July–December 2011

Also in this edition...

Microfinance put to the test

A foot soldier in the aid effectiveness battle

Shopping to help the poor

A publication of the Asian Development Bank

WHO WILL PAY FOR ASIA’S DOUBLE BURDEN? Innovative financing is needed to address an unprecedented burden of communicable and noncommunicable diseases

Cover.indd 1 10/21/11 2:45 PM Critical Thinking..

“Development Asia... comes across like Time or Newsweek in the good old days. Professional journalists research important subjects and report without being blinkered.

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www.development.asia A publication of the Asian Development Bank

Critical thinking AD.indd 68 10/20/11 4:47 PM PUBLISHER’S NOTE

WWW.DEVELOPMENT.ASIA © 2011 Asian Development Bank ISSN 1998-7528 ASIAN DEVELOPMENT BANK PUBLISHER Ann Quon Getting Better SENIOR EDITOR Floyd Whaley EDITORIAL ADVISOR Indu Bhushan ASSOCIATE EDITOR sian and Pacific countries are facing unprecedented challenges Maria Liza Solano COPY EDITOR related to health care. While wealthier countries tend to suffer Caroline Ahmad RESEARCH DIRECTOR from noncommunicable ailments, such as cancer and diabetes, Shawn Pang ART DIRECTOR and poorer countries from communicable diseases, like malaria Andy Martin and dengue, many parts of Asia and the Pacific are plagued by both. This Development Asia features development issues important to Asia and the Pacific. It is published ADevelopment Asia edition of explores the double burden of disease that four times a year by the Asian Development Bank. The views expressed in this magazine are those of political leaders in the region are grappling to address. At the root of this the authors and do not reflect the views and policies of the Asian Development Bank and Haymarket problem is health financing. Simply put: how do governments and their Media Ltd. Use of the term "country" does not imply any judgment by the authors or the Asian private sector partners provide solutions that keep the poor from suffering Development Bank and Haymarket Media Ltd. as to the legal or other status of any territorial entity. catastrophic health care costs? Advertising of any specific commercial product, Underlying this situation is the specter of a pandemic. Many health experts, process, service by trade name, trademark, manufacturer, or otherwise, in this publication both within Asia and around the world, believe that the next pandemic will does not constitute or imply ADB’s endorsement, recommendation, or favoring of any of the originate in Asia. Since severe acute respiratory syndrome (SARS) swept product or the entity thereof. the region and much of the globe in 2003, countries throughout Asia and COMMENTS Send your feedback to the editor at the Pacific have banded together in an unprecedented display of regional [email protected] cooperation in the health sector to stop the next pandemic at its source. ADVERTISING To advertise in Development Asia, contact For the articles section, regular contributor Karen Emmons explores the [email protected] troubles facing microfinance. SUBSCRIPTIONS Contact [email protected] Other stories include an interview with one of the pioneers in the use of randomized control tests in development work, which some believe is the future of efforts by development organizations to establish the effectiveness of their work. In our Reconnaissance section, regular contributor Margo Pfeiff offers tips on how to shop in ways that benefit—or at least don’t hurt—the poor. In this edition, we welcome two new contributors. Jade Lee-Duffy, a longtime Hong Kong, China business writer and editor, joins our team, along REPRINTS Material published in Development Asia with Frale Oyen, whose reporting has taken her from the tiniest islands of the and on www.development.asia, including articles, photos, graphics, and other content, is Pacific to Viet Nam and the Middle East. copyrighted. Material may not be reproduced, republished, or redistributed without written After reading this edition, ask yourself: What can countries in Asia and permission of Development Asia. For reprint permission, please contact editor@development. the Pacific do to improve health care, particularly for the poorest and most asia. Photographs not owned by ADB require permission from the copyright holder for reprinting. vulnerable? Then send us your thoughts at [email protected]. Development Asia Stay well! n Department of External Relations Asian Development Bank 6 ADB Avenue, Mandaluyong City 1550 Metro Manila, Philippines [email protected] www.adb.org

Cover photo: AFP Note: In this publication, "$" refers to US dollars Ann Quon Publisher

A publication of the Asian Development Bank, designed and distributed by Haymarket Media Limited

www.development.asia July-December 2011 Development Asia 1

P1 Publisher's note.indd 1 10/21/11 2:48 PM CONTENTS YEAR IV, NUMBER XI, JULY–DECEMBER 2011

