Health Care in Developing Nations

This blog has repeatedly reported on the success of microfinance organizations such as Nobel-prize-winner Muhammad Yunus’ Grameen Bank and ACCIÓN (see 26 Mar 07 and 26 May 06 posts). Up to this point, the organizations who have worked to make loans to the world’s poor have been nonprofit organizations. Now, however, The Economist reports (”Doing good…“) that CompartamosBanco is a private for-profit business who is aiming to make money making loans to the poor.

Having for-profit businesses service loans shows that microfinance is expanding. The profits from these loans can be used to offer more and more loans to the the world’s poor. However, for-profit firms do charge high interest rates. Interest rates at CompartamosBanco are currently 79%. These figures are so high because it costs $152 to service the average $450 loan.

While Muhammad Yunus is somewhat troubled by the advent of for-profit microfinance, ACCIÓN has partnered with CompartamosBanco on some projects.

Should microfinance be a for profit business? What is your opinion?

An estimated 1.6% of Ethiopia’s the population is blind, with approximately 12% of this blindness caused by trachoma.  Trachoma is a highly infectious disease; it is spread through contact with an infected person’s hands or clothing, or by flies that have come in contact with the discharge from an infected eye or nose.  One good piece of news is that trachoma is entirely preventable.

ORBIS International has been working to try to save the sight of many of those who are suffering from eyes diseases such as trachoma.

For more information on ORBIS, see:

• Their homepage:
• Pictures of those they’ve helped:
• Charity Navigator evaluation of ORBIS.

Does rainfall improve health for children in developing countries? Sharon L. Maccini and Dean Yang (2008) hypothesize that higher rainfall will lead to higher incomes for rural household and higher incomes allows increased food purchases and more disposable income to be made available for health care purchases. The authors find that in Indonesia, “[w]omen with 20% higher rainfall (relative to normal local rainfall) in their year and location of birth are 3.8 percentage points less likely to self-report poor or very poor health, attain 0.57 centimeters greater height, complete 0.22 more grades of schooling, and live in households that score 0.12 standard deviations higher on an asset index.” Similar effects were not found for males however.

It seems to be the case that generating more income for poor households in developing countries is the best way to improve the health status of their female children.

• Sharon L. Maccini, Dean Yang (2008) “Under the Weather: Health, Schooling, and Economic Consequences of Early-Life Rainfall” NBER WP #14031.

Abhijit Banerjee and Esther Duflo find that for rural households, the probability that the mother is alive is 36 percentage points higher if the family has a daily per capita expenditures (DPCE) of $6 to $10 versus a DCPE of $1 to $2.  Using a panel data set specification, the authors also find that adults over 50 living on less than $2 a day are at least three times as likely to die over the next five to seven years than those living on $6 to $10 a day.

Are people poor because they are sick or do they get sick because they are poor?  The direction of causality is unknown.

Economists predict that longer life expectancy leads to more investment in education. For those who live a short time, sacrificing working years for education is not worthwhile if the payback period is short. For those with a longer life expectancy, an individual can reap the monetary rewards from education over a longer period of time.

An NBER working paper by Seema Jayachandran looks at a what happens to educational investment after there was a 70% reduction in maternal mortality risk in Sri Lanka. The decreased maternal mortality rate was due to a number of factors: an increase in the number of hospitals, clinics and health centers, an increase in the number of trained birth attendants, transportation improvements such as free ambulances, and increased adoption of western technologies such as sulfa drugs and penicillin. Further, there was significant success in eradicating malaria during this time. Also, most of the medical services were provided for free.

Jayachandran uses a difference-in-difference-in-difference (DDD) strategy. “The first difference is over time, since maternal mortality fell between 1946 and 1953. The second difference is across geographic areas; the magnitude of the MMR declines varied considerably across Sri Lanka’s 19 districts. The third difference is between genders; maternal mortality is quite unique among major causes of death in that it exclusively pertains to women.”

The results of the study are that the decline in “…maternal mortality risk over the sample period increased female life expectancy at age 15 by 4.1%, female literacy by 2.5%, and female years of education by 4.0%.”

• Seema Jayachandran (2008) “Life Expectancy and Human Capital Investments: Evidence From Maternal Mortality Declines” NBER WP #13947.

The Economist (”Doctor on Call“) has an shows that mobile phones may have another use for doctors: a microscope.

“Mr Maamari is a member of a research team led by Dan Fletcher, a professor of bioengineering at the University of California, Berkeley, which has developed a cheap attachment to turn the digital camera on many of today’s mobile phones into a microscope. Called a CellScope, it can show individual white and red blood cells, which means that with the correct stain it can be used to identify the parasite that causes malaria. Moreover, by transmitting an image directly over the mobile network, the CellScope could greatly help with the remote diagnosis and monitoring of many illnesses.“

Paul Polak’s book Out of Poverty could have just as easily been titled “How to get rich: a guide for small-time farmers in developing countries” or “Marketing to dollar-a-day earners.” Polak’s book states that donations –especially those run through the developing country government–will not end poverty. They have not so far. One reason is that most donations are used to give away goods for free. But this destroys the incentive of any small businessperson to try to sell affordable priced goods to the poorest of the poor.

