Poverty and Human Development has been the major these of over 200 scientific and medical journals this fall. As part of that theme, PLoS Medicine asked a 30 commentators worldwide, “Which single intervention would do the most to improve the health of those living on less than $1 per day?” The respondents ranged from community activists to international experts.
Food, nutrition and related issues were common with 7 mentions. People mentioned direct food support, ensuring food security, exclusive breastfeeding as well as improvements in agriculture policy and land tenure systems that could boost food production. Five people stressed the importance of basic education, especially for females. Cash transfer and credit schemes received 4 mentions, while 4 people stressed basic water and sanitation interventions. There was some overlap in ideas.
Health related interventions fell in two broad categories, health technologies and health systems improvements. Five people suggested direct help that would provide medicines, vaccines and other technologies at the community level. Jeffrey Sachs was the only one to single out malaria when he said that, “n tropical Africa, a mass distribution of free long-lasting insecticide-treated bed nets to fight malaria accompanied by free access to artemisinin-based combination anti-malaria medicines. In other parts of the world, the situation will be different. I should add that I’ve spent years objecting to posing the question this way, since at low cost we could achieve major health advances through more comprehensive approaches.”
Health systems issues, mentioned by 5, were far ranging from community intervention to change in international agencies. Trained community health workers were suggested as the best way to deliver the above mentioned health technologies. Community/consumer participation in health policy formulation was mentioned. One person even suggested that the World Health Organization be made more effective. Better focused health/development aid was another more global approach.
Now that the malaria eradication vision has been put on the table, an economic rational for pursuing that strategy will become very important. We just need to remember that there are many other deserving interventions that will compete for funds and attention. Fortunately, taking a cue from the Millennium Development Goals, we can see the interrelationship among all these health and development issues.
A new study published in Tropical Medicine and International Health (TMIH) shows that the burden of malaria falls disproportionately on poorer households. Somi et al. report that, “Poorer households bear a greater economic burden from malaria relative to their consumption than better-off households. Households are particularly vulnerable to malaria in the rainy season, when malaria prevalence is highest but liquidity is lower. Alternative strategies to assist households to cope with seasonal liquidity issues, including insurance, should be investigated. The seasonal variation in the economic burden of malaria has implications for the design and interpretation of studies.” The attached graph shows these findings for the rainy season.
In the same issue of TMIH, Deressa et al. look at the experience of rural families in an area of epidemic malaria and conclude that, “Malaria poses a significant economic burden on rural households and individuals both through out-of-pocket payment and person-days lost.” They suggest that, “The promotion and implementation of insecticide-treated nets would alleviate the economic consequences of the disease.”
Malaria Journal reported last year that, “The impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future,” in a review article by Chuma et al. These negative coping strategies include borrowing money and selling assets, often because poor people have delayed seeking treatment they know they cannot afford.
As mentioned above, providing ITNs to the poor is a step in the right direction. Other pro-poor interventions that cut mortality and improve equitable access to services include “Strict monitoring of patients, removal of prescription charges for families, and small financial incentives for the staff cut hospital mortality for malaria” and “Implementation of home based practices using prepackaged antimalarial drugs.”
Ultimately, as Chuma et al., suggest, “To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.” In short – the Millennium Development Goals see malaria control as part of development, not a vertical disease program. Donors and health planners need to take note.
The World Development Report 2008: Agriculture for Development. points out starkly that agriculture has been neglected. Evidence exists that rural poverty has actually increased in Sub-Saharan Africa and South Asia, two areas of high malaria endemicity. Therefore the World Bank calls for greater investment in agriculture in developing countries. According to
Jaques Diouf in the International Herald Tribune, rising agricultural commodity prices, climate related disasters, and population increase are among factors threatening food security in the developing world. “World Bank studies show that a 1 percent price rise for staple food products leads to a drop of around 0.5 percent in calorie intake for the world’s poorest.” At the same time Diouf sees opportunities for African agricultural development if past neglect cited in the World Development Report is addressed. One needs to throw malaria into this equation.
