Category Archives: Public Health

Why Poverty Persists in America, pt. 2

The other day, I talked about the first of the four reasons why we cannot end poverty in the United States.  Now I will talk about the other three.

Single parenthood is another challenge.  According to Edelman, poverty rates among families led by single mothers is an astonishing 40%.  I don’t know enough about the problem to propose any solutions.  In the past, I have discussed how the the problem is systemic and self-reinforcing.  But, from a policy perspective, I am not sure there is much that can be done.  And race and gender are also big problem.  There are certainly policy prescriptions here, but the issue is so systemic that I won’t even try to address them in this post.

The last reason – the reduction of the safety net and elimination of certain assistance programs – is really troubling however.  Edelman explains the implications:

The census tells us that 20.5 million people earn incomes below half the poverty line, less than about $9,500 for a family of three — up eight million from 2000.

Why? A substantial reason is the near demise of welfare — now called Temporary Assistance for Needy Families, or TANF. In the mid-90s more than two-thirds of children in poor families received welfare. But that number has dwindled over the past decade and a half to roughly 27 percent.

One result: six million people have no income other than food stamps. Food stamps provide an income at a third of the poverty line, close to $6,300 for a family of three. It’s hard to understand how they survive.

At least we have food stamps. They have been a powerful antirecession tool in the past five years, with the number of recipients rising to 46 million today from 26.3 million in 2007. By contrast, welfare has done little to counter the impact of the recession; although the number of people receiving cash assistance rose from 3.9 million to 4.5 million since 2007, many states actually reduced the size of their rolls and lowered benefits to those in greatest need.

During a recession, expanding the food stamp program and other TANF programs provide the greatest ROI in terms of stimulating demand.  Unlike the stimulus checks of 2008, which most people used to pay down debt and squirrel away in a savings account, food stamps and other credits are spent immediately.  Aside from the fact that we, as a country, have an obligation to make sure that people can eat, these programs make sense from an economic recovery standpoint.

The chart on the right shows spending on low-income programs, with and without Medicare and Social Security, as a percentage of real GDP over time.  In the War on Poverty during the LBJ administration, federal spending increased significantly before leveling off until the recession in 2008.  It has increased since Obama took office, primarily in response to the downturn, which increased the rolls of people in need.  Despite this mini-surge in spending, there a danger that it could be reversed.

Edelman ends the article with a stark warning that the status quo, as inadequate as it is, may not last.  There are long-term ways of dealing with the growing income and wealth gaps – simplifying the tax code, allowing the Bush tax cuts to expire, increasing the capital gains tax, regulating financial institutions, and investing in education and infrastructure, to name a few.  But an easy short-term solution is to, at the very least, maintain the current TANF programs, if not expand them to include the growing numbers of people living at or below the poverty line in this country.

Poverty in this country is a challenge.  But we can deal with the problem by reforming our education system and maintaining and potentially expanding the social safety net.

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HIV-Positive in Philadelphia vs. Uganda

“What does it mean to say that one life is “worth more” than another? Aren’t all lives infinitely precious? Well, no, at least not in any sense that’s at all useful for making hard policy decisions about things like job safety and access to medical care.

Economists measure the value of a life by people’s willingness to pay for safety. Suppose you’d willingly cough up $50,000—but no more—to shave one percentage point off your chance of being killed in an accident. Then (except for some technical adjustments I won’t go into) we infer that the value of your life is 100 times $50,000, or $5 million.”

In economics, everything must have a value attached to it.  There is no such thing as “invaluable.” Intangibles like life, liberty, and the pursuit of happiness have some value at which the opportunity cost of having them becomes too high.  This is the value of abstract concepts.  But, according to the article quoted above from Slate, a life is worth $5 million.

Thinking about this reminded me of something interesting I heard while I lived in Nairobi.  I met someone who was working at a hospital in Uganda as an HIV counselor, disclosing the status of the test to the patient.  He was finishing up his Masters of Public Health at UPenn and worked during the year at a clinic in Philadelphia, doing the same work.   I asked him, between the two groups (Ugandans and Philadelphians), who took news harder?  Without question, he said, the people he worked with in Philadelphia.

HIV prevalence in Uganda, 1990-2007

I did not expect to hear that.  In the United States, anti-retroviral drugs allow people who can afford them the ability to maintain a normal life expectancy.  The drug cocktail that contained a regimen of dozens of pills per week has been concentrated to a single pill – Complera – taken daily, which keeps the virus from turning into full-fledged AIDS.  In other words, while it is no doubt traumatizing to learn you are HIV-positive, I wrongly assumed that, because it is no longer a death sentence, the personal devastation would not be nearly as severe.