Polak’s NGO, IDE, develops products for those in extreme poverty in developing nations. Polak stresses that any good targeted to poor rural farmers must be 1) cheap, 2) small scale and 3) expandable. Drip irrigation is one great way for poor farmers to conserve water and efficiently irrigate their crops. Further, drip irrigation will allow farmers to grow crops during their more lucrative off-seasons, when the price from the crops is higher. Unfortunately, most drip irrigation companies make large, capital intensive products targeting large farms. IDE has taught farmers to use less expensive versions of these drip irrigation technologies to increase their income. IDE has also helped to spread the treadle pump technology to many farmers.

Another NGO with a similar philosophy as IDE is the Scojo Foundation. Scojo gives small entrepreneurs the materials and training to start their own firm selling reading glasses to the poor. Not only do these small-time entreprenuers profit, but customers who’s vision improved also appreciate the market transaction.

Another seemingly obvious point Polak makes is that the cure for poverty is to find a way for the poor to make more money. Increasing the education or medical care the poor receive is not in and of itself a means out of poverty. Poor children get little education because their parents need them to work on their farms to survive, not because they do not understand the value of eduation. Polak claims that once farmers in developing countries increase their income, they do increase their spending on education for their children, and medical care for their entire families.

• Polak, Paul. (2008) Out of Poverty: What works when traditional approaches fail. Berrett-Koehler Publishers, Inc. San Francisco, 232 pages.

Diarrheal disease is a leading cause of childhood mortality in many developing countries. The best treatment when diarrhea strikes is to give the patient Oral Rehydration Solution (ORS). Who provides better care for this disease, public or private providers?

A paper in Health Economics by Waters, Hatt and Black (2008) looks at data from the Living Standards Measurement Surveys (LSMS). This data set draw observations from Latin American and Caribbean countries.

The first item that Waters and co-authors note is that richer household are more likely to see the private physician. “Each additional quintile of household economic status is associated with an increase of 6.5 percentage points in the probability that a child with diarrhoea is taken to a private provider.”

But do these wealthier households receive better care? According to the authors, “treatments provided in the private sector are manifestly of worse quality than in the public sector. A total of 33.0% of children visiting a public provider received Oral Rehydration Solution, compared to 13.7% of those visiting a private provider. Conversely, children treated by a private provider are more likely to receive drugs, most commonly unnecessary antibiotics.”

Private physicians have an incentive to prescribe the more costly antibiotics because they make more money. The publicly financed providers do not have this incentive. The authors claim that prescribing antibiotics may also augment the provider’s reputation with patients. This would be analogous to an American physician preforming an MRI when it is not necessary. The physician makes money on the MRI, the patient believe they are getting high-tech care that is the best in the world, but the MRI may often be a waste of resources.

Winner: Public Providers

• Hugh R. Waters, Laurel E. Hatt, Robert E. Black (2008) “The role of private providers in treating child diarrhoea in Latin America” Health Economics, 17(1): 21-29.

Yes, its true. The WTO has adopted a blue toilet seat for its logo. This is not surprising, however: the World Toilet Organization–you didn’t think I was talking about the World Trade Organization, did you?–is dedicated to improving sanitation issues around the world.
While the blue toilet seat logo, may be amusing, the WTO’s goal is life-and-death serious. In “A Sanitation Crisis that’s no Joke,” the New York Times reports that 40 percent of the worldwide population, or 2.6 billion people, has no access to hygienic toilets. “Diarrhea kills 1.6 million children each year — more, even, than malaria — and the pollution of drinking water with waste is a principal cause.”

During my time spent in El Salvador, I saw that the disposal of human waste was a serious problem. In the low-lying Bajo Lempa region of El Salvador, human feces often contaminated water sources used for drinking until new latrines were installed to prevent this contamination. Many of the children had diarrhea or parasitic worms preying on their health.

While potty jokes are funny, providing quality sanitation to more of the world’s population is not a laughing matter.

One of the UN Millennium Goals is to halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation. We know that large-scale investments in piped water have dramatic impacts on reducing childhood mortality. Piped water, however, may be prohibitively expensive for the nations to provide to rural residents in low-density areas. Thus, we need to find clean water alternatives for the 926 million people without access to a clean water source who are living in the rural areas of developing countries.

According to a paper by Iyer et al. 2006, nearly all of the $5.5 billion the World Bank invested in rural water and sanitation programs during 1978–2003 focused on improving water supply sources and quality through interventions such as well digging. During my time in El Salvador, many of the NGOs there were digging wells to provide clean water to the residents.

A recent NBER working paper by Alix Peterson Zwane and Michael Kremer, however, suggests that well digging is not an effective means to reduce diarrheal diseases. This diarrheal diseases kill over 2 million children in developing countries each year. One of the major reasons for this are the significant maintenance costs which need to be incurred each year in order keep the well functioning. In fact, one third of rural water infrastructure in South Asia is believe to be not functional. Other studies found that more effective rural interventions included: exclusive breastfeeding, immunization, oral rehydration therapy, micronutrient supplementation, point-of-use water treatment systems, and increased hand washing.

Careful evaluation of future clean water initiatives is necessary in order that money spent on infrastructure in the developing world is used in the most effective manner possible.

