large percentage of people not only support strong defence forces as the top national priority but would also contribute to this goal – 95% of all Rwandans and 96% of 15-29 year-olds surveyed said they would be willing to fight for their country. In the U.S., only 41% of 15-29 year-olds were willing to do so. 91% of Rwandans also expressed a preference for greater respect for authority in the country. All this suggests that so far, there is little evidence of a generational difference in security preferences. Nevertheless, it is important to keep in mind that most of the peacetime generation is still too young to be included in any survey. We are likely still observing the preferences of an adult population for whom the remnants of conflict may still be too fresh, and continued violence in eastern Congo too close.

In Uganda, evidence is mixed regarding whether the old and young have different preferences when it comes to national priorities, but there appear to be greater differences than in Rwanda. There are obviously serious economic challenges facing Ugandans, which may trump security concerns for the ordinary citizen — 64% of 18-29 year-olds were unemployed in 2008, according to an Afrobarometer survey. For most Ugandans, “improving economic conditions for the poor” is the most important national priority. Only 17% of 18-29 year olds listed maintaining order in the nation as the highest priority. Interestingly, young people expressed greater fear of political intimidation or violence than the very old in Uganda – 36% of young people said they had “a lot” of fear of political violence. And worryingly, the majority of Ugandans believe political competition often or always leads to conflict.

Uganda and Rwanda are both societies in transition  — transition away from conflict, transition toward greater political participation, transition out of poverty. How today’s children will view the behaviour and policies of leaders whose life experiences are increasingly distant from their own is yet to be seen. It may be too soon to detect generational differences in any scientific way, but ready or not, the youth bulge is coming into its own. Young people already make up the lion’s share of the population in the region. In just a few years they will be the king and queen-makers, or breakers. Watch this space.

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The UNSC: Performance and Perceptions

Published online February 16, 2012.

The actions (or inactions) of the United Nations elicit varied reactions. Supporters hold the institution in high esteem, and believe it has the power to promote peace, human rights, justice, and social progress, as the preamble of its charter suggests. Even the most ardent enthusiast will admit that the UN is not a perfect institution, but argue instead that it is as close to a functioning world government as we can hope for in this period of our history.

To others, the UN is a bumbling, impotent and ineffectual player in the realm of international relations. It is an expensive bureaucracy that both overreaches and underperforms. Critics cite inaction during crimes against humanity on the one hand, and intrusion of state sovereignty on the other. They argue that decisions are dictated not by the community of nations but the community of a few superpowers.

On either side of this chasm, and everywhere in between, are people who do not understand how the organization works. What most people see, if they see anything at all of the UN, are its loud condemnations, the roaring silence of its passivity, or its troops scattered across the world’s “troubled” spots.

The future of the organization depends not only on its performance, but also on global public opinion. The recent failure of the United Nations Security Council (UNSC) to back the Arab League-sponsored resolution on Syria brings to light afresh the challenges the organization faces. The halting process of decision-making at a time when hundreds of Syrian civilians are being slaughtered by the Assad regime is reminiscent of past faltering by the Council. Inability to gather consensus on resolution wording, much less action, has hampered the UNSC on many occasions.

UN intervention during the Rwandan genocide is only the most vivid example of a lumbering bureaucracy with at least as many interests as members stumbling at the feet of those who clamor for its attention, resources, and even salvation. An excruciating recollection of the events of the UN’s behavior in 1994 calls our attention to the power of a few words. What is said and not said, done or not done, leaves a mark on history, on leaders, and on ordinary citizens that cannot be removed.

It is not at all surprising, therefore, that according to the World Values Survey, only 8% of Rwandan respondents thought that policies regarding international peacekeeping should be handled by the United Nations. The remaining 92% thought peacekeeping should be handled by national governments or regional organizations. This response varied drastically from almost all other countries surveyed. On average, nearly 50% of people in nearly 50 countries around the world thought the UN, and not regional organizations or national governments, is best placed to handle international peacekeeping. Rwanda’s experience with peacekeeping operations has clearly damaged trust in the UN in this arena.

On the other hand, a greater percentage of respondents in Rwanda than in any other country think the UN is best placed to handle refugees. Only 10% of Rwandans thought national governments should handle policies related to refugees, while the vast majority, 73%, thought the UN should handle refugees. Meanwhile, 32% of respondents from all other countries thought national governments should handle refugees while only 48% thought the UN was best. A more thorough investigation could uncover the extent to which first-hand experience with the UN intervention, in all of it various forms, shapes public opinion regarding what the organization can and should do.