In Uganda, on the other hand, HIV could very much be a death sentence, particularly for the poor.  Anti-retrovirals are available for free through clinics and churches, but the availability of these and other ancillary services, like counseling or support groups, are limited.  Even though the HIV incidence in Uganda has declined from 15% in 1990 (one in eight people) to ~5% today (one in 20), it is not a small problem, particularly when you consider that the incidence is much higher in slums and other communities where unemployment is high and prostitution common.

Despite these facts, my friend told me that people he spoke with about their condition reacted calmly, almost with a sense of resignation and practicality.  They would want to know what they needed to do, what drugs they needed to take, and then move on.  While people in Philadelphia would break down under the weight of the realization that they contracted the virus, people in Uganda seemed to look at it as another problem to deal with and move on with their lives.

I don’t know why this is the case or whether I can extrapolate any conclusions beyond this localized case (which I only heard about through a single conversation).  But I thought about it a lot.  One theory is that HIV/AIDS in parts of Uganda and, to a greater extent, Sub-Saharan Africa, is just a part of life.   People contract the virus with a high-enough frequency that people know other people with the virus, and they understand the implications contracting it will have on their own life.  Maybe in Philadelphia the feeling that you are alone in this might make it more difficult to deal with, especially when you have so many preconceived notions about what life with virus entails.  So, in Uganda, maybe understanding the day-to-day implications causes people to accept the consequences.

Maybe it is exactly the opposite.  Maybe people in Philadelphia can really understand and conceptualize the extent to which their life will be different after contracting the virus.  It means taking one pill every day for the rest of your life, and disclosing your status to all potential sexual partners.  It places a huge amount of responsibility on your shoulders, not only for your own life, but those of others as well.  And in this hospital in Uganda, maybe the patients don’t understand at all just the significance of contracting the virus.  It could be that this is their first time in their lives they have been to the hospital and cannot really process the gravity of the situation.

Another theory is that poorer Ugandans who contract the virus have so much to deal with already that the added weight of knowing they are positive is an afterthought compared with the immediate concerns – specifically, how to make money and buy food for your family.  This is not to diminish the problems of the Philadelphians.  It is only to say that immediate concerns about the here and now trump those of the future, particularly when the treatment is offered free of charge.

And lastly, and maybe most controversially, maybe people in different countries and different socioeconomic levels place a different value on life.  Economists would say that every life is worth $5 million.  That, of course, is context-dependent.  It is an abstract idea that cannot be quantified.  But governments do place a specific value on the lives of their citizens.  I don’t know what it is in Uganda, but it is probably a lot less than $5 million.

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Why Jim Kim is Right for the World Bank

As faithful readers of this blog know, I am a big fan of the Barack Obama’s foreign policy positions and decisions.  Specifically, I like his deference to nuanced conditions and his emphasis on achieving the objective over claiming credit.  In my neck of the woods – specifically, Libya, Somalia, and Uganda – he understands and appreciates the nuances that made previous incursions into the region unsuccessful.  I think he understands that multilateralism and mutual respect can achieve more than the cavalier dependence on American exceptionalism.

That is why when I read that he endorsed Jim Kim, co-founder of Partners in Health with Paul Farmer and a giant in the field of public health, for the World Bank presidency, I tipped my hat.  Since its establishment, the executive positions of the World Bank and the International Monetary Fund (IMF) have been held by an American and a European, respectively.  Former French finance minister Christine LaGarde recently replaced Frenchman Dominique Strauss-Kahn after – in one of the great ironies in the history of the institution – he was arrested for allegedly assaulting a Guinean woman.  So when Robert Zoellick announced he would not re-run for the top spot at the World Bank, people debated whether Obama would be the first to break the streak and allow a non-American to run the Bank.

There is good reason for the Americans to run the bank.  For one thing, it was created by the U.S. and the Allies in 1944 at the tail end of World War II.  Though it started as a lender to post-war European economies, by 1968, the World Bank had shifted its focus to developing countries, funding infrastructure projects and enacting various poverty alleviation strategies. With some policy shifts here and there – most notably during the Reagan years, where neoliberalism was the approach du jour and the Bank’s sister institution, the IMF, created controversial structural adjustment programs that saddled many developing countries with tremendous amounts of debt in exchange for opening their economies – the Bank has focus on eradicating poverty and improving the lot of the four billion people living below the poverty line.