The Economist’s Free Exchange blog has some interesting commentary on income inequality and health (”Healthy, wealthy and wise“).  The post talks about Angus Deaton’s Spring 2003 NBER Reporter Commentary.  In the Reporter, Mr. Deaton states the following:

• “[In a study by Christina Paxon and I], We focused on the idea that health is determined by an individual’s income relative to other members of a reference group whose membership typically is unobserved by the analyst. Even if income inequality has no direct effect on health, the fact that the reference groups are not observed means that the slope of the relationship between health and income depends on the ratio of the between-to-within group components of income inequality. For example, if doctors’ health depends on the income of other doctors, and economists’ health on the income of other economists, then the health-to-income relationship in the pooled data will flatten if the average incomes of the two groups pulls apart.³ Among birth cohorts there is a strong protective effect of income on mortality; the elasticity of mortality rates with respect to income is approximately -0.5.”

Deaton also summarizes a working paper by Anne Case (”Does money protect health status?“) which looks at data from South Africa.  “Her work finds evidence of a large causal effect of income on health status — working at least in part through sanitation and living standards, in part through nutritional status, and in part through the reduction of psychosocial stress…Governments interested in improving health status may find the provision of cash benefits to be one of the most effective policy tools available to them. And cash provides a yardstick against which other health interventions can be measured.”

One problem with cash rather than in kind benefits is that there is more potential for corruption when cash benefits are handed out.  Cash, however, gives individuals more choice regarding how to use one’s limited resources and also can reduce the transaction costs of administering in-kind governmental transfers.

Muhammad Yunus is not only one of the pioneers of the microcredit industry as the founder of the Grameen Bank, he is also a Nobel laureate.  The World Health Care Blog is currently covering the World Health Care Congress Europe 2007 and has an enlightening video post of some of Dr. Yunus’s comments regarding health care in the developing world.

When Dr. Yunus was questioned as to whether or not poor individuals in Bangladesh should have to pay for health care, he replied: “I think it’s very important to have the patients, the people who are asking for health services, to pay. How that payment will be made…it can be in a variety of ways. But the important thing is they must pay. They must feel that this is a service they are buying so that they feel equal, so they don’t feel small.”

Dr. Yunus later states that payment for medical services can be made in a variety of ways. Of course, there are cash payments, but individuals also can pay by taking out a loan or making incremental payments, or purchasing health insurance in anticipation of the possibility of sickness or individuals could even pay in kind if they have little cash. The rest of Dr. Yunus remarks are just as interesting and I encourage you to view his remarks.

A 2007 NBER working paper by Banerjee, Iyer and Somanathan presents the following facts: “In Nepal, access to schools is ten times better in the best districts compared to the worst. For Kenyan provinces, this ratio is 8:1; it is more than 2:1 for both Indian states and Russian regions and slightly over 1.5:1 for Chinese provinces. In contrast, regional differences are small in Mexico and Thailand and negligible in Vietnam.” Why is the case? What determines these differences in public good allocations? The Banerjee, Iyer and Somanathan paper reviews some of the root causes of why public good provision can be so variable within and across countries.

• Land Ownership. Foster and Rosenzweig (2000) investigate 245 villages in India between 1971 and 1982 and find that “investments in schooling were greatest in areas with a high fraction of landed relative to landless households.”
• Cultural Norms and Religious Beliefs. The Brahman caste are traditionally considered to be priestly elite in India. A paper by Banerjee and Somanathan (2006) finds that “in the early 1970s, the population share of Brahmans in a constituency is positively correlated with access to primary, middle and secondary schools, to post offices and to piped water.”
• Sex of Politician. The 73rd Amendment to the Indian Constitution requires that one third of all local election seats be reserved for women. A paper by Chattoppadhyay and Duflo (2004) concludes that “political reservation for women in local government results in greater provision of goods which women value, such as drinking water and roads.”
• Ethnic Fragmentation. There has been a lot of work done to see whether or not ethnic diversity will increase or decrease the amount of public goods provided in a given area. Alesina, Baqir and Easterly (1999) find that U.S. cities with more ethnic fragmentation “spend proportionally less on schooling, roads and trash pickups but more on health and police.” Banerjee and Somanathan look at data in India and “construct a fractionalization index of social heterogeneity using population shares of non-Hindu religions (Muslims, Christians, Sikhs, Jains, Parsis), as well as 185 distinct Hindu caste groups…Of the fifteen different public goods considered in 1971, they find that the social heterogeneity measure has a significant negative effect in six cases and positive in two.”
• Monitoring and Communication. A general finding for the experimental literature is that individuals generally give more money to public goods than predicted by the Nash Equilibrium, but if games are repeated, the donations converge to the stingy Nash equilibrium. An experiment by Cason and Khan (1999) allowed the experimental group to converse for a few minutes before they decide on their contributions. Individuals receive information on others donations levels after either every round or every six rounds. The authors find that “in the absence of communication, contributions with both types of monitoring are fairly similar and decline over time. In the presence of communication, overall contributions are much higher (about 80% of the tokens were invested in the group activity as opposed to a high of 40% in the no-communication case) and did not decline in later rounds.” Thus one can conclude that a monitoring mechanism operated within a group where communication is frequent can lead to high levels of public good contribution.
• Autocratic Rule. Many public good expansions have taken place under colonial or autocratic rule. The European powers often helped to provide schooling for the people living in their colonies. The British, French and Dutch invested more in local public goods than did the Belgian or Portuguese. During the 19th century, autocratic princely states in India often invested heavily in public goods despite no political pressure to do so. “The Travancore state in present-day Kerala is particularly well-known for its long tradition of enlightened rulers. In 1817, the Regent Gauri Parvathi Bai declared, ‘The state should defray the entire cost of the education of its people in order that there might be no backwardness in the spread of enlightenment among them, that by diffusion of education they might become better subjects and public servants and that the reputation of the state might be enhanced thereby.’ “
• Political Atmosphere. “After independence, the Kenyan leadership played up tribal loyalties for political reasons and little effort was put into building a Kenyan identity; in contrast, the Tanzanian leadership put a lot of emphasis on creating a single Tanzanian identity. This seems to have implications for public good provision: in the Busia region of Kenya, ethnic heterogeneity at the local level is negatively correlated with the quality of public goods (mainly schools), while in the nearby Meatu region of Tanzania, they are slightly positively correlated.”