21 STOPPING THE NEXT PANDEMIC 34 EXAMINING MICROFINANCE 42 SHOPPING WITH A CONSCIENCE

FOCUS 21 HUMAN VS. BUG 40 PROFILES IN DEVELOPMENT HEALTH Most scientists believe that the next WHAT WORKS major pandemic will emerge from Asia. Yale University economist and 6 THE BIG READ Can the region pull together and stop it professor Dean Karlan is trying to CATASTROPHIC COSTS in its tracks? bridge the gap between academia As out-of-pocket medical expenses By Floyd Whaley and development to understand why threaten to drive millions of people ______projects succeed (or fail). in Asia back into poverty, innovative 25 ISLANDS OF HEALTH By Jade Lee-Duffy approaches to paying for health care Often isolated, sparsely populated, and ______are being sought. resource-poor, Pacific island countries 42 RECONNAISSANCE By Bruce Heilbuth face special challenges in terms of SHOP FAIR health care. Do you want to be an ethical shopper? Also, sidebar: VACCINE FUNDS By Frale Oyen Just look for the fair trade or similar CAN SAVE MILLIONS OF LIVES; label. Or is it that simple? BANGLADESH FLAGS A WAY Also, sidebar: LOVE PATROL By Margot Pfeiff FORWARD ______28 HEALTH FOR HIRE ______14 THE BIG PICTURE Some developing countries are DEPARTMENTS BURDEN OF HEALTH COSTS experimenting with turning over the Out-of-pocket health care expenses provision of basic health care to outside 4 OFF THE PRESS can easily strain a household budget, contractors. Can one of a society’s Reprint-worthy snippets from and the financial shock of a single most important public functions be publications worldwide on expensive event can push a family into entrusted to external organizations? development issues poverty. For those already living in By Karen Emmons ______poverty, the effects can be devastating. ______5 ON THE WEB By Mark Blackwell ARTICLES ______Hidden gems and important landmarks on the worldwide web 16 DOUBLE BURDEN 34 TINY LOANS, BIG QUESTIONS on development An explosion in infectious and Microfinance—seen by many as a ______noncommunicable diseases represents revolution in grassroots development— 32 OFF THE SHELF a worsening crisis for developing is facing tough scrutiny. The must-read development books of economies and health authorities. By Karen Emmons recent release By Bruce Heilbuth 44 ON THE RECORD Noteworthy quotes on development and economic issues

2 Development Asia July-December 2011 www.development.asia

P2_3 Contents/Contributors.indd 1 10/24/11 10:39 AM Letters to the Editor Access to Learning and Livelihood It is about engaging communities to Skills (EQuALLS2) Program, which is really embrace the notion that it does Empowering communities implemented by Synergeia Foundation take a village to raise a child. in that locality, helped finance two of I hope you will have many more Your recent issue on education in the classrooms with a minimal amount issues on education and bring out Asia is a must-read for development of funding, but the community put in the stories of how communities need workers and policy makers—and time and labor that allowed them to to stop thinking that this problem is should also be placed in the hands construct concrete rooms that would something only the government can of every public school teacher in house their children and make the solve. the region. Or at least one issue per young ones comfortable when they school. They need to look up from learn their Math and English. Ma. Salve Duplito their textbooks and from what they There are many such stories in this Information Officer intimately know on the ground, and part of the Philippines that makes one Synergeia Foundation appreciate the large issues on the think: what transformative force could macro side. be employed in the other corners of Email your comments to letters@ I have recently been to Tudok Mamot the nation to make the case of Tudok development.asia or mail your letter to: Elementary School, a 6-classroom Mamot commonplace, instead of a school on top of a breathtaking hill rarity? Is it possible? Development Asia, Department of External in North Upi, Maguindanao. The The gigantic efforts needed to avoid Relations, Asian Development Bank, 6 ADB Department of Education in ARMM losing generations of Asians because Avenue, Mandaluyong City, 1550 Metro built only one of those classrooms; of lack of access to quality education Manila, Philippines the other five were bankrolled by could perhaps be answered by that one the parents of the children and the question. Making this happen is not *Please include your full name and contact barangay leaders in that area. just about classrooms and textbooks information. Letters may be edited for space and The USAID’s Education Quality and and laptops in the hands of every child. clarity.

Contributors

Mark Blackwell has more than 20 years issues. She is a regular contributor to the Maria Liza Solano, of experience covering issues ranging South China Morning Post. associate editor of from science and economics to politics and Development Asia, is a cross-border issues in Latin America for Karen Emmons is a Bangkok-based journalist based in Manila, news organizations, including the Hearst journalist who writes on public health and specializing in print and Corporation and Capital Cities/ABC. He social issues. internet publishing. She worked for specializes in information graphics. the leading business newspaper in the Frale Oyen has worked Philippines for 15 years before venturing Bruce Heilbuth has worked as a journalist in media for more than 20 into magazine publishing and consulting and foreign correspondent on four years. She has worked as work. continents. He spent nearly a decade a journalist in Viet Nam and as the editor-in-chief of Reader’s Digest the Pacific, as well as in the Floyd Whaley, senior editor of magazine’s Australasian and Asian-English United States, Europe, and the Middle East. Development Asia, operates Asia Editorial editions. Services. His work has appeared in the Margo Pfeiff is a Canada-based journalist International Herald Tribune, USA Today, Jade Lee-Duffy has worked who worked as a special correspondent Los Angeles Times, and many other as a journalist in Hong Kong for Reader’s Digest for 17 years. She is media outlets. He contributed to the 2006 for more than 10 years, researching a book on the Arctic. book, SARS: How a Global Epidemic Was covering education, property, Stopped. the arts, food, and health

