Showing posts from category poverty.
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Irene Kitzantides
In FOCUS Coffee and Community: Combining Agribusiness and Health in Rwanda
›June 29, 2011 // By Wilson Center StaffDownload FOCUS Issue 22: “Coffee and Community: Combining Agribusiness and Health in Rwanda,” from the Wilson Center.
Rwanda, “the land of a thousand hills,” is also the land of 10 million people, making it the most densely populated country in Africa. Rwandans depend on ever-smaller plots of land for their food and livelihoods, leading to poverty, soil infertility, and food insecurity. Could Rwanda’s burgeoning specialty coffee industry hold the key to the country’s rebirth, reconciliation, and sustainable development?
In the latest issue of ESCP’s FOCUS series, author Irene Kitzantides describes the SPREAD Project’s integration of agribusiness development with community health care and education, including family planning. She outlines the project’s successes and challenges in its efforts to simultaneously improve both the lives and livelihoods of coffee farmers and their families. -
Ecological Tourism and Development in Chi Phat, Cambodia
›Chi Phat is a single-dirt-road town nestled in the Cardamom Mountains of Southwestern Cambodia, one of the largest intact forests in Southeast Asia. The town is only accessible by two routes: a three-hour river boat trip up the Phipot River or, if the road isn’t flooded by the rainy season, an exhilarating 30-minute motorbike ride from Andoung Tuek, a blip on the one paved road that runs along Cambodia’s southwestern border. Since 2007, Wildlife Alliance has been running an ecotourism project in Chi Phat (full disclosure: I used to work for Wildlife Alliance in Washington, DC).
The project has been featured in The New York Times and since its inclusion in the Lonely Planet travel guide, has become a destination for backpackers looking to leave the beaten path. I recently visited the project after spending time in neighboring Vietnam and was struck by the contrast between the densely populated and urbanized Mekong Delta and the visibility of rural poverty in Cambodia.
“Cambodia’s contemporary poverty is largely a legacy of over twenty years of political conflict,” reads a 2006 World Bank Poverty Assessment. The Pol Pot regime’s agrarian collectivization forced millions into the countryside and as a result, even in today’s predominantly-urban world, Cambodia remains 78 percent rural. Today 93 percent of Cambodia’s poor live in rural areas, two thirds of rural people face food shortages, and maternal and reproductive health outcomes in the country lag far behind those in the cities. Chi Phat and the sparsely populated northeast have over ten or twenty times the rate of maternal deaths of Phnom Penh.
A Town Transformed
Before Wildlife Alliance began the Community-Based Ecotourism (CBET) project in Chi Phat, most villagers made a living by slash-and-burn farming, illegal logging, and poaching endangered wildlife. Wildlife Alliance Founder and CEO Suwanna Gauntlett described the ecological zone around the town as “a circle of death,” in an audio interview with New Security Beat last year.Now, Chi Phat is a rapidly growing tourism destination offering treks and bike tours. In 2010 they brought in 1,228 tourists – not huge by any means, but over twice the number from 2009. The town now boasts a micro-credit association, a school, and a health clinic that offers maternal and reproductive health services. The village is also visited by the Kouprey Express, an environmental education-mobile that provides children and teachers with lessons, trainings, and materials on habitat and wildlife protection, pollution prevention, sustainable livelihoods, water quality, waste and sanitation, energy use, climate change, and adaptation.
One villager, Moa Sarun, described to me how he went from poacher and slash-and-burn farmer, to tour guide, and finally, chief accountant:Since I have started working with CBET, I realize that the wildlife and forest can attract a lot of tourists and bring a lot of income to villagers in Chi Phat commune. I feel very regretful for what I have done in the past as the poacher…I know clearly the aim of CBET is to alleviate the poverty of local people in Chi Phat, so I am very happy to see people in Chi Phat have jobs and better livelihoods since the project has established.
It’s hard to imagine what the town would have looked like before Wildlife Alliance arrived. The visitor center, restaurant, and “pub” (really, a concrete patio with plastic chairs and a cooler filled with beer), together make up nearly half of the town’s establishments. For two dollars a night, I stayed in a homestay and lived as the locals do on a thin mattress under mosquito netting, with a bucket of cold water by the outhouse for a shower, and a car battery if I wanted to use the fan or light (but not both). These amenities place Chi Phat above average for rural Cambodia. According to 2008 World Bank data, only 18 percent of rural areas had access to improved sanitation and only 56 percent had access to an improved water source.