Note: The term “public good” is used in a very general sense in the paper. Using a stricter definition, education has some public good elements if working with more educated individuals increases one’s productivity. Medical care generally is not seen to be a public good with the exception of services such immunization, but Public Health efforts—such as maintaining a clean water source—are more likely to fall within the public good arena.

• Banerjee, Iyer, Somanathan (2007) “Public Action for Public Goods” NBER Working Paper, #12911.

In yesterday’s Wall Street Journal (”In China…“), there is an interesting article about health care in rural China. The article gets at the heart of a number of health care issues:

• Physicians paid on a fee-for-service basis treat their patients more intensely compared to physicians paid on a salaried or capitation basis. In rural China, doctors made almost all of their annual earnings from prescribing pharmaceuticals. Thus, it comes as no surprise that patients were often over-prescribed drugs; some patients even died from excess drug prescription. “Ni Shiqiao, a 37-year-old doctor in a nearby village, whose father and grandfather were both village doctors, says that before the experiment started, he made nearly all his income selling prescription drugs. Now he makes a monthly salary and prescribes fewer drugs than before.” On the other hand, salaried doctor may under-treat patients since they make zero marginal revenue from most medical services they provide.
• The benefits and costs of a government-run health care system. It is easy to see that when the health care system is federally run, the risk of any idiosyncratic negative health shock is spread across a large population. Nevertheless, rural farmers in China were hesitant to contribute to this risk-sharing national health plan. Harvard health economist William Hsiao states, “When the government collects money from them [the villagers], they often worry that the money is going into the pockets of the government officials, not beings used for the people.”
• The pros and cons of decentralization. Dr. Hsiao started a program in which villagers would elect their own representative to administer their own health insurance funds. The village doctor would be hired and fired by this council. One can see that decentralization empowers villagers; “the more the villagers understood about where their money was going, the more they would want to participate.” Having decentralized health insurance, however, may not be optimal when risk is not idiosyncratic. For instance, if a virus was to infect all the farmers in a village, the local health insurance pool would likely not be sufficient in order to cover the necessary cost of treatment for each individual.

The Economist magazine (”Pyramid power“) has an interesting article on how to get reading glasses to poor individuals in third world countries. Below are two excerpts:

Government health clinics are understandably preoccupied with life-threatening maladies and urban optical shops typically shun simple reading glasses in favour of costly, high-margin prescription glasses. But this neglect takes a dramatic toll even on illiterates: farmers can no longer identify pests and choose the proper pesticides, craftsmen cannot manage fine handiwork, seamstresses cannot sew. As their sight fades, so does their income.

Unsurprisingly, The Economist looks to a market-based solution to the problem: “micro-franchising.”

“We deliver a ‘business-in-a-box’ to local entrepreneurs, train them and enable them to make money helping people see better,� [Dr. Kassalow] says. Each pair of glasses that Scojo provides to these entrepreneurs costs the firm about $1 to make and deliver. The franchisee pays it $2 or so and sells for about $3. Because every step of the value chain is profitable, the business model is sustainable. Profits are reinvested to expand the scheme. Scojo has sold 50,000 pairs of glasses so far and is aiming for 1m pairs by 2010 and 10m by 2016.

Micro-franchising may be successful when there are supply chain issues or individuals in third world countries are ignorant of new technologies available to them. These issues often occur in the health care industry. In other sectors, however, which need to be more responsive to local consumer demand, centralized micro-franchising may not be as successful.

In earlier posts, I have reported on health issues in China—such as the AIDS epidemic in western China and problems of potable water in northern China.  Today, the Boston Globe has an interesting report on The graying of China. 

While China is still relatively young now, the country will age quickly.  With the implementation of the One-child Policy (aka:计划生育 , Planned Birth policy) in 1979, China’s fertility rate has dropped to 1.8.  If socialist/communist style government welfare programs are to continue, the paucity of young working adults will create severe fiscal problems.  China’s ratio of workers to retirees is predicted to drop to 2 to 1 by 2040; this is far below the 5 to 1 ratio needed to maintain a U.S.-style Social Security system.  Already we see that where once almost all Chinese were covered by a rudimentary healthcare system, today about half the country lacks healthcare coverage. 

According to a World Bank Report “China’s pension debt of about $1.5 trillion is woefully underfunded, in part because pension money is often misused by corrupt government officials.”  In November…”China’s National Audit Office announced it had uncovered $1 billion in misused pension funds.” 