www.development.asia July-December 2011 Development Asia 3

P2_3 Contents/Contributors.indd 2 10/24/11 10:40 AM OFF THE PRESS

Compiled by Maria Liza Solano

A Linguist’s Changing Face of Aid Nightmare “The old binary division of the world—between rich countries which give aid and poor ones which get it—is gone. Fewer countries are poor and eligible for “If languages are our how-to guides for cheap loans. Two-thirds of the world’s poorest people—those with less than $1.25 living on planet earth, and we stand to a day—live in middle-income countries, such as India, which increasingly are lose up to 90% of them, then that seems donors as well as recipients.”—The Economist, 13 August 2011 like we are looking at handing our descendants an encyclopedia of human life on Earth with all of the pages ripped out, except sections X, Y, and Fostering South–South Cooperation Z.”—The Rosetta Project’s Laura Welcher “A key concern for development agencies and policymakers is how to extend talks about the challenges of archiving the and sustain rapid expansion of South–South trade and investment flows in world’s languages in an interview with pursuit of lasting development gains. Tapping the potential of South–South Fast Company in June 2011 economic relations requires more than passive reliance on market forces and private initiative. Creating policy space for government action and regional policy coordination is crucial.”—Thomas Elhaut, director for Asia and the Pacific at the International Fund for Agricultural Development, writes for The Guardian’s Poverty Quantity Rather Matters blog on 2 August 2011 Than Quality “If reporters are setting aside a portion of their days for social media, that Managing Global Risks leaves less time for thinking and “In this era of global warming, smart bombs, cyber warfare, and worldwide traditional reporting. And if the chase epidemics, our societies must be protected with more complex and subtle in journalism becomes one for the strategies. We cannot continue to pursue strategies that ignore our common greatest number of page views, Twitter exposure to global risks, and the resulting environment of mutual dependence. followers, and Facebook friends, We must learn a new grammar of power in a world that is made up more of the instead of the great story, we all lose.” common good—or the common bad—than of self-interest or national interest.” —Ombudsman column, Washington Post, —Former NATO Secretary General Javier Solana with Daniel Innerarity, Project 2 July 2011 Syndicate, 1 August 2011

Population Debate Deal Breaker “A million babies a year means many things to many people. To pessimists it “The big question for the world means only more schools that have to be built, more mouths that have to be fed, economy is whether advanced and obviously more people that have to crowd into the limited space we have.… countries in economic distress will There is nothing wrong with these diviners with their sad vision of the future, be able to make room for faster- except that one gets a very uneasy feeling over their disregard for the past. At a growing developing countries, whose time when the United States has gone past a [Gross National Product] of US$1 performance will largely depend on trillion per year, with a population of more than 200 million, one should not miss making inroads in manufacturing staring at its record: Its income rose the fastest at a time when its population was and service industries in which rich rising most rapidly.”—Stefan S. Handoyo writes in The Jakarta Post on 28 June 2011 countries have been traditionally dominant.... Considerable social conflict could become unavoidable, threatening political support for economic openness.”—Harvard University’s Dani Rodrik writes for Project Syndicate in July 2011

4 Development Asia July-December 2011 www.development.asia

P4 Off the Press.indd 1 10/21/11 2:54 PM ON THE WEB

Researched and written by Floyd Whaley Deep Thoughts Chris Blattman’s blog: Research, international development, foreign policy, and violent conflict

http://chrisblattman.com/

hen researchers for development organizations survey the poor, should they compensate them for answering questions? What happens when W management consultants donate their expertise to Indian garment factories? These are a few of the intriguing topics addressed by Chris Blattman in his popular blog Research, international development, foreign policy, and violent conflict. The assistant Insert Tongue professor of political science and economics at Yale, who advises a variety of international organizations, casts a wide net for the latest thinking on development issues. into Cheek “I use fieldwork and statistics to study poverty, political participation, the causes and consequences of violence, and policy in developing countries,” Blattman states of his work. Stuff Expat Aid Workers Like Blog That philosophy can be seen in his lively blog. In addition to thoughtful analysis of weighty topics, http://stuffexpataidworkerslike.com/ the blog offers basic advice on working in development, including thoughts on how to get a job in the field and what evelopment workers are not known for poking to bring when doing fieldwork. The blog tackles some of the fun at themselves, but deep in the catacombs of toughest issues in the world of development, yet Blattman is the internet young aid workers are giving it a try. able to keep a light tone, such as when he describes his work DThe Stuff Expat Aid Workers Like blog mixes satire, veiled before academia. criticism, and humor to needle those in their profession who “My work ethic and habits derive from 2 years cooking take themselves too seriously. chicken at a vaguely militant KFC outlet,” he says. “After a One post—comically illustrated by a clearly frustrated manager resembling Hulk Hogan forces you to clean grease cartoonist—discusses how to use e-mail strategically, traps, you can handle pretty much anything.”■ noting that a well-worded e-mail can allow a development professional to “pretend to be doing work when he’s really making summer plans… feel good about himself by giving orders to an assistant in a passive aggressive way (and) show some muscle by copying the right people to a ‘gentle reminder.’” Another post offers tips on how those working at headquarters can establish their “field cred.” “It’s extremely important for … those no longer working ‘in the field’ to unassumingly drop in little clues that establish ‘field cred’ if they want to stand out and be taken seriously by their coworkers and peers…” The bloggers suggest mentioning your field assignments when you are introduced at meetings: “I’m Joanne. I lived in a rural community with no electricity or running water in Zambia for 3 years before starting my current position…”■

www.development.asia July-December 2011 Development Asia 5

P5 On the Web.indd 1 10/21/11 2:55 PM HEALTH: THE BIG READ

Catastrophic Costs As out-of-pocket medical expenses threaten to drive millions of people in Asia back into poverty, innovative approaches to paying for health care are being sought

BY Bruce Heilbuth

hen 81-year-old Francisa medications and visits to the doctor— LOW COVERAGE A nurse checks Reyes suffered a stroke were paid for by her husband’s pension on a patient undergoing dialysis at a at Christmas in 2007, and the contributions of her eight government hospital in Manila. In the she was confined for children. Philippines, PhilHealth, the national more than a month in the intensive care Most of the children had jobs, so health insurance program, covers only Wunit of a hospital in Quezon City in the the family was able to foot these bills. 53% of the population. Philippines. The 1-month confinement was a huge It posed major problems for the drain, though, because Reyes had no Reyes family. Not only were her eight insurance cover of her own. That meant 20% senior citizen’s discount and had PICTURE CREDIT: AFP children worried about their mother’s the children had to give whatever they been declared a dependent by one of health, they faced a frightening had to see her through. her children, entitling her to coverage financial crisis. The eventual hospital bill was a from PhilHealth, the government- Ever since Reyes’ husband died in staggering 1.5 million pesos ($35,000). funded health care system. But this 1986, her medical expenses—mainly for It helped that Reyes was entitled to a accounted for only a fraction of the fee.

