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

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.

Explaining health behavior

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

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

Gender and Development

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

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

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

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

Researching Nodding Disease

Nodding disease is a syndrome that was first reported in Tanzania in 1962, has been spreading in South Sudan and Uganda more recently. The number of cases in northern Uganda appear to have increased at a particularly fast clip in the last year. Nodding disease sounds made-up, but it is very real and often fatal, and is becoming a growing problem in the region. Most problematic is that the causes of nodding disease are still unclear, although there appears to be a connection with a parasitic infection from Onchocerca Volvulus, which causes river blindness.

Adult Onchocerca volvulus worms (WHO)

The Daily Monitor ran a story on December 23, 2011, quoting director of health services in Uganda, Dr. Jane Achieng, as saying that there are around 2,200 reported cases of nodding disease in Uganda (most in Acholi sub-region) and that the first case in the area had been reported in 2009.

A letter to the Daily Monitor written by Dr. Ddungu, of the Uganda Programme on Cancer and Infectious Diseases, notes that a similar phenomenon was studied in Kyarusozi sub-county as early as 1991. A 1992 study by E. Ovuga et al. on this topic was published in the East African Medical Journal.

Nodding disease appears to afflict children between the ages of 5 and 15 and is usually diagnosed by the characteristic nodding it produces in children. The head nodding (HN) is often triggered by eating or seeing familiar foods, or when a child becomes cold. Winkler et al. (2008) write:

HN represents a repetitive short loss of neck muscle tone resulting in a nodding of the head, sometimes associated with a short loss of muscle tone of the upper extremities. Loss or impairment of consciousness may be present, but not always. To date HN is not mentioned in any classification and it remains unclear whether it represents a seizure disorder and if so, whether it belongs to the group of generalized or partial seizures.

Nodding disease appears to be a growing problem that warrants serious attention from the government. The CDC and WHO have been involved in investigating its causes, but there has been relatively little information available to the public about this illness. I’ll be posting information on the published medical literature on nodding disease, as well as news updates and commentary as they become available.

Analyzing Africa: The Audacity of Despair

A new, defiant image

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

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

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

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

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

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

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

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

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

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

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

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.

Childhood vaccination in sub-Saharan Africa

First of all, if you are in Kampala and interested in health, don’t miss the health journalism conference hosted by the Health Journalists Network in Uganda taking place today at Hotel Africana. Follow HEJNU on twitter for live updates here.

Since I am very far from Kampala, I have been spending time with health data instead. Today I was looking at immunization rates over time in sub-Saharan African countries. The colorful fruits of my labor, looking at measles, polio, and BCG (TB) are below. Each colored line represents a country:

Measles:

Polio (three shots):

BCG:

 

What can we make of these graphs? Well, it looks like measles vaccination rates tend to get “stuck” somewhere around 80% of coverage. Meanwhile, BCG coverage rates hit near 100% by the late 1980s in many countries. Polio has less clear patterns. Why is this? Is it a data problem? I’m not sure, but I’d like to find out.