One proposal is to end the one-child policy and encourage births. The government is also experimenting with different healthcare policies. But the central problem is cost. While advanced countries that have aging patterns similar to China’s have annual per capita incomes of about $10,000, China’s annual per capita income is just about $1,300, said Chen Zhi, chief of the department of population and social science in Sichuan Province, which has the highest proportion of seniors in China.

“We are like a man getting old before he gets rich,” Chen recently told the local press.

The New York Times has an interesting article (”China’s Muslims…“) of how AIDS is affecting Muslims in western China. The newspaper reports that there is a “sea change by the Chinese public health establishment” in which intravenous drug users are now being sent to treatment instead of jail. The major impetus for this change was the Chinese government’s desire to stem the spread of AIDS.

Media that Matters is an organization dedicated to producing films portraying controversial issues relevant to today’s society and encouraging viewers to work towards social change.  While the organization is heavily left leaning politically, they do have a wide variety of health-related films (see health/health advocacy section).   I did come across an interesting short film regarding women in the Congo (map) titled In Transit.  Below, you can find an excerpt from a discussion of In Transit by the film’s directors.  The directors plan to make a full length version of the movie in the future.

“The Goma Film Project came about when Doctors on Call for Service (DOCS—now called HEAL Africa), a teaching hospital and nonprofit organization located in Goma, Democratic Republic of Congo (DRC), enlisted filmmakers Louis Abelman, Bent-Jorgen Perlmutt, and Nelson Walker III to produce assorted informational videos. The first of our assignments was to create a small series of surgical training videos documenting vesico-vaginal fistula (VVF) repair, the most common procedure performed at DOCS on any given day.

A vesico-vaginal fistula is a tear in the vaginal wall that opens into the urethra. In the first world, fistulas are rare; in most parts of the third world, they are caused by complications during childbirth. In the eastern Congo, they are primarily caused by an epidemic of violent rape and torture taking place in the war-ravaged countryside. Marauding armies and militias, some responsible for the Rwandan genocide of 1994, continue to stalk the forests and villages of the region. Women and girls of multiple tribal and ethnic backgrounds have increasingly become victims of plunder, rape, and slavery by the many armed groups involved in the ongoing conflict. At least 40,000 rape cases have been documented in the past several years, with some estimates of up to a million additional undocumented cases. DOCS/HEAL Africa is the only hospital in the region that offers a comprehensive rehabilitation program for women who have acquired fistula from rape.”

On Wednesday, Marketplace on NPR ran a story on how providing eye care to individuals in the developing world can not only improve their well-being, but increase economic productivity.  Fortunately, low cost solutions are available.  To view the story, click here.  Some excerpts are below:

“153 million people around the world live with poor vision that could be corrected with glasses. Ninety percent of them live in developing countries. Those with bad vision have problems working and going to school.”

“We know that in many countries we can provide cataract surgical services, say, from $30 to $50 per eye. For glasses, of course, it’s substantially less….And then there’s Vitamin A supplementation, which targets children’s vision. That runs a few cents a capsule”

In Sunday’s L.A. Times I found two articles regarding population growth.  The first (”America at 300 million“) notes that although the U.S. is nearing 300 million people, there is plenty of space available for these newcomers.  Although the birth rate is still not at replacement, the recent increase in immigration has allowed the U.S. to maintain steady population growth.  The article notes that “Today, about 12% of Americans are foreign-born, versus about 5% when the country had 200 million people.”

This is juxtaposed with an article in the main news section which documents population trends in another country with an abundance of land: Russia.  While the U.S. is growing, the Russian population is experiencing a drastic decline (”A Dying Population“).  Part of this trend is due to emigration.  Part of this trend is from higher mortality.  Forty eight percent of Russians die between the ages of 15 and 60 compared to only 13.7% of Americans.    According to the CIA world factbook, Russian life expectancy ranks below Morocco, Honduras, North Korea and Algeria and just ahead of Kazakhstan, East Timor, and Trinidad and Tobago.  AIDS is also a major problem:

“Officially, more than 300,000 Russians are infected with HIV or have AIDS, but the U.N. says the number could easily be much higher.  The problem is not as serious as Africa’s. The difference, experts say, is that African birthrates are high enough to replace those who die. Not so in Russia.  Compounding the problem, the prevalence of AIDS among young people threatens to add to the population decline by killing them before they can bring a new generation into the world…Five million to 10 million Russian teenagers could contract the disease within a few years, federal health officials say.”

There are two other major causes for a low life expectancy: alcohol abuse and income inequality. 

“The average Russian drinks five gallons of pure alcohol a year, causing an estimated 900,000 deaths over the last decade from acute alcohol poisoning, fights and accidents, according to figures released by Tatyana Yakovleva, head of the Russian parliament’s healthcare committee.”

The article also notes that although Russia has the second highest concentration of billionaires in the world, one fifth of Russians live on less than $38/month.  Russia ranks behind Libya, Chile, and Costa Rica in terms of GDP per capita. 

Today’s L.A. Times looks at the poor state of Russia’s health care system (”For the sick, no place to turn“).  Health care is nominally free, but in practice patients must pay hefty bribes in order to receive any more than basic medical services.  Former Soviet industrial areas, such as Karabash, are heavily polluted with chemical and radiation leaks.  Russia has at least 120,000 new tuberculosis cases each year.  Since physicians are using mostly outdated equipment (except for the modern medical centers which cater exclusively to the wealthy), technological progress in the medical field is not keeping up with the West. 