6 Development Asia July-December 2011 www.development.asia

P6_12 The Big Read.indd 1 10/21/11 3:00 PM The hospital stay meant her children evidence of this; if you can prescribe the humanitarian news agency Irin, had almost zero balances in their bank more as a doctor, you earn more.” Sharif cites the case of a patient with accounts. It took 2 years for them to Unless you have money, you can’t high blood pressure who took the pills bounce back from the edge of financial access medical services without she was supposed to take daily only catastrophe. borrowing. That’s why in countries once a week, because it was all she where this scenario is prevalent, could afford. POVERTY TRAP like Cambodia, the Lao People’s Managing their mother’s illness caused Democratic Republic (Lao PDR), the REGRESSIVE SPIRAL them financial pain, but by some Philippines, and to a lesser extent Viet The systemic flow-on from avoidance standards in Asia the Reyes family Nam, utilization of health services is of care is obviously regressive, says was lucky. Across the region, high extremely low. “The reality for the poor ADB’s Bhushan. It means, firstly, that out-of-pocket health-care costs are of having no money means sick people those near or below the poverty line forcing millions of others into actual simply don’t visit hospitals,” Bekedam (measured as earning $1.25 or less a poverty and jeopardizing the efforts says. day), spend a greater proportion of of governments and development The human cost can be higher than their income on health care. agencies to alleviate disadvantage. mere embarrassment. Rather than pay Second, since health-care Out-of-pocket health spending medical bills of 50,000 yuan (CNY) expenditures are nonvoluntary, by households accounts for more (about $7,700), one PRC woman sudden, and in many cases large, they than half of total health financing in recently cut into her own belly with a inevitably push extended families most developing countries in Asia. kitchen knife to relieve herself of fluid into poverty at once, or push poor As a result, according to one Asian congestion, a local newspaper reported families into deeper poverty. If an Development Bank (ADB) report, some in May. Wu Yuanbi, a 53-year-old earning member falls sick, the family 78 million people have been pushed migrant worker in Chongqing, had no can lose their source of income at the below the poverty line. medical insurance. “If I’d passed away, time they incur large expenses. In some Henk Bekedam, director for Health I would have at least spared my family cases they then have to sell productive Sector Development at the World the trouble of looking after me,” she assets like land or livestock, which Health Organization (WHO), has said later. compromises their ability to bounce witnessed the problem first-hand, A pathetic litany of such cases exists back. having worked with WHO for 5 years in Asia. In some areas, such as in parts Third, out-of-pocket expenditure in the People’s Republic of China of Pakistan, even when people are able discourages poor households from (PRC) and 6 in Cambodia. “The single to see a doctor they can’t afford follow- seeking early or preventive care, biggest reason I saw causing people to up care as medicines are beyond their Bhushan says. They tend to seek health fall into poverty was their health-care budgets, says Waheed Sharif, a general services only when the health condition bills,” he says. practitioner in Lahore. In a report by has worsened. Indu Bhushan, deputy director Finally, faced with high expenditure general of the Strategy and Policy for health care, it’s the household Department and community of practice members with lowest bargaining leader for health at Asian Development power, like women and female Bank (ADB), agrees. “High levels of “High levels of children, who mostly don’t receive out-of-pocket expenditures for health out-of-pocket adequate or timely help. care are one of the key development expenditures for challenges in the region,” he says. WRONG POLICIES Herein lies one of the most difficult health care are one of The issue is especially evident in the problems for the delivery of affordable the key development Western Pacific, which has some of health services in Asia. In many challenges in the the world’s highest out-of-pocket countries, the patient normally has expenditure in the area of health— to pay the medical provider directly, region” ironically, as its economies are which, as Bekedam says, makes the generally performing well. “It’s clear – Indu Bhushan, deputy director system vulnerable to abuse. Because general of the Strategy and Policy these Asian nations don’t have the providers rely heavily on the money Department and community of right policies in place,” says WHO’s they get directly from patients, they practice leader for health at Asian Bekedam. tend to overprescribe. “There’s clear Development Bank (ADB) This means that in Cambodia and

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P6_12 The Big Read.indd 2 10/21/11 3:00 PM HEALTH: THE BIG READ