Kim, the MD/PhD

Unlike many previous World Bank presidents, Jim Kim is not a bureaucrat, politician, or World Bank insider.  He is a proven innovator and a man whose commitment to the cause cannot be questioned.  He has an MD/PhD from Harvard and has worked with some of the pre-eminent public health institutions in the world.  In founding Partners in Health, he built an organization that now employs 13,000 people in 12 countries, serving the poorest populations in the world.  Most recently, he served as the first Asian-American president of Dartmouth College.  In a letter to The Guardian, Professor Martin McKee explains why Kim is a smart choice:

Some commentators will no doubt be offended by the idea that someone who is neither a banker nor an economist could occupy this post. Others may think that, in these difficult times, we need someone like Jim Kim, who combines academic rigour with practical first-hand experience of the reality facing the world’s poor.

Jim Kim is a perfect candidate for the World Bank presidency.  He is a first-generation Korean immigrant with a proven record of success.  He is clearly innovative and committed to the work that the Bank is mandated to carry out.  Having spent his life outside of government, he is apolitical and carries no baggage.  Unlike one of his top competitors, Jeffrey Sachs, his positions on development are much more nuanced and his views less explicit.   Recently, Sachs withdrew from the race and endorsed Kim himself.  I find myself in agreement with his assessment:

Obama has shown real leadership with this appointment. He has put development at the forefront, saying explicitly, “It’s time for a development professional to lead the world’s largest development agency.”

Kim’s appointment is a breakthrough for the World Bank, which I hope will extend to other global institutions as well. Until now, the United States had been given a kind of carte blanche to nominate anyone it wanted to the World Bank presidency. That is how the Bank ended up with several inappropriate leaders, including several bankers and political insiders who lacked the knowledge and interest to lead the fight against poverty.

The Bank can be where the world convenes to address the dire, yet solvable, problems of sustainable development, bringing together governments, scientists, scholars, civil-society organizations, and the public to advance that great cause. This is a global imperative, and we can all contribute to fulfilling it by ensuring that the World Bank is an institution truly for the world, led with expertise and integrity. Kim’s nomination is a tremendous step toward that goal.

Over the past few years, I have talked about Jim Kim a lot after my father – a physician and Dartmouth graduate – recommended the book Mountains Beyond Mountains about the work of Kim and Paul Farmer.  My dad often compared people to either Farmer or Kim.  The former loved working in the field directly with patients, while the latter preferred tackling the problem at a high level, prioritizing policy over practice as a way of maximizing his impact.  Clearly, Barack Obama’s endorsement is both recognition of Kim’s record and another example of the strategic underpinning of Obama’s approach to foreign policy.  After all, if Obama plans to pivot away from the Middle East toward Asia, endorsing Kim, an Asian-American born in Korea, sends the right signal.  Plus, Kim’s impeccable record exists in spite of his American citizenship, yet the presidency of the World Bank would still remain in the hands of an American.

As someone who works in the field and appreciates the nuances of foreign policy, I applaud the decision to elect Kim.  I look forward to seeing what innovations he will bring to the institution.

The founders of Partners in Health - Kim, Ophelia Dahl, and Paul Farmer

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Please Help: Tragedy in the Philippines

Tragedy has struck the Philippines, my adopted second home.  From NPR:

The United Nations is rushing food, shelter and clean water to the Philippines, following last weekend’s devastating tropical storm. The UN estimates about 1,000 people died when Tropical Storm Washi burst ashore last Friday on the big southern island of Mindanao.

Washi, known as Sendong in the Philippines, may be the world’sdeadliest storm of 2011, according to Washington Postmeteorologist Jason Samenow. The system raked the southern Philippines islands, finally emerging in the South China Sea, where it lost strength.

Philippines president Benigno Aquino declared a state of calamity and ordered coffins sent to the two cities worst affected by the storm, Iligan and Cagayan de Oro City. AP reports he’ll order an investigation to find why more people didn’t seek higher ground and the reason for the high death toll. While visiting Cagayan de Oro, he said “Our national government will do its best to prevent a repeat of this tragedy.”

Victims need the aid. According to Mindanao News, survivors in Cagayan de Oro City should look for missing relatives in the city’s dump, where dozens of bodies have been left because local funeral parlors don’t have enough coffins or embalming fluid.