Economist Tyler Cowen of George Mason University has an interesting paper (”Avian Flu: What should be done“) on the optimal policy to combat avian flu.  Below, I cite a few of the more interesting points from his executive summary:

• Prepare social norms and emergency procedures which would limit or delay the spread of a pandemic. Regular hand washing, and other beneficial public customs, may save more lives than a Tamiflu stockpile
• Decentralize our supplies of anti-virals and treat timely distribution as more important than simply creating a stockpile.
•  Make economic preparations to ensure the continuity of food and power supplies. The relevant “choke pointsâ€? may include the check clearing system and the use of mass transit to deliver food supply workers to their jobs.
• We should not rely on quarantines and mass isolations. Both tend to be counterproductive and could spread rather than limit a pandemic.
• We should not obsess over avian flu at the expense of other medical issues. The next pandemic or public health crisis could come from any number of sources. By focusing on local preparedness and decentralized responses, this plan is robust to surprise and will also prove useful for responding to terrorism or natural catastrophes.

Zeyad is a Baghdad-based dentist, and the author of the Healing Iraq blog. In his post on The Guardian website, Zeyad describes how corruption is siphoning off medical supplies from physicians who need them for patient care. Even in areas where terrorism is not a problem, the health care is still abismal. Zeyad states:

“The culpability lies mostly on the shoulders of the new Iraqi government. It often blames terrorism for the deterioration of health services, which is true to a certain extent, but Iraqis in safer regions, such as southern governorates, where there is no impediment to reconstruction, continue to suffer from the same problems. I have served a full year at a state clinic in Basra and I have faced the same problems I face today in Baghdad.

The real reason is the cancer that is threatening to deliver the deadly blow to the system: widespread corruption from the lowest janitor in a public clinic up to the minister of health’s office.”

It is a great achievement that China has one of the highest life expectancy rates (72.6) of any country in the developing world. However, the CIA World Factbook reports that “One demographic consequence of the ‘one child’ policy is that China is now one of the most rapidly aging countries in the world.” The Demography Matters blog reports “Beginning around 2015, China’s post war baby boom generation will reach retirement age, and because of the one-child policy implemented since 1980, working-age population will start to shrink. By 2050, China will lose 18% of its workforce, assuming a fertility rate of 1.8, or 35% assuming a fertility rate of 1.35“

The greying of China is a serious matter. As the future comes nearer, there will be less workers to pay for huge costs of elderly medical benefits. Continued rapid economic growth is one cure to this problem, but economies of the world are inherently volatile. Allowing immigration of younger workers in the future could also help to alleviate the fiscal burdens. We can see that the ‘one child’ policy, in addition to reducing the individual liberties of China’s citizens, has also created a serious fiscal problem for China’s future.

Nata, in Botswana, is a village of 5000 people located on the edge of the Makgadikgadi Pans. Unfortunately, HIV/AIDS is having a devastating effect on the people of this small village. Botswana has the second highest HIV infection rate in Africa. The current rate of infection is 37% nationally and Nata’s rate of infection is even higher. The pandemic has left Nata with over 400 orphans.

Still, these people live half-way around the world. How can we help them? Much of foreign aid is stolen by dictators or bureaucrats. What can be done?

Fortunately, the village of Nata, Botswana has a blog (”The Nata Village blog“). Jon Rawlinson set up the site and Melody Jenkins, a U.S. peace corps volunteer, writes the posts. You can learn a great deal about the village and also donate if you so choose.

For instance, patients in Nata are not adhering to their anti-retroviral treatment at the same rate as those that live nearer to the clinic in Gweta; this is due to a lack of transportation to the nearest clinic to pick up the medicine. Also, the site has a brief biography of an inspirational villager named Reggie.

Another reason to love the Internet.

Iqbal Quadir is not your typical investment banker. Inspired by the non-profit Grameen Bank’s success in his native country of Bangladesh, Quadir has created a variety of initiatives which allow the private sector to be the driving force for development in the Third World. CNN and The Economist (”Power to the People“) both report of Quadir’s initiatives to bring cell phone service, power, and other clean water to the developing world using entrepreneurs. For instance, Emergence Energy is one of his ventures which aims to establish small, neighborhood power plants in Bangladesh that can provide electricity to a handful of homes. Below is an excerpt from the Economist article on Quadir’s clean water program:

At the same time, Mr Quadir is pursuing two other bottom-up initiatives. The first, CleanWater, is dedicated to supplying safe drinking water to Bangladeshi villages, where arsenic contamination is a grave problem. Rather than relying on aid agencies or governments to install equipment, Mr Quadir hopes to license a chemical preparation that can remove arsenic from water and make it safe to drink. The chemical would then be distributed and sold, like salt, via a network of local entrepreneurs; Mr Quadir estimates that buyers would have to spend around $3 per person per year on the chemical to ensure a safe water supply, which is well within reach of most villagers. Again, this initiative would create jobs, provide a wider societal benefit, and give people the means to solve a serious problem themselves.