the Lao PDR, out-of-pocket health exacted a heavy cost. Assets were sold. over the next 2 decades, changes in expenditure is 60%, he points out. That Debts were incurred. population size and structure alone means for every dollar spent on health, Three years later, Gokalji died. After will increase total health care spending 60% comes from people’s own pockets. his death their shop was taken away by needs by 14% in Central Asia, 37% in In the Philippines and Viet Nam, the Gokalji’s brothers. As is the custom in East Asia and the Pacific, and 45% in figure is 54%. In the PRC, it has come this region, the widow inherited only South Asia. down to 45%. the house in which they’d lived along The way national health-care Throughout much of Asia, out-of- with a small remaining piece of land, financing and health insurance pocket payments are the principal which she eventually sold to settle schemes work is an equally big means of financing health care, debts. problem, says WHO’s Bekedam. according to a recent study published Today Chandibai labors on In many countries the proportion in the journal Health Economics. The construction projects, on other of people who can afford private study examined the magnitude and people’s fields, and in their homes, health insurance is tiny. The PRC distribution of out-of-pocket payments usually earning less than the official has the highly subsidized New for health care in 14 countries and minimum wage. Yet far from being Rural Cooperative Medical Scheme, territories accounting for 81% of the a foregone conclusion, her descent introduced in 2003, which covers 95% Asian population. Several South Asian into chronic poverty could have been of the population. Under this system countries, including Bangladesh, India, prevented, says Krishna, “if cheaper premiums are less than CNY50 (about and Nepal, were found to rely most and more effective health care had been $7) a year. In return, beneficiaries get heavily on out-of-pocket financing and available,” among other factors. reimbursements equal to 70% of the have a high incidence of catastrophic cost of their inpatient medical care. In payments. In some Central Asian SHOW US THE MONEY the Philippines, PhilHealth covers 53% countries, the problem is acute as well. Why are many health care systems in of the population. In Kyrgyz Republic, where there are no Asia and the Pacific so inaccessible But like similar schemes in other exemptions on out-of-pocket payments and ineffective? According to an Asian nations, outpatient departments for poor patients, medical payments ADB operational plan for improving are barely covered, if at all. So people can be catastrophic. access to health, it’s helpful to view with chronic diseases who need Obviously, health expenditure as a the public–policy health challenges of regular check-ups or medicines from proportion of nonfood income is the the region, such as maternal and child outpatient departments are not having highest for the poorest quintile, says mortality, as all linked by the common their costs met. ADB’s Bhushan. But even for those theme of inadequate or inefficient Where their costs are covered, the who are not desperately poor to start expenditure. reimbursement levels are not high with, the fall into poverty resulting Public expenditure on health in enough, says Bekedam. “If you go to from health care costs can happen developing countries is simply too the hospital you pay the bill first, then incrementally, pushed along by little. South Asia, for example, spends get a percentage back from insurance,” successive everyday events. less in absolute and relative terms he says. “It’s nice you get money In Gujarat, an economically fast- than any region in the world including back, but the poor can’t afford to pay growing part of India, Anirudh sub-Saharan Africa, according to ADB. the balance of the bills. To minimize Krishna, a professor at the Sanford Per-capita government expenditure the potential for hardship, the total School of Public Policy at Duke on health was just $9 per person in reimbursement level needs to be University in North Carolina, recently Pakistan in 2005 compared with $2,052 around 70%–80%, with a safety net for met Chandibai, a woman aged about in Japan. very poor people.” 50. Realistically, this situation is unlikely Perversely, the health sector Chandibai’s husband, Gokalji, had to be rectified any time soon. All offers some of the most affordable, owned a general-purpose shop in their countries in the region face enormous village, notes Krishna in his book One cost-containment pressures. Health Illness Away. The couple also owned expenditures are absorbing more and BIGGER BUDGET The People’s Republic a house and agricultural land, which more of governments’ budgets due to of China is among the countries in the they leased out for a share of the crop. growing and aging populations with region that are stepping up efforts to Then Gokalji developed an illness expensive-to-treat chronic diseases like improve public health, increasing its that confined him to bed. Doctors, diabetes and cancer. spending on the sector to 4.6% of gross testing facilities, and pharmacists The World Bank estimates that domestic product in 2009.

8 Development Asia July-December 2011 www.development.asia

P6_12 The Big Read.indd 3 10/21/11 3:00 PM 10/21/11 3:00 PM GAVI is campaigning to change all is campaigning GAVI The alliance is seeking an additional GAVI says. A new vaccine has the new A says. GAVI incidence of potential to halve the during the diarrhea rotavirus severe life. But because of first year of a child’s it is only included insufficient funding, immunization programs in the routine poorest in a handful of the world’s countries. its funds to reach that. It wants to raise of supporting the introduction target vaccines in at least 44 low- of rotavirus Asia income countries by 2015, many in and the Pacific, says spokesman Dan Thomas. donors to fund the $3.7 billion from of the vaccines and for other purchase life-saving interventions. If it gets it, it will be able to immunize an additional in the poorest 243 million children Asia against pneumococcal nations in Haemophilus disease, rotavirus, influenzae type b, hepatitis B, and the complete and ensure yellow fever, the 5-in-1 pentavalent of roll-out vaccine. n A health worker A Finding the money for such which causes severe Rotavirus, administers polio vaccine to a child in Afghanistan. FIGHTING POLIO vaccinated. an ongoing Asia remains in programs to the GAVI according problem, Alliance, a global health partnership between the private and public sectors immunization committed to increasing in poor countries. in infants and children, diarrhea of continues to take hundreds Asia, thousands of lives throughout

n a slum district in Jalalabad, n a slum district in Jalalabad, healthAfghanistan, a volunteer door to door worker goes from who haven’t looking for children When she finds a child who needs When she finds a child Fund The United Nations Children’s

VACCINE FUNDS CAN SAVE MILLIONS OF LIVES OF MILLIONS SAVE CAN FUNDS VACCINE I been immunized against polio. She been immunized against benefits of about the talks with parents the potentially fatalvaccination against disease. she of oral polio vaccine, the two drops opens a thermos and administers it, while her companion maintains a list of in the they’ve reached all the children neighborhood. (UNICEF) and its partners—including Afghanistan and the Government of frequent WHO—have organized national immunization days, when of health volunteers hundreds house to house like this go from UNICEF provides vaccinating children. the vaccines, supplies, and other equipment, and pays daily wages for and supervisors. Since the coordinators amazing 10 an the beginning of 2011, have been Afghan children million