Please consider making a donation to the Philippine Red Cross or Gawad Kalinga, both reputable charities providing support to the affected areas.

Preventing the Next Pandemic with Cell Phones

Human biologist Nathan Wolf with a Cameroonian hunter.

Much is known about patient zero, allegedly the first carrier of HIV and catalyst for one of the greatest pandemics the world has ever known.  But the origins of the virus can be traced much further back than that.  The roots of the virus that has plagued humanity for the last three decades snake from the United States, through Haiti, and back to Africa, where all life began.

A recent Radiolab show titled “Patient Zero” traces the virus from the French-Canadian steward who recklessly spread the virus through the gay community in the early 80’s through an evolutionary timeline that begins in a 100 square-mile patch of jungle between three rivers in the southeastern part of Cameroon.  There, Colobus monkeys carrying variants of SIV (simian immunodeficiency virus) found their way into the stomachs of much larger chimpanzees.  At some point, multiple strains of these SIVs crossed and mutated and became the virus that was the precursor to HIV.

According to the “cut hunter” theory, sometime around the turn of the 20th century, a Bantu man living in this region of Cameroon killed a chimpanzee for food.  While gutting and cleaning the chimp, the hunter nicks himself with his blade and comes into contact with the infected chimp’s blood, transferring the SIV virus into the man.  SIV becomes HIV and, just like that, the human immunodeficiency virus is born.

Now that the virus exists, it begins its long journey into bloodstreams of 60 million people.  It is impossible to know exactly how it happened – perhaps the hunter infected a prostitute, who in turn infected a fisherman.  Because this region is located along two major rivers that feed down into what is now called the Democratic Republic of the Congo, the fisherman may have traveled downstream to Brazzaville, Kinshasa, or one of the many other urban centers that were sprouting up across the Belgian Congo and the rest of colonial Africa.  And from here, HIV exploded.

The story is fascinating and I recommend listening to the Radiolab episode in its entirety.  But one of the things I found most interesting is the way scientists and public health researchers are now using this information to prevent this from ever happening again.  As the Radiolab hosts point out, it took 75 years – 1908 to 1981 – before HIV hit the mainstream in a big way.  What if we had been looking for it all that time?

That is precisely what we are doing now.  The remote communities where HIV entered this world are often only accessible by plane.  With few roads, they are isolated from the world.  Yet, as the most recent Economist points out in its lead article, “Africa Rising,” there are 600 million mobile phone users in Africa – more than half the population.  As I have written about extensively in this blog, technology has adapted to suit the specific conditions of Africa.  Mobile banking, for example, allows people to access cash in places with no banks.  This same dynamic makes it possible to pinpoint the start of a potential epidemic before it has a chance to leave the community where it began.

HIV Researcher Nathan Wolf actually traced the path of the virus from Cameroon down the river to the cities of the Congo.  He understands firsthand the circuitous path a virus can take before it reaches the tipping point.  To identify future outbreaks, he and his colleagues have set up monitoring stations to track “viral chatter” across Central Africa.   He identifies where an immunodeficiency virus makes the jump from chimpanzee to human hunters.  And the way he finds them is fascinating.

In the DRC, for example, communities with no roads still have cell phone towers.  So Nathan and his team actually track cell phone patterns in rural communities.  When a flurry of calls is made to a local medical center or clinic in a short period of time, it raises a red flag.  The researchers swoop in to identify the cause and take samples to study the new virus.  This is how we stop a virus before it spreads throughout the world.

A few months ago, Kentaro Toyama, a pre-eminent thinker in the ICT4D (information, communications, and technology for development) gave a talk at the iHub, the shared workspace I frequented while in Nairobi.  He spoke about how it is impossible to get rich running a socially-focused technology business – a “social enterprise.”  After the talk, I asked him what he thought about Mo Ibrahim, the Sudanese-British founder of Celtel, the first telecom in Africa and the man who literally created the mobile telecom market in Africa out of nothing.  Surely, this is a man who has changed the world in a positive way and become massively rich in the process.  Toyama disagreed with me, saying the telecoms are explicitly profit-oriented.  But I still disagree, and stories like this reinforce my view.

A decade ago, we could have never tracked the spread of disease the way we can today with the aid of cell phones.  What Wolf and his team are doing is nothing short of amazing, and it has been enabled by creating a communication network that extends to even the most remote communities around the world.