The World Development Report identifies several ways in which malaria affects agriculture and agriculture affects malaria. Production systems, particularly irrigation and micro dams facilitate mosquito breeding. Generally the siting of villages and farms near water sources increases the likelihood of malaria, and malaria in turn is a major drain on agricultural production. The neglect of agriculture and the farming population over the years has rendered them less able to purchase or access malaria prevention and treatment services.
On the other hand some practices like keeping livestock near the house may deflect mosquitoes from humans. Even better, the Report identified that improved income from agricultural investments actually makes it possible for people to buy ITNs and obtain treatment in a timely manner. The key lesson from the report is that rural development – both in terms of health and agriculture – must be planned together for optimal benefits.
Nothing is straightforward in Washington, though with modern communications technology it is a bit transparent for those willing to dig out the facts.Â USA Today reports that, “The Senate Appropriations Committee … is boosting Bush’s $4.2 billion request for the foreign aid bill’s global HIV/AIDS account by $940 million. Lawmakers are adding $590 million to the Bush administration’s request for a global fund to combat AIDS, tuberculosis and malaria; that is enough money to almost triple it,” while cutting money from the Millennium Challenge Corporation (MCC). The reason for the latter move is lack of absorptive capacity – a charge that is often leveled against grant recipients in developing countries.
Ironically the lack of faith in the US contribution to the Millennium goals process comes at a time when the UN warns that anti-poverty targets in Africa will not be met. According to the Guardian, “UN said the world was failing in the battle to combat hunger, cut infant mortality and put every child in school.” Likewise Reuters reports that, “Sub-Saharan Africa, the poorest corner of the world, has struggled to keep up with other regions, the report said, noting urgent needs in its fight against HIV/AIDS, malaria and tuberculosis, as well as basic medical care and education.”
The MCC recently awarded “Mozambiqueâ€™s five-year $506.9 million Millennium Challenge Compact aims to reduce poverty levels throughÂ increased incomes and employment by improving water, sanitation, roads, land tenure, and agriculture. This program is expected to benefit approximately five million Mozambicans by 2015.”Â This package should complimentÂ efforts by the President’s Malaria Initiative in Mozambique, for example as “improved water systems, wastewater disposal, and storm water drainage” may help control mosquito breeding.
While we certainly do not advocate funding agencies that cannot spend money in a wise and timely manner, we do encourage the viewpoint that sees malaria control as part of a wider health and development effort.
Cotton subsidies enjoyed by U.S. farmers has a dampening effect on agricultural family incomes in the Sahelian countries of West Africa according to a news story in the New York Times. An Oxfam supported study found that a typical farm family of 10 in Chad, Mali, Burkina Faso or Benin “that now earns $2,000 a year would have an extra $46 to $114 a year to spend if American subsidies were removed.
While critics were quoted as saying that the amount of gain is low, that cotton prices are naturally volatile, and that countries would gain more by investing in industry, the seemingly slight potential economic improvement would be quite meaningful to rural families.
Daniel Sumner of the University of California Davis, who was involved in the Oxfam study, has previously written that, “The United States is the only WTO member that highly subsidizes cotton and that plays a significant role in the global cotton market.” He Further explains that, â€œUnlike rice, where poor nonfarm consumers likely gain from lower world prices, the rich-country cotton subsidies likely have little benefit for any of the poor in poor countries. And, unlike sugar, for which some poor countries get valuable preferential access to rich-country markets, there are no poor-country cotton producers that gain from the rich-country cotton subsidies.â€
Oxfam has been raising concern about the cotton subsidy issue for over five years. For example in 2002, Oxfam explained that, “American cotton subsidies are destroying livelihoods in Africa and other developing regions. By encouraging over-production and export dumping, these subsidies are driving down world prices. Oxfam also documented that, “Federal subsidies to the 25,000 US cotton farmers were worth more than $4.2 billion dollars in 2004-2005 â€“ more than the gross national product of Burkina Faso.” In addition to subsidies, Oxfam has addressed World Bank policies and programs that seem privatization of the cotton industry at the expense of the rural poor.