Poaching Persists
Real change has certainly hit Chi Phat, but illegal activities persist, as a Wall Street Journal review of the project noted. In one Wildlife Alliance survey, 95 percent of members participating in the project made less than 80 percent of their previous income and 12 percent of people made less than 50 percent. “That, to me, is a red flag,” Director of U.S. Operations Michael Zwirn acknowledged to me. Nevertheless, he said “it is well documented that it’s the most lucrative community-based ecotourism project in Cambodia. That doesn’t mean that everyone is making money, or that they’re making enough money, but the community is clearly benefiting.”
Harold de Martimprey, Wildlife Alliance’s community-based ecotourism project manager, told me in an email interview:We monitor closely the impact of the CBET project on the diminution of poaching and deforestation. We estimate that since the beginning of the project, the illegal activities have decreased by almost 70 percent.
As Chi Phat ecotourism continues to scale up, de Martimprey expressed hope that more and more villagers would participate in the project and stop destructive livelihoods.
After four years, Chi Phat has already developed enough to operate financially on its own. Wildlife Alliance will stop funding the project later this year and transition it towards total self-sustainability. The plan is to then ramp up efforts at a neighboring project in Trapeang Ruong, due to open to the public next month.
A Land of Opportunity
So far Chi Phat lacks much of what do-gooder tourists are hoping to find when they come in search of ecotourism. There is little to no information about the work of Wildlife Alliance and how ecotourism benefits the town, or the health, education, and economic benefits the villagers have received. A little more obvious justification for ecotourism’s inflated prices might appease the average backpacker used to exploitatively lower prices elsewhere in the country. The guides, staff, and host families for the most part speak little English, which does not bode well for its tourism potential. “This is a work in progress,” said de Martimprey.
Most of my time in Chi Phat, I felt like the only foreigner to ever set foot in the town – refreshing after witnessing much of the rest of Southeast Asia’s crowded backpacker scene. As Chi Phat continues to grow, hopefully it will “bring in enough people to support the community without the adverse effects of tourism,” said Zwirn. “They don’t want it to turn into the Galapagos.” Thankfully, de Martimprey told me, “Chi Phat is far from reaching this limit and can be scaled up to much bigger operation,” without negatively impacting the environment.
Luckily, plans to build a highly destructive titanium mine near the town were recently nixed by Prime Minister Hun Sen in what was an unexpected victory over industrial interests. However, soon after, the town was again under threat – this time by a proposed banana plantation nearby.
“The Cardamom Mountains are still seen as a land of opportunity for economic land concessions for some not-so-green investors looking at buying land for different purposes, and often disregarding the interest of the local people,” said de Martimprey.
Eventually Zwirn hopes that as more tourists come to the Cardamoms, they will become “a constituency for conservation,” he said. “We need to build a worldwide awareness of the Cardamoms as a destination, and as a place worth saving.”
Sources: BBC, IFAD, Phnom Penh Post, New York Times, United Nations, Wall Street Journal, Wildlife Alliance, World Bank, World Wildlife Fund.
Photo Credit: Hannah Marqusee. -
Women in Agriculture: Closing the Gender Gap for Development and World Hunger
›June 22, 2011 // By Kellie FurrProviding women with equal access to productive resources and opportunities may be the key to bolstering the struggling global agricultural sector and feeding communities living in extreme hunger, according to the UN Food and Agriculture Organization’s (FAO) latest State of Food and Agriculture report, which this year is sub-titled, “Women in Agriculture: Closing the Gender Gap for Development.”
“Women are farmers, workers, and entrepreneurs, but almost everywhere they face more severe constraints than men in accessing productive resources, markets, and services,” write the authors. “This ‘gender gap’ hinders their productivity and reduces their contributions to the agriculture sector and to the achievement of broader economic and social development goals.”
Barriers to Productivity
Globally, women comprise 43 percent of the agricultural labor force, ranging from 20 percent in Latin America to 50 percent in southeastern and eastern Asia and sub-Saharan Africa, according to the report. But despite their significant global presence, female farmers face gender-specific constraints that hinder access to productive resources, financial support, information, and services required to be viable and competitive. “The yield gap between men and women averages around 20 to 30 percent, and most research finds that the gap is due to differences in resource use,” write the authors.