PICTURE CREDIT: AFP P6_12 The Big Read.indd 4 HEALTH: THE BIG READ

cost-effective interventions, and In a perfect world of course, accessible and affordable health care to politically visible results in the field universal coverage schemes that its people. of development. A recent analysis by harness the power of billions of Many countries in Asia are making the Copenhagen Consensus—a Danish contributors and all-embracing progress toward covering more people think tank—concluded that four of government-funded mass public health in the safety nets. “Progress in the PRC the top five most cost-effective ways programs would solve the health-care and the Philippines is promising; in to help the world’s poor were health financing conundrum. Cambodia, Lao PDR, and Viet Nam, interventions. more needs to be done,” Bekedam says. “Engagement in governance and MASSIVE PRICE TAG To give all people access to public expenditure management in The problem with delivering universal affordable health care services, WHO health also makes sense for ADB from coverage of the kind that exists in says total health expenditure should be the results perspective,” says ADB’s developed nations such as Australia at least 4%–5% of GDP. In this, much operational plan for health. and Canada—and with subsidized of Asia lags. The Lao PDR spends less For the poor of Asia, results are what health insurance like the PRC’s—is than 1%; the Philippines spends 1.3%. really matter, though practical catch-all the monumental price tag. In the PRC Is it realistic then to expect the Lao solutions in such a vast and disparate in 2009, the government announced PDR, say, in a few years, to raise its region are neither easy to shape nor to it would spend CNY850 billion ($125 spending on health from 1% to 5% implement. billion) over the next 3 years to provide drastically? No, admits Bekedam. Yet

BANGLADESH FLAGS A WAY FORWARD

angladesh is plagued by environment, and greater awareness of poverty and corruption and health issues facilitated by population subjected to frequent natural density and a common language and disasters. But despite low culture. per capita income and a population In particular, donor funding has Bin which 40% of people live below the helped encourage a sector-wide poverty line, the country’s health sector approach, ensuring alignment under has shown progress. Its achievements government plans, ADB says. Despite in affordable health care provision the changing political scenario, in recent years, prioritizing the poor, administrations have maintained women and children, may show the primary health care as a priority focus EMPOWERED Women in a village way for other developing nations in and made health financing predictable in Bangladesh queue to have their Asia. and flexible. photographs and signatures added to the Life expectancy in Bangladesh is now There is evidence to suggest voters’ database. Life expectancy and 66.9 years compared with India’s 64.4, Bangladesh’s current progress has other health indicators have improved according to Nobel Prize economist much to do with the role liberated in the country partly because of growing Amartya Sen. The proportion of Bangladeshi women are beginning female literacy and empowerment. underweight children in Bangladesh to play in the country according to (41.3%) is lower than in India (43.5), Amartya Sen in his essay Quality of approaches to provide a range of health and its fertility rate (2.3) is also lower Life: India vs. China in The New York services. They have also empowered than India’s (2.7). Review. “The female literacy rate among women (through offering microcredit What are the ingredients for young Bangladeshis is higher than the and informal education), which has this success? The following factors male rate, whereas young women still had an indirect but important influence emerge, according to ADB’s Bhushan: have substantially lower rates than on demand for health services. comparatively good female literacy young males in India,” he says. Government priorities and public PICTURE CREDIT: AFP and empowerment, the involvement The widespread and generally expenditure also seem to be a factor. of grassroots and community-based effective programs of NGOs are The percentage of government nongovernment organizations (NGOs) important too. Most NGOs in expenditure going to health is arguably in health services, good government Bangladesh work at the grassroots a more revealing statistic, say some focus and a supportive policy level, using innovative, participatory experts. n