With biological terrors like multi-drug resistant tuberculosis and malaria still ravaging parts of the world, humans still have their hands full with disease.  But, thanks to cell phones in Africa, we might never see another HIV again.

There Is a Famine in East Africa Right Now

Photo credit: Foreign Policy magazine

The official definition of a famine:

  1. More than 30% of children must be suffering from acute malnutrition
  2. Two adults or four children must be dying of hunger each day for every group of 10,000 people
  3. The population must have access to far below 2,100 kilocalories of food per day

This how the UN now characterizes the worst drought in Somalia in 50 years.  When the UN declares a famine in a country of 3.7 million people, that means that either 1,200 children or 600 adults are dying of hunger.   Every single day.

Two weeks ago, 140 million people either watched or listened to the verdict of the Casey Anthony trial.  Enraged, people protested.  Last week, people watched Rupert Murdoch testify before the British Parliament as he tried to defend his company against allegations of cell phone hacking.  And right now, people are flooding to the Dadaab refugee camp in Northern Kenya in unprecedented numbers, as mothers come from Somalia, Uganda, and Kenya in search of food, water, and medical care for themselves and their children.  If they haven’t perished already on the long journey to Dadaab, malnourished children are succumbing to disease and dying from starvation.  The latter has not received the coverage it warrants, as the Guardian explains:

This is a children’s famine, and it shines a light into the empty places of our conscience.

Arot Katikov is the opposite of a thriving western baby. Looking much younger than he is, the boy can’t stop crying and vomiting, and he has diarrhoea. On arrival at Lodwar district hospital he is discovered to be suffering from malnutrition and one of its complications, tuberculosis. When Setina, aged 10 months, turns up at the same place, she faints with hunger. Her mother, Ngiupe, grabbed Setina and her brother and ran from their farm near the Ugandan border when Pokot raiders came and stole their cattle and killed their neighbours. Setina’s three-year-old brother died on the way to the hospital, and she is now lying in her mother’s arms, too weak to lift her head, her eyes glazing over as her mother rocks her to sleep or oblivion.

Further to the south, Somalia is suffering its worst drought in 50 years. This is the children’s famine. Running from conflict, and sick with hunger and thirst, people are fleeing to the borders or the aid camps, many children dying on the way or too weak to survive once they get there. In some areas one in three children is seriously malnourished and at severe risk of death. In October the rains will come, most likely bringing epidemics of malaria and measles. Some of the children just lie down and wait for death, which is likely; or mercy, which is elsewhere.

This week, while the famine was happening, every media outlet in the western world devoted itself to the circus surrounding a gang of communications reprobates. Public outrage over News International is justified, of course, and the abuse suffered by the family of a murdered girl cannot go unheeded. There can be no hierarchy of moral outrages, and the wrong done to Milly Dowler and her family and dozens of other victims should be its own category. But must it chase the possible death of 500,000 children off the front pages? We don’t have to find the Murdochs acceptable in order to find the famine intolerable, but it is no category error to think of them at the same time.

How is it possible that this can happen in 2011?  To say that it is a travesty that the world has collectively ignored this crisis would be cliché, since it is not a departure from the norm.  But I am not sure how else to describe it.

Donate to UNICEF:

Photo credit: Foreign Policy magazine

Insite: A Step Beyond a Needle Exchange

The following is a guest post by Shawn Zhou, a country program analyst with the Clinton Foundation on the Clinton Health Access Initiative in Shanghai, China.

An interesting progressive model for combating HIV/AIDS has emerged over the past 5-10 years in Vancouver, BC. Once home to the highest rate of HIV infection growth in North America, Vancouver has seen a significant decline in the spread of HIV among its intravenous drug users. The model they’ve implemented encourages drug users to enter a “safe house”  called Insite, where individuals are free to use illicit drugs while being supervised by nurses, and are offered treatment if suspected of suffering from HIV. Insite is trying to provide an aggressive and controversial model of reaching and treating a difficult and high-risk population….and so far it appears to be working.

According to one of the center’s studies, financed by the United States National Institutes of Health, from 1996 to 2009 the number of British Columbians taking the medications increased more than sixfold — to 5,413, an estimated 80 percent of those with H.I.V. The number of annual new infections dropped by 52 percent. This happened even as testing increased and syphilis rates kept rising, indicating that people were not switching in droves to condoms or abstinence. (Full Article)

There are two key foundational beliefs to the creation of this model 1) As one nurse put it: “people are going to use drugs whether they have clean needles or they don’t.”   2) A Test and Treat system where all patients regardless of CD4 count are treated if they are HIV+ (aka….don’t prioritize patients, treat everyone, stop the spread).