So what if the poor in the Sahel cotton producing countries had the extra cash? Would they use it to buy bednets to prevent malaria? Would they access ACT malaria treatments? Such actions might help offset the tremendous economic burden of malaria. Freedom From Hunger Foundation has found a successful link between microcredit and controlling malaria by families whose income improves. Doing away with cotton subsidies in rich countries may have an even wider impact on poor families’ ability to control malaria in Africa.
The G8 has just reaffirmed its pledge to support malaria and other disease control efforts in Africa and many countries are in the process of developing their Global Fund Round 7 grants. Therefore it is an interesting time to consider a 2005 Der Spiegel interview of Kenyan economist James Shikwati that calls on the industrialized world to STOP AID.
According to Shikwati, â€œSuch intentions have been damaging our continent for the past 40 years. If the industrial nations really want to help the Africans, they should finally terminate this awful aid. The countries that have collected the most development aid are also the ones that are in the worst shape. Despite the billions that have poured in to Africa, the continent remains poor.â€Â Walter E. Williams of George Mason University echoed these views in the Baltimore Examiner on 28 June 2006 when he said, â€œNo amount of Western foreign aid can bring about the political and socio-economic climate necessary for economic growth.â€
Shikwati said the problem arises because, â€œHuge bureaucracies are financed (with the aid money), corruption and complacency are promoted, Africans are taught to be beggars and not to be independent. In addition, development aid weakens the local markets everywhere and dampens the spirit of entrepreneurship that we so desperately need. As absurd as it may sound: Development aid is one of the reasons for Africaâ€™s problems. If the West were to cancel these payments, normal Africans wouldn’t even notice. Only the functionaries would be hard hit, which is why they maintain that the world would stop turning without this development aid.â€
On the other side is praise for aid. The Global Fund has praised the announcement by the G8 to commit US$ 60 billion for disease control efforts. This may be a way for GFATM to reach its recently announced goal to become a $US 6-8 billion operation annually. Ironically, these efforts are criticized as inadequate. The BBC News reported Bob Geldorf as saying, â€œThis wasn’t serious; this was a total farce… I wonâ€™t have it spun as anything else except a farce.â€ According to BBC, Geldorf added that instead of re-committing to the promises made two years ago, the G8 leaders had to get serious and deliver. Oxfam was reported to analyze that only â€œ$3bn of the money was new.â€
So the question remains â€“ is global development and disease control aid helpful, inadequate or a hindrance? Aid can hinder entrepreneurship as was the case in Nigeria where one donor was working with local textile and pharmaceutical companies to develop net and insecticide bundled packages while other donors started importing LLINs for their programs. Can aid be more effective if there is donor coordination? Can aid succeed if it focuses on technology transfer and trade? Finally, does a performance based approach to aid as practiced by the GFATM really work and make bureaucracies deliver the goods and be accountable? If the answers to these questions are yes, there may be some hope for development aid.
A recent AFP report focuses on the village of Sauri near Lake Victoria in Kenya. Sauri is one of the first 12 Millennium Development Villages (MDVs) in Africa and has been making strides using an integrated development approach. The Millennium Development Goals (MDGs) focus broadly on improving income, food supply and education, enhancing womenâ€™s empowerment, improving health, reducing disease, protecting the environment and encouraging partnership in addressing all these issues. These goals are now being pursued by many nations, but are specifically being addressed in a total of 80 MDVs.
In Sauri both women and men are producing more on their farms after learning new techniques, are sending more of their children to school, and are able to feed themselves. These results are interrelated since improved farming improved diet and makes children more alert in school. School attendance and school performance ranking in the district have risen. To round out the development efforts a free clinic has opened and free ITNs have been distributed in the village. Villagers attribute better school attendance to reduced malaria burden in their children.
Villagers also raise the question about sustaining these achievements. They ask whether the government will maintain the improvements. Some talk of a slow weaning process of donor support for village improvements as a way to ensure the village can stand on its own. In the meantime more people are moving in as they see the benefits enjoyed by their neighbors.
Questions arise. Can we achieve MDGs one village at a time? Can economic improvements enable villagers themselves to maintain the improvements, e.g. through revolving funds to guarantee continued supplies of malaria drugs and nets? Can all the thousands of villages in Africa become MDVs?