Generally, women are more likely than men to hold lower-wage, part-time, or seasonal positions and tend to get paid less even when they are more qualified. Furthermore, domestic and occupational lines are blurred for women, who are often not compensated for work that is closely related to domestic food preparation. Most significantly for agricultural productivity, women across the developing world often lack access to quality land, sometimes being barred from land ownership. This ban precludes female farmers from exercising managerial discretion over farming activities, such as entering contract farming agreements. Women also generally own less livestock and contract for less labor – two crucial assets for marketable agricultural production in many developing countries. Moreover, because of insufficient land and resources, women farmers are also more vulnerable to climate shocks.
Resource barriers for female farmers extend to education, finance, and technology as well. The authors observe that “female household heads in rural areas are disadvantaged with respect to human capital accumulation in most developing countries, regardless of region or level of economic development,” which represents a historical bias against females in education. Despite notable success observed in finance projects involving female farmers, gender bias exists in the financial system, which prevents women from bearing initial financial risk in order to increase long-term productivity gains. Sources of gender bias in the financial sector include legal barriers, cultural norms, lack of collateral, and institutional discrimination by public and private lenders. Due to the aforementioned lack of credit, labor, and education, women farmers are deficient in all aspects of technology, such as the acquisition of new equipment, information about new seed varietals and animal breeds, pest control measures, and management techniques.
Global Implications
Closing the gender gap could have profound implications for easing world hunger. According to the FAO, approximately 925 million people are currently undernourished, most of whom live in developing countries. If women were given all the inputs and support as men, agricultural output could increase by 2.5 to 4 percent in developing countries, potentially reducing the world’s hungry by 100 to 150 million people. “This report clearly confirms that the Millennium Development Goals on gender equality (MDG 3) and poverty and food security (MDG 1) are mutually reinforcing,” FAO Director-General Jacques Diouf argues in his introductory remarks.
Increasing the economic viability of women farmers may also translate into better infant and child health indicators – when women control additional income, they tend to allocate more of their earnings toward the health and well-being of their children. Closing the agricultural gap is “a proven strategy for enhancing the food security, nutrition, education, and health of children,” Diouf asserted. “Better fed, healthier children learn better and become more productive citizens. The benefits would span generations and pay large dividends in the future.”
Finally, the FAO notes that in addition to reducing child mortality rates, increasing female education and economic prosperity helps lower fertility rates, which over time increases human capital and can help drive a demographic transition towards lower dependency rates and higher per capita growth.
Closing the Gender Gap
“The conclusions are clear,” write the authors:1) Gender equality is good for agriculture, food security, and society; and
Though they note that “no simple ‘blueprint’ exists for achieving gender equality in agriculture,” the authors do recommend some basic principles to the development community, including working towards eliminating discrimination against women under the law, strengthening rural institutions and making them gender-aware, freeing women for more rewarding and productive activities, building the human capital of women and girls, bundling interventions, improving the collection and analysis of sex-disaggregated data, and making gender-aware agricultural policy decisions.
2) Governments, civil society, the private sector and individuals, working together, can support gender equality in agriculture and rural areas
Recognizing that “women will be a pivotal force behind achieving a food secure world,” the U.S. Agency for International Development (USAID) has actually launched initiatives aimed directly at closing the gender gap. The Feed the Future initiative, announced last spring, includes a heavy focus on gender equity and integration with small-scale farming initiatives. For example, the Office of Women in Development is supporting a three-year project in Liberia, “Integrated Agriculture for Women’s Empowerment,” that aims to train and support 1,500 small farmers in Lofa county, two-thirds of whom are women. And in Rwanda, USAID helped the Ministry of Agriculture and Animal Resources – headed by Dr. Agnes Kalibata – develop a national investment plan, which has been successful in bringing in donor support.
However, the FAO report does not offer specific feedback on programs like Feed the Future, which is arguably a crucial component of a truly comprehensive assessment on the current state of agriculture. Though they write that the State of Food Agriculture series is intended to simply be “science-based assessments of important issues,” the infancy of these food security efforts and the immediacy of the problems examined (see recent food price instability) creates an excellent opportunity for critical input. “Women in Agriculture” offers perhaps the most comprehensive report on the gender gap and development to date, but more specific critiques on the current efforts of USAID and others might make more of an impact in a field where the issues at play have been fairly clearly enumerated many times before.
Sources: Food and Agriculture Organization, The Hunger Project, International Fund for Agricultural Development, Population Action International, USAID.