In the meantime, the most recent failure of the UNSC to come down firmly on its position towards a regime that is clearly brutalizing its population raises questions about the limits of an international institution whose explicit and primary goal is world peace. It is precisely the collapse of these talks that chips away at people’s faith that the UN, or any organization for that matter, can promote peace in any way beyond that which is lip service.

Students in a class I am helping teach this term learned this lesson the “hard” way in a UNSC simulation last weekend. For two days the fifteen delegations, made up of at least some students who are destined to be diplomats and policymakers themselves one day, met to draft and pass a resolution on the international community’s response to Iran’s nuclear program. They took turns making statements to the council, drafting the resolution, and debating each word and paragraph. It soon became apparent that delegations were not all equal. The permanent five (P5) had the unique power to make or break a deal. After nearly twenty hours of debate, the council came to the final vote.

In a bizarrely parallel universe to the actual meeting and vote of the UNSC taking place the same day, the students’ resolution was vetoed by China, a member of the P5. A collective “boo!!” filled the room. But it was over. After days of work, side deals, compromises, and urgent pleas, the resolution had failed. Meanwhile, in New York, the real Chinese and Russian delegations killed the Syrian resolution. The palpable disappointment of the students was only a whisper of the hundreds of disappointments, much larger and all too real, of both UN action and inaction.

Those who have been burned before, in ways small or large, have no choice but to alter their behavior domestically and make do with the politics in New York. The UN has proven time and again that it is not an organization that leaders or publics can rely on when times get tough. Whether or not a resolution can be reached depends not only, not primarily, on the gravity of the situation at hand, on the peril at which lives are placed, or on the number of lives in danger. Instead, alliances, precedents, and power creep into the corners of debates between great and small countries, and the diplomats that represent them.

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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.

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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.

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What is the (global) village gossiping about?

What is the (global) village gossiping about?

Published online December 22, 2011.

Accessing people’s thoughts and interests from Asia to Africa is just a click away

It used to be that education primarily took place in a classroom. These days, the chalk and blackboard are fading away and steadily being replaced, or at least complemented, by new technology. Even in some of the world’s hardest-to-reach places, cell towers and solar-charging stations are re-inventing the learning and communication experience. Alongside the traditional classroom teacher are laptops and cell phones, paving the way toward a whole new way of seeing the world.

A world of data is at your fingertips, quite literally. The advent of personal computers and increasing interest in making information open and accessible to all means that we now have the ability to answer many questions faster and more accurately than we ever thought possible. Information on everything from economic growth to weather patterns to flu outbreaks is just a Google search away.  Data and data sources are not without their flaws, but we can often see broad patterns much more clearly across and within countries than we once could. The question is, how can we take advantage of new and ever increasing sources of information? Perhaps one of the most novel uses of data pieces together the wisdom of the crowd. In particular, Internet search terms are an amazing guide to all sorts of phenomena we care about, including public opinion on politics and policies, investment interests, and even trends in infectious disease.

What kind of information are people searching for? What are the questions to which they seek answers? One can of course look at broad trends in search engine search terms across countries, something similar to looking at words and topics that are “trending” on Twitter, but one can also look for more specific information. How many people in the U.S., Europe, or Asia look for information about Rwanda, for example? What kind of information do they look for? Google Insights for Search can help answer these kinds of questions, and reveal interests from potential investors, tourists, and others that can be useful to the local business community, government, civil society, and individuals.

If you look at the most frequent search terms related to “Rwanda” used by those living in the United States, France, or even China, you’ll find that most are related to the genocide or the movie, Hotel Rwanda. Within the U.S., searches for “Rwanda genocide” spike every April and May, although the spikes are becoming smaller over time. This is some indication that while the world still heavily associates Rwanda with genocide, this association is becoming weaker with time. Searches for “Rwanda safari” or “Rwanda gorillas” increased greatly in 2005 and 2007 respectively, and most of these searches came from individuals living in the United States or the UK.

Meanwhile, searches about Rwanda in the East African region show a very different pattern. The top three search terms about Rwanda from those living in Uganda and Kenya are all related to jobs, and primarily come from three cities, Kampala, Nairobi, and Mombasa. Meanwhile, searches from within Rwanda about Uganda focused on news outlets, such as the Daily Monitor, New Vision, and “news Uganda” more generally. The most common searches in Rwanda about Kenya include Kenya Airways, the Daily Nation, and Kenyan universities.

Understanding search trends can be useful for businesses and entrepreneurs, but they are also a cheap and easy way to do public opinion polling. In the U.S., search trends of the past couple of months have tended to mirror official polling trends for presidential candidates in the Republican party, for example. If you look over time, you can see the rollercoaster levels of support for candidates such as Rick Perry, Mitt Romney, Herman Cain, and Newt Gingrich. In the U.S., regular and nationally representative polls are conducted throughout the campaign period, but the more informal “search” polling can be very informative as well, and far less expensive.