10 Development Asia July-December 2011 www.development.asia

P6_12 The Big Read.indd 5 10/21/11 3:00 PM increases in government allocations for health across Asia are nevertheless essential to ensure the situation doesn’t rapidly get worse. “Definitely in a few years they need to be spending at least 2% of GDP on health.” Bekedam notes that the booming PRC has indicated it’s ready to spend even more. And in the Philippines, the government has admitted, with input poor sanitation in rural areas, and SMART AID Bill Gates, Microsoft from WHO and the World Bank, that public health services are poor and chairman and cochair of the Bill and it needs to start spending around 2.5% underfinanced, the country has a Melinda Gates Foundation, talks about of GDP. universal health care system run by how targeted spending is advancing its constituent states and territories. global health and reducing poverty “MARKET PRINCIPLES DON’T WORK” It is generally acknowledged to have during the Living Proof campaign. While public–private partnerships have overseen the eradication of mass an important role in containing costs, famines and includes many aspects reducing waste, and inefficiencies, that meet or exceed international Millennium Development Goals. most experts agree it is chiefly the quality standards. In Viet Nam, for example, ADB has government’s responsibility to drive helped the government to establish health investment. “That’s because in PAYING THE PROVIDERS health insurance cover for poor health, market principles have a limited Along with better government and marginal populations, and to role,” asserts Bekedam. “To reduce funding and control, changing the way expand the coverage of free public patient’s expenditure and guarantee providers are paid is an essential step health services. More recently, says access, safety, and quality, governments to boost health services and outcomes, Bhushan, ADB has been helping (as must ensure the funds are there.” says Bekedam. The chief negotiator in the Philippines) with conditional Though its health system is far in this process should not be the cash transfers, which provide money from perfect, the PRC, again, offers an patient, but governments and health to families if they take certain health example of how increasing investment authorities, especially through health measures such as prenatal care, in public health and reducing out- insurance. delivery in medical facilities, or of-pocket expenditures can make a “In that way authorities can immunizing children. difference for millions. negotiate directly with the provider One of the most recent testimonies to After the severe acute respiratory to give better services and value for the role of such “smart aid” comes from syndrome (SARS) epidemic a few money,” he says. Microsoft founder and philanthropist years ago, the Government of the PRC Changing the way you pay the Bill Gates. Speaking to the press in increased its commitment to tackling provider isn’t easy, he admits. In the Berlin in April, he introduced the public health problems. Among other Republic of Korea, doctors went on “Living Proof” campaign to present efforts it increased public health strike for a year when faced with such evidence of how targeted spending on funding; revised laws that concerned reforms. “But if you want better cost development can save millions of lives the control of infectious diseases; control as a government or health and help people lift themselves and implemented the world’s largest insurer, you need to be closer to their families out of poverty. internet-based disease reporting where the costs are being made,” adds A statement released during the system to improve transparency, reach, Bekedam. event said the campaign will show and speed; and started a program to that “we are on the brink of enormous rebuild local public health facilities and THE ROLE OF AGENCIES successes in advancing global health national infrastructure. According to For Asia’s poorest, the role of and fighting poverty but these victories WHO’s Global Health Observatory, the development agencies and institutions will only become reality if donor PICTURE CREDIT: AFP dragon economy spent 4.6% of GDP on in developing more equitable and governments keep up their support.” health in 2009. comprehensive health financing It cited impressive numbers: In India, too, hopeful signs exist. systems seems to be vital. Growing • In the past 50 years, child deaths While Indians still suffer high levels bodies of evidence attest to this in the developing world have of malnutrition and disease with fundamental assumption behind the been cut by more than 50%,

www.development.asia July-December 2011 Development Asia 11

P6_12 The Big Read.indd 6 10/21/11 3:00 PM HEALTH: THE BIG READ

despite the birth rate increasing. line to seek help with the birth of who’d been almost blinded by • Polio cases have been reduced babies at private hospitals, and covers cataracts. by 99% since 1988, and we their out-of-pocket costs and loss of are now on the threshold of wages. KEY FACTORS MAKE A DIFFERENCE eradicating only the second Private medical practitioners (mainly In summary, then, what do experts disease in history. obstetricians) in these districts provide say are the key factors that can make a • Malaria cases have been reduced delivery-care services to women. These difference for Asian nations struggling by 50% in 38 countries between providers are then reimbursed on a with health-care financing problems? 2000 and 2008. fixed rate for the deliveries they carry They include the development of “Smart aid works,” Gates said. out. strategies to reduce out-of-pocket “While we have facts and figures as Beneficiaries have saved more medical expenses, ongoing increases evidence, it’s the lives saved and the than 3,000 rupees (Rs), about $75, in in health budgets by governments and futures restored that are real living delivery-related expenses and are agencies, improvements in the way proof that our investments in aid are generally satisfied with the scheme. providers are paid, and the increased working.” By buying the services in bulk from involvement and support of the private private care providers, the government sector in delivering better outcomes. PUBLIC–PRIVATE PARTNERSHIPS gets delivery services at a lower price In addition, improved cooperation If state authorities should generally than the market rates being paid by by all parties involved in delivering drive investment in and management non-beneficiaries (Rs4,000 or $100). health services, including those that of health, experts say, development In some instances, the involvement set policy, is a factor of overriding agencies should support the increased of business in paying for better health importance, according to WHO. involvement of the private sector, outcomes is even more direct. Hong It’s clear that governments, appropriately regulated, in making Kong, China-based Yip Chemical development bodies, and health a difference in delivering affordable Holdings has donated two mobile authorities have a critical responsibility health care for the poor. eye surgery centers with advanced to work together to improve the ADB is a strong proponent of such ophthalmic equipment to Ningxia performance of health systems, involvement, pointing out in its Hui Autonomous Region and Jiangsu remarked WHO’s regional director for operational plan for health that the Province of the PRC. The company the Western Pacific Shin Young-soo in private sector plays a dominant role in has provided treatment—free—to a recent speech. Health policy, strategy, health care delivery in much of Asia, hundreds of cataract patients, mostly and planning cannot stand by itself, he especially South Asia. Several countries from remote areas. “I can see things said. They need to link with national have sought ADB advice and input on now,” says Liu Guangying, a farmer development planning processes. n managing public–private partnerships in sectors including health. “Public–private partnerships are part of the solution for sure,” says Bhushan. “A large and growing proportion of health services are provided by the private sector in developing countries.” One example is the Chiranjeevi Scheme in India. Implemented by the Gujarat state government, it encourages families below the poverty

PRIVATE CARE A nurse looks after a PICTURE CREDIT: AFP premature baby at a maternity hospital in India. In Gujarat, the state government is able to cover delivery-related expenses of poor families by negotiating for lower, bulk rates with private care providers.

12 Development Asia July-December 2011 www.development.asia

P6_12 The Big Read.indd 7 10/21/11 3:00 PM Some solutions for climate change

...really do grow on trees

Climate change endangers all living things. The loss of forestland contributes greatly to the problem. Plants breathe carbon dioxide, making forests natural carbon storehouses. Unfortunately, cutting trees causes as much as 20% of all greenhouse gas emissions. Forest degradation contributes emissions as well.