Photo Credit: Adapted from “Ngurumo Village-Ntakira (Kenya),” courtesy of flickr user CGIAR Climate. -
The Implications of Urbanization on Food Security and Child Mortality of the Urban Poor
›In the chapter, “Urban Agriculture and Climate Change Adaptation: Ensuring Food Security Through Adaptation,” of the edited volume, Resilient Cities: Cities and Adaptation to Climate Change – Proceedings of the Global Forum 2010, authors Marielle Debbeling and Henk de Zeeuw assess the viability of urban and peri-urban agriculture (UPA) as a method of climate change adaptation for the urban poor. Debbeling and de Zeeuw assert that UPA increases the resilience of cities by diversifying both food supply and income streams for the urban poor; decreasing the negative effects of “heat island effect,” air pollution, and urban flooding; conserving water and utilizing organic waste; and reducing energy use and greenhouse gas emissions. Given the scale and impact of modern urbanization, the authors write that “the integration of UPA into urban development and master plans, urban land use and zoning plans, as well as active maintenance of the protected agricultural zones…is crucial.”In “Urban Area Disadvantage and Under-5 Mortality in Nigeria: The Effect of Rapid Urbanization,” published by Environmental Health Perspectives, authors Diddy Antai and Tahereh Moradi found a significant link between the mortality rate of children under five years of age and a poor and disadvantaged urban environment; such an environment is characterized by poor sanitation, overcrowding, a lack of access to safe water, and high levels of disease-inducing air pollution and hazardous wastes. Although urban living may increase proximity to health care and other social amenities, low- and middle-income countries, such as Nigeria, have overstretched their adaptive capacities and the result is poor health indicators. Antai and Moradi predict that the rapid urbanization of Nigerian cities will bring increased infant mortality, unless individual- and community-based policy interventions are implemented to counter the adverse environmental conditions of deprived areas. -
Climate Change, Development, and the Law of Mother Earth
Bolivia: A Return to Pachamama?
›May 20, 2011 // By Christina DaggettIn Bolivia, environment-related contradictions abound: shrinking glaciers threaten the water supply of the booming capital city, La Paz, while unusually heavy rainfall triggers deadly landslides. The government is seeking to develop a strategic reserve of metals that could make Bolivia the “Saudi Arabia of lithium,” while politicians promote legal rights for “Mother Earth” and an end to capitalism.
This year has been particularly turbulent. In La Paz, landslides destroyed at least 400 homes and left 5,000 homeless. While the rain has been overwhelming at times, it has also been unreliable – an effect of the alternating climate phenomena La Niña and El Niño, experts say, which have grown more frequent in recent years and cause great variability in weather patterns. Bolivia has endured nine major droughts and 25 floods in the past three decades, a challenge for any country but particularly so for one of the poorest, least developed, and fastest growing (with a total fertility rate over three) in Latin America.
Environmental Justice or Radicalism?
Environmentalism has become a major force in national politics in part as a response to the climatic challenges faced by Bolivia. A new law seeks to grant the environment the same legal rights as citizens, including the right to clean air and water and the right to be free of pollution. (Voters in Ecuador approved a similar measure in 2008.) The law is seen as a return of respect to Pachamama, a much revered spiritual entity (akin to Mother Earth) for Bolivia’s indigenous population, who account for around 62 percent of the total population.
Though groundbreaking in its scope, the new law may prove difficult to enforce, given its lack of precedent and the lucrative business interests at stake (oil, gas, and mineral extraction accounted for 70 percent of Bolivia’s exports in 2010).
On the global stage, President Morales has issued perhaps the most aggressive calls yet for industrial countries to do more about climate change and compensate those countries that are already experiencing the effects. Bolivia refused to sign both the Copenhagen and Cancun climate agreements on grounds that the agreements were too weak. In Cancun, Morales gave a blistering speech:We have two paths: Either capitalism dies or Mother Earth dies. Either capitalism lives or Mother Earth lives. Of course, brothers and sisters, we are here for life, for humanity and for the rights of Mother Earth. Long live the rights of Mother Earth! Death to capitalism!
Bolivia’s stance has alienated potential allies: In 2010, the United States denied Bolivia climate aid funds worth $3 million because of its failure to sign the Copenhagen Accord.
Going… Going… Gone
Bolivia’s Chacaltaya glacier – estimated to be 18,000 years old – is today only a small patch of ice, the victim of rising temperatures from climate change, scientists say. Glaciologists suggest that temperatures have been steadily rising in Bolivia for the past 60 years and will continue to rise perhaps a further 3.5-4˚C over the next century – a change that would turn much of the country into desert.