One challenge for using this type of data in countries like Rwanda and Uganda is that relatively few people are online, although the number of internet users is growing by the day. In Rwanda, approximately 13 percent of people accessed the Internet in 2010, up from 7.7 percent in 2009, according to the International Telecommunication Union. More and more people are using their mobile phones, rather than computers, to access the Internet, which makes it easier to get online. Although there may not be enough people using Google to get a good measure of public opinion in Rwanda, this will very likely be possible in the not-too-distant future.

Already, one can observe trends in public interest in politicians among those living in capital cities. Searches for “Besigye”, Ugandan President Yoweri Museveni’s archrival, spiked within Kampala in November 2005, a few months prior to the heated 2006 presidential election, and spiked again to a lesser degree in February 2011, during the most recent election. It appears there was much more interest in Kizza Besigye leading up to the 2006 election (even with considerably fewer people online) than during the time leading up to the most recent elections, a trend which was reflected in Besigye’s support on election day as well. Online searches for Besigye spiked again in April, during the Walk-to-Work protests, but unfortunately for the repeat presidential candidate, by then the election had already passed. Despite the limited connectivity of the population living in Uganda, general election trends were evident in people’s online behavior.

Searches for "besigye" in Uganda, 2004-2011

Finally, search terms can be useful for tracking trends in infectious disease. When people fall sick, they often turn to the Internet for information about their symptoms or illness. Tracking search terms can thus identify and follow outbreaks of particular types of illnesses. Google Flu, for example, uses data on search terms to estimate trends in the spread of the flu virus. Again, their data is best for countries in which the majority of the population has access to the Internet, but as Internet connectivity increases in countries like Rwanda and Uganda, crowd-sourced data on infectious disease may help health officials identify and address outbreaks.

The wisdom of the crowd has for long eluded policymakers, investors, and even public health experts because it is costly to collect information from a large number of people, and people often have incentives to misrepresent their interests and beliefs. Using search trends, however, as one measure of people’s interests, opinions, and concerns, is one way to crowd-source information gathering in a relatively inexpensive and expedient manner.

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Tackling Global Health: Women and Water

Below is my column, online this week, for the Rwanda Edition of the Independent magazine.

Tackling Global Health: Women and Water

Published online November 29, 2011

History suggests that women and water are essential in conquering the developing world’s health challenges

World Toilet Day came and went without much fanfare. In between using the toilet yourself, you probably missed it. Talking about toilets is not sexy, and discussing water and sanitation is probably not at the top of your list, but it should be. Women and water, specifically clean water, have been responsible for major improvements in health in the developed world and hold enormous potential for tackling its health challenges.

At the turn of the 20th century, some of the top killers in the United States included tuberculosis, pneumonia, typhoid, meningitis, influenza, and diarrhea (for children under two years of age).  In 1900, approximately one in six American babies would not live to see their first birthday, according to one recent estimate. In just thirty years, however, infant deaths in the U.S. had fallen by more than half, to an estimated 70 deaths per 1000, approximately equivalent to infant mortality rates in Rwanda today. What accounts for this tremendous improvement in child health in America?

It is tempting to suggest that new medical technologies led to massive improvements in health, and particularly child health. In the course of the 20th century we saw an unprecedented period of medical innovation, which ultimately led to the widespread availability of life-saving vaccines, antibiotics, and other medical technologies we take for granted today. But what is remarkable is that the decline in mortality, particularly due to infectious disease, occurred before the spread, and often before the invention, of these technologies.

Deaths due to scarlet fever had fallen to nearly zero by the time penicillin, a common antibiotic today, was invented in 1946. Similarly, deaths from typhoid and tuberculosis fell dramatically before the introduction of antibiotics to treat these bacterial infections were invented in 1948 and 1950, respectively. It was not until 1963 that a vaccine to prevent measles was invented, by which point very few people died of measles in the U.S. Most of the decline in mortality from infectious diseases in the U.S. occurred before the introduction of medical technology used to prevent or treat them.

So what accounts for the decline in mortality due to infectious disease? To a large extent, women and water. Recent research by Grant Miller of Stanford University finds that women’s suffrage in the U.S. directly contributed to increases in public health spending in the 1920s. Much of this health spending went toward public campaigns to improve hygiene. Around 20,000 child deaths were averted as better hygiene prevented the spread of deadly infectious diseases. Miller argues that legislators anticipated women support of public funding for health, and voted for more progressive public reforms as soon as they won the right to vote.