This first fundamental belief is probably the biggest sticking point for those opposed to the program. Fundamentally while this model may appear to encourage drug use, as the article suggests, many other cities worldwide have already adopted free needle exchange programs as a means of encouraging cleaner and safer drug use.

A 1997 study in The Lancet found that in 29 cities worldwide with needle exchange, H.I.V. infection dropped 6 percent a year among drug injectors, while in 51 cities without, it rose by about 6 percent.

By funding a safe house for users, monitored under the careful watch of medical professionals, Vancouver has taken this belief one step further and is trying to manage dangerous behavior in a contained and safe environment.

In 2009, the site recorded 276,178 visits (an average of 702 visits per day) by 5,447 unique users; 484 overdoses occurred with no fatalities, due to intervention by medical staff. Health Canada has provided $500,000 per year to operate the site, and the BC Ministry of Health contributed $1,200,000 to renovate the site and cover operating costs. (Wikipedia site)

This is of course a difficult pill for public officials to swallow, since such clinics and programs are costly and goes against conservative principals. However, regardless of its implications on drug use, the model undeniably offers a safer environment for drug addicts than they previous had, and should probably get strong consideration in other communities in the developed world where drug use and the spread of HIV is rampant. I’m curious to see how this all shakes out as apparently Canada’s supreme court is reviewing law suits to close down the facility.

mHealth in Northern Ghana

This post originally appeared on Next Billion.

“Some women feel they want to hide their pregnancy at the early stages. Maybe because they fear the ‘the evil eye,’ miscarriages, the unknown or visiting a midwife. These fears are normal. Here are some tips to help you deal with them: Seek healthcare even before traditional rites are performed. Nothing should prevent you from going to see a midwife at the early stages of your pregnancy.”

If you are a pregnant woman in the Upper East region of Ghana who has registered with MOTECH, you will receive this message during the fifth week of your pregnancy. Started in 2009, MOTECH is an mHealth platform created in partnership between the Ghana Health Service, Grameen Foundation, and Columbia Mailman Public Health School, with funding from the Bill and Melinda Gates Foundation.  It is designed to facilitate better medical information dissemination to rural areas and improve operational efficiency at community- and district-level health centers in one of the poorest regions of the country.

MOTECH is currently in its pilot phase, with plans to expand throughout Ghana in the future. The Upper East is one of the smallest and least urbanized regions in Ghana, with 85 percent of the population living in dispersed communities throughout the rural areas. The low population density and infrastructure barriers create a challenge for health care delivery, necessitating a community-based approach. Over the past decade or so, Ghana has been operating its CHPS (Community Health Planning and Services) program, which utilizes traditional institutions and social networks with support from outreach nurses employed by the Ministry of Health to reach as many people in the rural areas as possible. It is on these CHPS centers and the nurses who work there, in particular, that MOTECH focuses its efforts.

I had the opportunity to visit a few of the CHPS centers myself with Williams Kwarah, the program officer for Grameen Foundation in Ghana. Together we visited a few of the nurses and I asked them about the system.

MOTECH offers two main applications: mobile midwives and the nurse application. For mobile midwives, pregnant women and their families register for the service through the CHPS centers. They receive weekly time-specific messages about their pregnancy, including alerts and reminders regarding visits to the local CHPS center, actionable information and advice about best practices, and educational info to ensure a healthy pregnancy. MOTECH customers have the option of receiving messages via SMS or voice, though, due to the low literacy rate in the region, 99 percent opt for voice. Text messages are sent at a set time, three times a week. The voice messages are sent at a time specified by the women. If for some reason they miss the call, the women can “flash” the system (call and quickly hang up to avoid charges), and MOTECH will immediately call back, ask for the patient ID number, and deliver the message to the client. The pre-written script provides pre-natal information for 42 weeks and the first week of life of the baby. MOTECH is increasing the frequency to include the first year of the life of the baby.

The nurse application allows the CHPS centers in the rural areas to collect patient data via mobile phone and update the medical records via SMS. Each patient is given a MOTECH ID number. The nurse collects the data and uploads it to the MOTECH system, which stores the information in a central patient electronic medical records system (EMR). The system analyzes the patient data against a clinical regimen and the medical staff develops a program based on the protocols of the Ghana Health Service. The patients are then sent messages based on the schedule, similar to the mobile midwives program. For children under five, the parents receive reminders on tetanus vaccination and immunization schedules, while recent mothers receive information on post-natal care for mothers and babies.