Other Andean glaciers face a similar fate, according to the World Bank, which estimates that the loss of these glaciers threatens the water supply of some 30 million people and La Paz in particular, which, some experts say, could become one of the world’s first capitals to run out of water. The populations of La Paz and neighboring El Alto have been steadily growing – from less than 900,000 in 1950 to more than 2 million in 2011 – as more and more Bolivians are moving from the countryside to the city, putting pressure on an already dwindling water supply.
If the water scarcity situation continues to worsen, residents of the La Paz metropolitan area may migrate to other areas of the country, most likely eastward toward Bolivia’s largest and most prosperous city, Santa Cruz. Such migration, however, has the potential to inflame existing tensions between the western (indigenous) and eastern (mestizo) portions of the country.
Rising Prices, Rising Tension
The temperature is not the only thing on the rise in Bolivia; the price of food, too, is increasing. According to the World Food Program, since 2010, the price of pinto beans has risen 179 percent; flour, 44 percent; and rice, 33 percent. Shortages of sugar and other basic foodstuffs have been reported as well, leading to protests.
In early February, the BBC reported President Evo Morales was forced to abandon his plans to give a public speech after a group of protestors started throwing dynamite. A week later, nation-wide demonstrations paralyzed several cities, according to AFP, closing schools and disrupting services.
The Saudi Arabia of Lithium?
One way out for Bolivia’s economic woes might be its still nascent mineral extraction sector. Bolivia possesses an estimated 50 percent of the world’s lithium deposits (nine million tons, according to the U.S. Geological Survey), most of which is locked beneath the world’s largest salt flat, Salar de Uyuni. The size of these reserves has prompted some to dub Bolivia a potential “Saudi Arabia of lithium” – a title, it should be noted, that has also been bestowed upon Chile and Afghanistan.
Demand for lithium, which is used most notably in cell phones and electric car batteries, is expected to dramatically increase in the next 10 years as countries seek to lower their dependence on fossil fuels. Yet, some analysts have wondered if Bolivia’s lithium is needed, given the quality and current level of production of lithium from neighboring Chile and Argentina.Others have questioned whether Bolivia has the necessary infrastructure to industrialize the extraction process or the ability to get its product to market, though Bolivia recently signed an agreement with neighboring Peru for port access. In an extensive report for The New Yorker, Lawrence Wright writes that “before Bolivia can hope to exploit a twenty-first century fuel, it must first develop the rudiments of a twentieth-century economy.” To this end, the Bolivian government last year announced a partnership with Iran to develop its lithium reserves – a surprising move, given Morales’ historical disdain for foreign investment.
Nexus of Climate, Security, Culture, and Development
The Uyuni salt flats are both a potent economic opportunity and one of the country’s most unspoiled natural wonders. How will Bolivia – a country of natural bounty and unique indigenous tradition – balance the need for development with its stated commitment to environmental principles?
Large-scale extraction may be worth the environmental cost, a La Paz economist told The Daily Mail: “We are one of the poorest countries on Earth with appalling life-expectancy rates. This is no time to be hard-headed. Without development our people will suffer. Getting bogged down in principles and politics doesn’t put food in people’s mouths.”
“The process that we are faced with internally is a difficult one. It’s no cup of tea. There are sectors and players at odds in this more environmentalist vision,” said Carlos Fuentes, a Bolivian government official, to The Latin American News Dispatch.
Sources: American University, BBC News, Bloomberg, Change.org, Christian Science Monitor, The Daily Mail, Democracy Now, Green Change, The Guardian, Instituto Nacional de Estadística de Bolivia, IPS News, Latin America News Dispatch, MercoPress, The New York Times, The New Yorker, Population Reference Bureau, PreventionWeb, Reliefweb, Reuters, SAGE, Tierramerica, USAID, U.S. Geological Survey, UNICEF, Upsidedownworld, Wired UK, The World Bank, Yahoo, Yes! Magazine.
Photo credit: “la paz,” courtesy of flickr user timsnell and “Isla Incahuasi – Salar de Uyuni, Bolivia,” courtesy of flickr user kk+. -
Watch: Edward Carr on Delivering Development and Rethinking Assumptions
›May 13, 2011 // By Schuyler NullWhile visiting West Africa first as an archaeologist, Edward Carr, an associate professor in the Department of Geography at the University of South Carolina and author of Delivering Development: Globalization’s Shoreline and the Road to a Sustainable Future, found that the villages in which he was working were far more resilient to the impacts of climate change than he expected. Increased frequency of drought, declines in rainfall, severe storms – these challenges are the sort of thing that can “totally destroy someone’s livelihood in a year,” he said in an interview with ECSP, “yet they were surviving and surviving really, really well.”