In related work, Miller and economist David Cutler find that improvements in water systems in the U.S. between 1900 and 1940, specifically filtration and chlorination, contributed to three quarters of the decline in infant mortality and two thirds of the decline in child mortality during this period. Waterborne diseases were responsible for a large proportion of deaths during this time, particularly in U.S. cities, and water treatment and filtration led to a major decline in these waterborne illnesses.

Today, over one billion people around the world do not have access to clean water, and over two billion to not have access to sanitation facilities. In Rwanda, only an estimated 23 percent of the population had access to adequate sanitation in 2006, and in Uganda only 33 percent. In Uganda’s capital city, Kampala, only eight percent of homes are connected to a sewage line. A greater proportion of the population have access to clean water—64 percent in Uganda and 65 percent in Rwanda—but nearly one third of the population continues to consume unsafe water on a daily basis.

Much of the emphasis on public health today focuses on supply-side factors – on health care rather than health, on curative rather than preventive treatments, on hospitals rather than homes. But history suggests that the greatest improvements in health have taken place within the home, with a focus on preventing infectious disease rather than treating it. Women play a key role in this process. Women are more likely to be in charge of feeding children and ensuring their homes have clean water and adequate sanitation, and some research suggests women tend to place greater value on child welfare (this is why cash transfers programs often target women in the household, rather than men). As we have seen in the U.S., women voters can have a profound impact on legislator behavior and consequently, public policy.

Survey evidence from the Afrobarometer suggests that health is a major concern for ordinary Ugandans, and populations throughout sub-Saharan Africa. In 2011, 26 percent of Ugandans said that “improving public services such as education and health” was their top concern, and 50 percent said that health was among the “most important problems facing this country that the forthcoming 2011 elections should address,” and ranked health higher than any of the thirty-odd other policy issues. Whether legislators act on the policy preferences of their constituents is another matter altogether. Nevertheless, the potential of the electorate, and women in particular, to influence public policy should be taken seriously, especially with regard to health.

A focus on hygiene may be as efficacious, if not more so, than the antibiotics and antimalarial drugs that are ubiquitous in public health today. The difference between 1920s America and the developing world in 2011 is that we are not forced today to rely on prevention of disease, because the momentous gains in medical technology allow us to treat the most common causes of death and disability. But this new technology should not become a crutch, and we should not forget the tremendous gains in population health that can be made by focusing on hygiene rather than a vaccine. Toilets may not be sexy, but life without adequate sanitation just stinks.

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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.

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Impact evaluation and RCTs in health

I am currently working on a proposal for a pilot of performance-based contracts (PBC) in Uganda’s health sector, and have been busy navigating the literature out there. Fortunately for me, there is also a lot of discussion on randomized controlled trials (RCTs) and impact evaluation in the development blogosphere of late.

Today I’ve been reading “Performance Incentives for Global Health,” published by the Center for Global Development, and available for purchase or downloadable chapter-by-chapter here. It has proven very useful so far in helping me think through the various ways in which PBC pilots could be designed. In Chapter 5, A Learning Agenda, the authors write:

Impact evaluation is more than a tool for gauging impacts at the end of a program and providing the inputs into a cost-effective analysis. It can also help a program to evolve. For example, in the initial phase of a pay-for-performance program, three contracts with different risk levels can be piloted. Based on the results from an early evaluation, the most effective contract can be scaled up. Several parameters lend themselves to this kind of experimentation, including the relative effects of supply versus demand interventions, the level of rewards offered for performance, and the balance of trade-offs between access and use.

Rwanda is often noted as a pay-for-performance (P4P) success story, and Chapter 10 is devoted to this case study. The original study by Basinga et al. (2010) is available here (and co-authored by Rwanda’s current Minister of Health, Agnes Binagwaho, also available at @agnesbinagwaho). The authors find that P4P has a significant effect on the number of deliveries in health facilities, quality of prenatal care, and number of preventive care visits for children, but they find no effect on the number of prenatal care visits or immunizations.

In Uganda, a similar pilot, this time of private-not-for-profit (PNFP) facilities, found no effect of bonuses on health facilities’ performance in achieving self-selected health targets. They did find that financial autonomy improved health facilities’ performance, however. The study, “Contracting for Primary Health Care in Uganda”, remains an unpublished World Bank manuscript, as far as I can tell (publication bias at work), but the slides from the 2007 CGD presentation are available here.

I’d like to examine the effect of PBC on health outcomes in the public rather than PNFP sector (hopefully using a few variations of the contract “treatment”), as well as better understand why performance-based pay (in the form of bonuses) did not seem to have an effect on health outcomes in the Uganda pilot. Finally, I am interested in understanding the relative efficacy of supply-side (such as PBC) vs. demand-side (such as conditional cash transfers) efforts in improving various health outcomes. More updates on this to come.