Interested in the medical field but not a doctor?  Looking to help those in developing countries who are live without access to a physician?  A great resource to use is Where there is no doctor, a classic text published by Hesperian Books.  I recently bought a copy in Spanish (Donde no hay doctor) while I was in El Salvador and the book is spectacular.  Diseases, symptoms and treatments are described thoroughly but simply; pictures abound to help clarify the narration.  Dr. David Morley called it “The best medical book written in the last 10 years…”  One customer from Malawi stated that:

“Everything and anything you need to know about healthcare. We live in the heart of Africa where there are no doctors, and mysterious illnesses and bacteria keep popping up. Since we have this book there is much less cause for worry. Don’t leave home without it!”

Unlike most the publishers of most reference guides, the Hesperian Books encourages individuals to copy relevant sections of the book and distribute them to needy communities as long as the material is provided at no cost.  Since the book has been translated into over 70 languages, literate populations in developing countries now have a resource to educate themselves on their own healthcare needs.

In El Salvador, one finds two parallel health care system.  The first uses state-of-the-art technology, qualified doctors, and physician spend ample time with patients.  The second employs third world technology, treats severe illnesses superficially, and doctors are overworked.  Which of these systems is run by the government?  Which of these systems serves the poor?

As you probably guessed, the first healthcare system described above involves doctors in private practice with a fee for service (FFS) provider payment system.  Using the private physician and medical facilities is expensive; only the wealthy can afford these procedures.  The poor are relegated to using the free government hospitals and clinics.  These facilities do an adequate job of providing immunizations, prenatal care and educational material, but do not have the funds or the staffing to perform surgical procedures which in the U.S. would be considered routine.  Many Salvadorans I spoke with complained that doctors in the public hospitals treat all serious diseases the same: they give patients an aspirin and tell them to grin and bear it since surgery or other complicated procedures are not available.

Also, one notes a distinct difference between urban and rural clinics serving the poor.  Both provide only the most basic of services, however, rural physicians do have more time to spend with patients due to the lower population density.  One physician in the village of Isla de Mendez told me he only saw about 25-30 patients per day and about half of these were educational prenatal visits.  The residents of Isla de Mendez, however, do not have access to medical care on weekends because the physician returns to his home three hours away in the city of San Miguel.  In an urban clinic, patient volume is much higher and wait times of many hours is common, but physicians are available on weekends for emergencies.

The central government also employs promotores, workers who visit villages (such as Ciudad Romero) who do not have a clinic and educate the population about public health risks.  Unfortunately, it seems that the promotores are not very effective since the villagers do not hold these workers in as high esteem as physicians.  Further, since the promotores travel from village to village, they rarely establish a strong bond with the community to make sure that the educational information they impart is implemented.

Plastic bottles strewn on the street, trash fires burning in front of homes, and primitive latrines…El Salvador is pretty much the antithesis of a stereotypically pristine European city. While in the US, we take trash collection for granted–we put our waste into the trash/toilet and it is taken away–in El Salvador waste disposal does not operate as smoothly.

Many residents in rural villages do not have access to trash collection and thus resort to burning their garbage under a pile of leaves. The smoke from burning mounds pollutes the air and the smell is potent. In addition to problems of cigarette smoke and excess dust from dirt streets, the burning of trash has contributed to a high rate of respiratory disease in El Salvador. The burning of garbage made from plastic pollutes the air even more than the typical household refuse. The solution to the problem that one NGO came up with was to have a trash compost area for each house where biodegradable waste could be buried under a layer of dirt and leaves in order to reduce air pollution. The waste would slowly decompose and air pollution—and thus respiratory disease—could be reduced. Paved streets would also reduce pollution from the dust spewed into the air from passing cars and farm animals but this solution is more expensive (although it does have the economic benefit of decreased transportation costs).

Another problem rural El Salvador faces is the disposal of human waste. Since the water level is only 10-15 feet below the ground in the low-lying Bajo Lempa region, allowing residents to defecate into the ground can pollute drinking water, leading to parasitic diseases. One NGO has used raised latrines to solve this problem. The latrines have a concrete box located above ground and below the toilet. Feces fall from the toilet into the chemical lined concrete box in which the chemicals dry the human feces into a solid mass. The feces/chemical mixture can them be removed from the area below the latrine and be used for fertilizer. The cost of one of these raised latrine units is around $600 per unit.

“What are the most significant problems facing El Salvador today?” I asked ‘Chungo’, the nickname of a fifty one year old representative of Ciudad Romero? His response was: 1) clean water, 2) electricity and 3) paved roads.

When visiting a clinic in the village of Isla de Mendez, I asked the resident doctor what single project he would elect to improve the health status of his patients, he stated “Clean water for the residents to drink.”

In El Salvador, like most other developing nations, their most pressing need is that for clean water. CNN reports that over 1.1 billion people do not have access to clean drinking water in the world. The NGO Global Water claims that over 40,000 people die each day from diseases directly related to drinking polluted water.

Fortunately, El Salvador has very good access to water. Rivers are abundant; the water level in the Bajo Lempa region I visited was only about 10-15 feet below the ground. Access to clean water, however, is another story. Many residents were ill with parasitic infections and a fellow volunteer received a rash after wading into a polluted bay on the Pacific coast.

Since El Salvador is not water poor, the solution to its health problem is simply to clean the water which already exists. In the largest city, San Salvador, water is provided by the government in a centralized manner, much as it is in the United States. The small village of Ciudad Romero employed wells from which its residents received running water.