That experience and others challenged his understanding of “how I thought the world was supposed to work, how I’d been taught the world was supposed to work, versus what I was actually seeing happen on the ground,” said Carr. “I became so struck by what people were dealing with in the current context that my interest started to shift much more towards what they were doing now.”
Now serving as a AAAS fellow and the climate change coordinator for the Bureau for Democracy, Conflict, and Humanitarian Assistance at the U.S. Agency for International Development, Carr said he is trying to change how the U.S. government does development.
“The last 13 years of my career have been trying to figure out what’s actually happening on the ground first,” Carr said, and that led to writing Delivering Development.
“One of the key arguments I have is that the world does not work the way we assume it does – we are fundamentally misunderstanding what’s happening for most people living out, especially in rural areas, in the developing world,” said Carr. “The challenges they face are significant but not necessarily the ones we’re aimed at.”
For example, said Carr, “we see rising food prices globally and…the presumption is that the poorest people in the world are going to get really hammered by this.” But, he said, “That’s not entirely true, because a lot of the poorest people in the world living in rural areas have an option to just disconnect from markets completely – they go total subsistence if they need to.”
There’s an assumption that people shouldn’t be disconnecting like that, but, Carr pointed out, when new places are integrated into larger markets, “we’re also integrating them into new sources of risk that they may not be very well equipped to manage, and that becomes a really significant challenge.”
“We’re starting with the fundamental assumption that markets can be a solution, without necessarily really looking carefully at how markets can be part of the problem,” said Carr. -
Reporting on Global Health: A Conversation With the International Reporting Project Fellows
›“The story is the story, the information is the information, but you can frame it in very different ways,” said freelance journalist Annie Murphy at a roundtable discussion on the current state of global health reporting. Fresh off their five-week assignments, Murphy and three other fellows from the International Reporting Project (IRP) – Jenny Asarnow, Jill Braden Balderas, and Ann S. Kim – spoke at an event at the Woodrow Wilson Center on April 28 about their experiences researching underreported health issues in Haiti, Botswana, Mozambique, and Uganda. [Video Below]
Taking the Temperature of Global Health Reporting
Global health reporting, like many other forms of journalism, has felt the pinch from the global financial crisis, said Balderas, who edited a recent Kaiser Foundation report on the issue, “Taking the Temperature: The Future of Global Health Journalism.” Other challenges that have led to less global health coverage in mainstream media include an increased focus on “hyper-local” news; “story fatigue” from years of HIV/AIDS coverage; greater focus on epidemics and disasters; and the increasing number of advocacy groups starting their own news services.
Placing global health stories is a big challenge, agreed all four panelists. Who will want to run the story? What form – radio, documentary, print, online – will the story take? According to Murphy, some creative thinking may be needed: “It is global health, but that doesn’t mean we always have to frame it in this box of global health. It will be global health no matter what we do, so I think it’s also important for us to feed it into other events and issues that are important.”
(Re)building Maternal Healthcare in Haiti
With the worst maternal and infant mortality rates in the Western Hemisphere, Haiti needs medical providers of all kinds, said Asarnow, but especially skilled birth attendants. The devastating earthquake in 2010 destroyed Haiti’s only midwifery school, located in Port-au-Prince, killing many students and instructors. The school is still struggling to graduate a class of 15 people, she said.
In the rural town of Hinche, located in Haiti’s Central Plateau region, Asarnow frequently visited a public hospital that provided pregnant women with free obstetric care. Yet, she said, “even with free care, there [were] still a lot of barriers for women coming to the hospital to get care.” For example, the family members of expectant mothers had to provide sheets, clothing, food, and a bucket for personal needs. In addition, some women were too poor to afford transportation to and from the hospital.
Most women in Haiti, though, give birth at home with the help of traditional birth attendants, called matrones, Asarnow said. These matrones, popular in rural areas, are not formally educated in midwifery, but the government, along with non-profits such as Midwives for Haiti, have provided the matrones with training in basic health care and emergency situations.
Simply reporting on childbirth turned out to be a challenge, said Asarnow. “It’s hard to get people interested in something that just happens to most women,” she said; other more unusual health problems, such as infectious diseases, tend to garner more interest.
Finding Health Sovereignty in Mozambique
Health sovereignty, explained Murphy, is “the idea that nations have the right to make decisions about health and about how people are going to be treated” – an issue that is particularly pointed in Mozambique, where 50 percent of the national budget and 70 percent of the annual health budget is tied to international aid.