The nurse application also offers a robust electronic reporting tool that is designed to replace the old system of pencil and paper. Nurses are required to submit monthly reports detailing all patient visitations to the sub-district supervisors and the district health management team in their areas. The manual reporting process is time intensive, consuming up to two days each month. With the MOTECH system, nurses enter the data into the phone at the time of visitation, and it is stored and submitted to the EMR in bulk (each entry takes up less than 1 KB). At the end of the month, MOTECH generates an electronic report and submits it to the sub-district supervisor, who delivers the hard copy to the nurses at CHPS centers for verification. After three months of 85 percent accuracy, the nurses no longer need to produce manual reports. What used to take two days now takes ten minutes.

In addition, the nurse application sends reminders to the nurses themselves about patients who are overdue for a consultation. Because the system tracks the schedule of immunizations, for example, it automatically alerts the nurses when a mother is late in bringing her child to the CHPS center. Based on this data, they can schedule a home visit to ensure that the proper care is administered.

Many mHealth programs try to improve the efficiency of their systems and maximize the impact of medical professionals serving rural areas. One of the main concerns in rural areas is Pulse Vascular — vascular surgeon are making use of this mHealth program to keep track of the development. Telemedicine, for example, allows doctors to see patients from a distance.  Through its nurse application, MOTECH increases efficiency, to be sure. But it also gets patients to think consciously about their health. By maintaining a weekly connection with the patient and getting them to actively contemplate their health, it makes them more likely to visit the CHPS center, regardless of whether they are told to do so by the system.   Through constant communication, MOTECH can change the way people think about their own health and the health of their families.

MOTECH is currently in a pilot phase, and has had to adapt the system to fit the cultural context.  As a result, its evolved over time, and shared many of the lessons learned recent report.  The program is not without its shortcomings.  For one thing, the cost of sending SMS and voice messages and distributing handsets to nurses currently subsidized.  Sustainability of the project will depend on finding funding to maintain the system and pay for the communications costs.   It certainly will be an mHealth program to watch in the future, as it is potentially a scalable model applicable to rural areas around the world.

The Silver Bullet of Conditional Cash Transfers

There is a new paper from DFID (the British overseas development assistance authority) about the usefulness and effectiveness of conditional cash transfers.  I have written a few times about this topic in early 2011 and way back when in 2010 (see here and here) and have always been pretty bullish on the use of them as tools for poverty alleviation.  Conditional cash transfers effectively pay the poor in exchange for meeting certain requirements regarding healthcare and education.  Welfare programs for individuals and families are contingent on achieving certain targets.  For achieving a certain school attendance rate for children, a family will receive a certain amount of money.  For bringing your child to the doctor a certain number of times per year, you get money from the government.

The advantage of these schemes is that they offset the opportunity cost of keeping your child in school, or the actual cost of bringing your child to the doctor.  So, by creating incentives around behavior modification, you can more effectively target the root causes of poverty.  Good decision-making becomes in the best financial interest of families, and mitigates the costs of neglect.

What they do not address are systemic problems.  For example, within education, conditional cash transfers aren’t going to build more schools, improve teacher training, reduce class sizes, or provide additional jobs for people once they get out of school.  Nor will they improve the quality of healthcare delivery or the caliber of physicians.  This gives some people pause.  This is from the report:

Well-designed and implemented cash transfers help to strengthen household productivity and capacity for income generation. Small but reliable flows of transfer income have helped poor households to accumulate productive assets; avoid distress sales; obtain access to credit on better terms; and in some cases to diversify into higher risk, higher return activities. These intermediate outcomes help draw poor people into the market economy on terms that allow them to benefit from and contribute to growth.…

There is robust evidence from numerous countries that cash transfers have leveraged sizeable gains in access to health and education services…However, transfers have had less success in improving final outcomes in health or education.  Cash transfers can help the poor overcome demand-side (cost) barriers to schooling or healthcare, but they cannot resolve supply-side problems with service delivery (e.g. teacher performance or the training of public health professionals). Cash transfers therefore need to be complemented by ongoing sectoral strategies to improve service quality.

The whole notion of a silver bullet is a non-starter for me.   Continue reading