In other rural areas, however, centralized water provision may be too costly to justify for areas which are not densely populated. There were two solutions the villagers used: chlorine tablets or individual filtration systems. The clinic I visited gave chlorine tablets to some residents without clean water, but I was not able to discern if these were free. Most residents resisted using the tablets since they claimed that the water tasted bad. Fifty five of about 350 families in Isla de Mendez had a filtration system in which bath and laundry water passed through different stone basins, with each basin filtering out a different kind of impurity. In the last stage of the treatment, the water passed through stone filters. The system seemed to be working well, but the local NGO had to educate the population on its use since the device had to be cleaned every three days. Without the education component, the funds invested in the filtration system could have gone down the drain.

This week, I will be doing a five part report on what I have learned from my eight-day community service trip to El Salvador. The trip was organized by the non-profit AJWS and was led by employees of the Salvadoran non-profits La Coordinadora del Bajo Lempa and the Foundation for Self Sufficiency in Central America (FSSCA). The majority of the time I was located in the rural town of Ciudad Romero in the Usulatan department, but I did visit other towns as well as the capital of San Salvador. In the course of the week, I was able to speak with a variety individuals: a doctor at a local clinic, community leaders from the villages of Ciudad Romero and Isla de Mendez, a student from the Universidad Centroamericana, workers at various non-profits, and many Salvadoran families.

The major healthcare issues for rural Salvadorans for which they seek medical treatment are the following:

• Childbirth
• Fever
• Dehydration
• Diarrhea
• Injuries from Accidents (eg: lacerations, broken bones, etc.)
• Parasites
• Asthma Attacks

Basic immunizations are widely available to all citizens free of charge. Access to doctors in urban areas is relatively easy, but expect to spend a large amount of time in the waiting room. For rural citizens, one may have to travel up to an hour to reach a nearby clinic and hospitals are often more than an hour away due to the poor state of most roads. For instance, to drive from Ciudad Romero to the nearest hospital took a little over two hours. In a larger country, the problem of transportation from rural areas to hospitals would be even more prevalent than in the case of the small country of El Salvador.

Below is the Schedule for the rest of the week’s posts:

• Tuesday: (Part II) Water
• Wednesday: (Part III) Sanitation
• Thursday: (Part IV) The Salvadoran Healthcare System
• Friday: (Part V) Government, History, and Service Procurement

Today I attended a seminar where Elsa Artadi presented her paper on: “Going into Labor: Earnings vs. Infant Survival in Rural Africa.” Artadi asked the question ‘why do families not optimize childbearing to coincide with months of minimal infant mortality?’ Artadi demonstrated that infant mortality rates vary significantly from month to month in Sub-Saharan Africa due to 1) the variation in disease incidence mostly from changes in rainfall and 2) agricultural cycles. Often mothers are faced with a trade-off between earning more income by working during the harvest season versus having a child during the low infant mortality months which may coincide with the harvest season. This is a serious tradeoff since giving birth in a low infant mortality month may not be optimal if the loss of income jeopardizes the health and well being of the entire family. For some countries, the low infant mortality months coincide with non-harvest months. Thus, these countries do not face this tradeoff and Artadi expects these individuals to concentrate births in the low infant mortality months.

Methodology

Artadi constructs a ‘probability of survival’ variable for each country and month based on 1) whether that month was part of the rainy season, 2) whether that month was a high risk month for famine, 3) a fixed effects dummy for each mother, and 4) demographic characteristics. After calculating the fitted values of the expected survival rate (E[Surv]) for each month in each country, she creates another variable which measure the loss of infant health due to being born in a poor month (LossE[Surv]_m,c=max(Surv)_c-E(Surv)m,c). She then constructs a ‘Tradeoff_c’ variable which measures the difference between the expected survival rate during the high labor demand season (harvest) and the expected survival rate during the low labor demand season (non-harvest). Artadi runs a regession of ‘LossE[Surv]_m,c’ on ‘Tradeoff_c’, and demographic variables to see if citizens in countries whose low infant mortality months coincide with the harvest season choose poor survival months more frequently.

Artadi presents persuasive evidence that the sacrifice of potential income is the major reason why births would be concentrated in high infant mortality months. Although she had some technical problems (incorrect standard errors), her specifications of the model to check for robustness were convincing.

Significance of the Paper

While this paper provides a good description of the tradeoffs Sub-Saharan African women face in childbirth decisions, it does not offer any policy options for improving the welfare of these societies. Changing agricultural cycles is infeasible; most families already have some access to family planning (whether modern contraceptives or more traditional methods). In my opinion, the best means to decrease infant mortality in developing countries is to improve overall GDP/capita (easier said than done). Increasing incomes above subsistence levels will: 1) allow families to save so they will not go hungry if they decide to have a baby during harvest time 2) increase the available amount of money in a country to be spent on education and literacy which will help women become more knowledgeable about their health and 3) facilitate a demographic transition where more resources are devoted to each child. As an example India’s GDP has been growing steadily since 2000 and its infant mortality rate has decreased from 64.9 deaths/1000 live births in 2000 to 56.3 deaths/1000 live births in 2005. Further, the most famous micro-credit organization, Grameen Bank, claims that its small loans have lifted 50% of its members above the poverty line. In a report by H. I. Latifee in 2003, infant mortality decreased by 34% among Grameen Bank members. While part of this effect may be due to the educational programs Grameen offers, much is certainly attributable to the increase in income.