Mozambique, said Murphy, has only 1,000 doctors to serve a population of 22 million. By contrast, the country has an estimated 50,000 traditional healers. As a result, she said, most Mozambicans use traditional healing for at least part of their regular health care.
While researching traditional healers in the northern province of Tete, Murphy investigated a large Brazilian-owned coal mine that had displaced 5,000 local people when it was built. Mining is a major economic activity in Mozambique, yet mining companies are taxed a mere three percent by the government, said Murphy.
Health reporting doesn’t have to only cover traditional health issues, said Murphy. “The environment, natural resources, and how a country earns its money very much have to do with the health of the people who are living there,” she said. “How can you talk about being sovereign and providing health to your citizens if you don’t have the money to do that?”
Treating the Over-Treatment of Malaria in Uganda
“Malaria is quite over-treated” in Uganda, said Balderas. There’s the “idea that if you have a fever, you have malaria.” Consequently, the rate of misdiagnosis can reach alarming rates in some areas, she said.
Balderas said an estimated 50 percent of Ugandans get free treatment through the public sector. However, only donor-funded facilities are equipped with the rapid diagnosis test (or RDT), which takes only 20 minutes to determine the presence of malaria in a blood sample, she said. If these facilities were more widespread, misdiagnoses rates could easily be lowered.
Other challenges to the accurate diagnosis and treatment of malaria include faulty equipment, shortages of electricity and lab technicians, human error, corruption, bureaucratic entanglements, and presumptive diagnoses. For example, sometimes health workers do not know what is causing a patient’s fever, Balderas said, but they prescribe malaria treatments anyway because “they want to be able to give someone a treatment; they want to feel like they’re helping people.”
“There are certainly a ton of issues that relate to health,” Balderas said, such as poverty and corruption. Everyone she interviewed in Uganda – with the exception of government officials – identified the corruption in the country’s drug sector as a key problem.
Helping “Africa” One Small Story at a Time
Inspired by a World Health Organization study, which found “at least a 60 percent reduction in HIV infection among men who were circumcised,” Kim went to Botswana to investigate infant circumcision, a practice that is gaining popularity but is still alien. “I would meet people in the course of my day and they would ask me what I was doing there and I would talk about circumcision. They’d say, ‘Oh, I really want to get my baby circumcised. How do I do that?’” she reported.
The most powerful moment of her trip, said Kim, came when she was researching cervical cancer – the number one cancer among women in Botswana. As she waited with a woman to receive her lab results, Kim asked her if she was nervous. The woman, who was HIV-positive, said, “Yeah, I’m really worried. To me, it would be worse to get cervical cancer than to have HIV.” Even though Botswana is a middle-income country, said Kim, there are far more resources available to treat HIV than cancer.
Kim said that when presenting her work it was important for her to bring in the human element and not just the statistics: “I hope that, in whatever small way, even these small stories will help get issues in various countries on the map, especially in Africa where we tend to think of it as ‘Africa’ and not so much as different countries with different personalities and different situations.”
Sources: Malaria Journal, UNFPA, World Health Organization.
Image Credit: David Hawxhurst/Woodrow Wilson Center. -
Designing Health and Population Programs to Improve Equity: Moving Beyond the Rhetoric
›“There needs to be ongoing flexibility and creativity in our ways of approaching health equity,” said John Borrazzo of the U.S. Agency for International Development (USAID) at a recent Global Health Initiative event at the Wilson Center. Borrazzo is the chief of the Maternal and Child Health Division in the Bureau for Global Health. He moderated a discussion on practical strategies to improving access to health services for the world’s poor and other marginalized groups, with panelists Mickey Chopra, chief of health and associate director of programmes at UNICEF; Davidson Gwatkin, senior fellow at the Results for Development Institute and senior associate at Johns Hopkins Bloomberg School of Public Health; Cesar Victoria, professor of epidemiology at the Federal University of Pelotas in Brazil; and Jennifer Luna, senior monitoring and evaluation adviser for the Maternal and Child Health Integrated Program (MCHIP). [Video Below]
MDG 4: An Equity Approach
“Massive benefits can be gained by reaching the poorest and most marginalized,” said Chopra. “It’s actually more cost effective to have an equity-based approach; it’s not just right in principle, it’s right in practice.”
While there has been some progress in reducing the rates of mortality for children under five (the UN’s Millennium Development Goal 4), Chopra said “there has to be a change” if they are going to be achieved completely. Most of the 30 percent decline in child mortality so far has been in Asian countries, while Africa as a whole remains stagnant. Further, two-thirds of the 35 countries that have made significant progress to meet MDG 4 show worsening inequalities between the highest and lowest income brackets of the population.
In the majority of countries, the “rich are still capturing most of the benefits of new investments and interventions,” said Chopra. “The challenge at the program and policy levels is to understand why there is this gap between the richest and the poorest in terms of uptake of critical interventions.”
Delivery channels are faced with “bottlenecks” that prevent services from reaching marginalized communities, said Chopra. Clinic-based services often lack adequate human resources, consistency in the quality of service, and can be very expensive. Population-oriented services, which include government and NGO-led outreach and scheduled services at health facilities, are often challenged with low demand and lack of continuity, while availability and cost of health commodities are barriers for community-based interventions delivered through local organizations or social marketing campaigns.
Shifting delivery of services within channels, appropriately shifting delivery to different channels, or improving the performance of an established delivery channel could help increase uptake of treatment and prevention among poor and marginalized communities, concluded Chopra. He stressed that progress need not come at the expense of the poor. According to a UNICEF report, Ghana, Eritrea, Nepal and Malawi have all reduced under-five mortality and inequality by prioritizing providing essential services to the most marginalized communities first.
Designing Equity-Based Health Programs
“Performance variability in terms of equity across countries is very large,” said Gwatkin. “In some places a given technique can work well and in others it can be a complete flop.”
To pick the right technique for the right place, Gwatkin advocated for an iterative approach to program design and implementation, beginning with setting targets in terms of the poor population group of concern. After fully assessing country-specific conditions, a set of potential pro-poor interventions can be selected, based on an analysis of current interventions and suggested alternatives as well successful interventions in other countries. Each of these interventions should be delivered to a large, representative area, he said.
“The next step is to find out how well you have done,” said Gwatkin, stressing the importance of assessing and monitoring interventions with a specific focus on the marginalized target group. Successful approaches should be expanded, while those that are not having the intended benefits of helping the poorest communities should be modified or abandoned.
In sum, said Gwatkin, “It’s more promising to focus on designing a process to fit techniques to individual country settings than to focus on the techniques themselves.” Doing this helps effectively integrate equity concerns into the design and implementation of programs, and as a result, he said, can have a major impact on improving the lives of the poorest people in developing countries.
Analyzing Equity to Maximize Impact
“It’s always possible and useful to include equity in monitoring and evaluation, however, it has to be planned ahead of time,” said Victoria.
The Countdown to 2015 Initiative is an effort to monitor progress made towards the health-related Millennium Development Goals globally. The Countdown’s efforts not only aim to promote access to health services at the aggregate level but also specifically to ensure the equitable distribution and uptake of health services among disadvantage populations, said Victoria.
Generally, in countries with high coverage of preventative and treatment services, like Brazil, there is “bottom inequity,” said Victoria, in which the poor are much worse off than everyone else. Targeting the poor specifically in such countries is therefore essential to improving equity.
Alternately, Victoria continued, countries with low coverage at all levels, like Cambodia or Haiti, suffer from “top inequity,” in which the rich are typically much better off the rest of the population. These countries should work towards increasing coverage for all people and focus on the poor after there are some universal gains, he said.
“Analyzing the shapes of inequity curves can help drive decisions about delivery channels and targeting…and can lead to practical strategies for maximizing the impact of interventions,” concluded Victoria.
Health Equity: From Evidence to Practice
“Projects often state that they are really interested in equity, but when you read the project descriptions, you don’t see exactly what they mean by equity or how they plan on addressing it,” said Luna, speaking of her work at MCHIP.
Luna presented the Health Equity Guidance Document that outlines a systematic, six-step process for professionals who design and implement community-oriented projects to ensure equity is effectively integrated into their programs:1) Understand the equity issues in the project area
Luna stressed that there is no “one size fits all” strategy: “This approach is not a prescriptive one; it presents a series of concepts and approaches to take into consideration and then make decisions.” But for program implementers on the ground, she said, these guidelines and tools “should help lead to a coherent health equity strategy and can serve as a basis for dialogue among stakeholders.”
2) Identify the disadvantaged group on which to focus
3) Decide what is in the project’s manageable interest to change
4) Define equity goals, objectives, and a project-specific definition of equity
5) Determine equity strategies and activities
6) Develop equity-focused monitoring and evaluation
Sources: UNICEF, United Nations Development Programme, World Health Organization.
Image Credit: “Malaria prevention, Kenya,” courtesy of flickr user DFID.