A global forest carbon market is proposed to arrest deforestation by compensating developing countries for conserving their forests. This would generate billions of dollars in new funding for rural development and environmental management under the scheme of Reduced Emissions from Deforestation and Forest Degradation (REDD).

ADB supports pilot activities developing this approach in the People’s Republic of China, Indonesia, Lao People’s Democratic Republic, the Philippines, Thailand, and Viet Nam. Trees are our friends. Helping save them is one of the many strategic actions ADB is taking in the fight against climate change.

www.adb.org

ADB Climate Change Posters_DA3 203x273.indd 1 13/04/2010 11:27:55 AM THE BIG PICTURE

More People Would Fall Beneath Poverty Line Free or Nearly Free Burden of Health Costs In some countries in Asia, Out-of-pocket health care expenses can easily strain a household budget, if Health Care Spending Is Considered portions of the population receive free or nearly free and the financial shock of a single expensive event can push a family into poverty. When the impact of health care costs on household resources is factored in, health care. about 78,000,000 more people in developing Asia would fall into poverty. For those already living in poverty, the effects can be devastating. Percentage of Population With Free or Nearly Free Who Bears the Cost Priority of Health Care Rising Costs Health Care Across developing Asia, the percentage of An indicator of the priority a government Spending per capita on health care rose Kyrgyz Republic Selected countries health care costs that must be paid out of places on health care is the portion of its across developing Asia from 2000 to 2008, 4.7% more People’s Republic pocket varies widely. overall spending dedicated to health care. often more than doubling. 6,000 more people of China 50% to 70% India 30% to 40% Portion of Health Care Expenditures, Government Expenditure on Health Per Capita Spending on Health Indonesia 30% to 40% by Source in 2008 as Percentage of All Government In international dollars as NOTE: The source study for this People’s Republic Philippines 30% to 40% Expenditure purchasing power parity chart used a poverty benchmark of China Thailand More than 70% Out-of- Other private Government of living on less than $1.08 a day. pocket sources 2008 2000 2008 2000 18.8% more Viet Nam 20% to 30% 4% Afghanistan 57 32,400,000 more people Kyrgyz Republic 45% 7% 48% Afghanistan 7% 16 3% 395 Kazakhstan 41% 1% 59% Azerbaijan 4% Azerbaijan Nepal % 100 42% 0% 58% 7 Georgia 433 Turkmenistan Georgia 7% 142 5.7% more 8% Kazakhstan 444 Tajikistan 69% 4% 28% Kazakhstan 9% 195 516,000 more people 12% Kyrgyz Republic 123 Uzbekistan 49% 1% 51% Kyrgyz Republic 12% 61 3% Pakistan 62 Pakistan 54% 14% 32% Pakistan 2% 47 5% 78% 1% 22% Tajikistan Tajikistan 95 India Afghanistan 7% 40 Household Resources Used Central and West Asia Central and West Asia Central and West Asia 9% Turkmenistan 124 Azerbaijan 73% 7% 19% Turkmenistan 6% 82 11.9% more Viet Nam % For Out-of-Pocket Payments 67% 3% 31% Uzbekistan 9 Uzbekistan 134 Thailand Georgia 6% 81 37,400,000 30.1% more Average; as percentage of 7.9% more % all household resources more people 15% 4% 82% 8 Mongolia 131 850,000 Mongolia Mongolia 11% 87 100,000 % 10 PRC 265 % more people Philippines Asia Asia Asia East East PRC 44% 9% 47% East PRC 11% 107 Bangladesh 5.1 more people PRC 4.1% Sri Lanka 3.7% more 12% Tonga 21% 4% 75% Cook Islands 361 % 445,000 more people 10% Cook Islands 244 India 4.8 8.3% more % Malaysia 0% 0% 100% Kiribati 17 304 % Tuvalu 14% Kiribati 145 Indonesia 1.8 % 60,000 more people 3% 0% 97% 15 % 251 4.4% more Marshall Islands Marshall Islands 21 Marshall Islands 299 Kyrgyz Republic 2.4% % 9% 0% 19 408 Cook Islands 91% FSM 11% FSM 208 Malaysia 1.4% 11,000 more 19% 440 Solomon Islands 4% 2% 93% Nauru 11% Nauru 554 Nepal 2.8% people % 9% 0% 90% Palau 17 991 Indonesia FSM 12% Palau 758 Philippines 1.9% 7% 70 10% 6% 85% Papua New Guinea % Samoa 10 Papua New Guinea 69 Sri Lanka 2.1% 8.7% more Pacific Pacific 10% 168 Kiribati 0% 16% 84% Republic of Fiji % Republic of Fiji Pacific 10 138 Thailand 1.7% 1,400,000 more people % Vanuatu 10% 6% 84% Samoa 15 Samoa 264 12% 149 Viet Nam 5.5% 14% 139 Republic of Fiji 16% 9% 75% Solomon Islands 18% Solomon Islands 81 12% 112 Palau 9% 13% 78% Timor-Leste 13% Timor-Leste 67 Tonga 14% Tonga 194 Papua New Guinea 8% 12% 80% 15% 164 Tuvalu 8% Tuvalu 266 Nauru 0% 21% 78% 6% 223 Vanuatu 14% Vanuatu 170 Asia’s Double Burden Timor-Leste 6% 11% 83% 10% 107 Communicable diseases are the leading cause of death in Asia and the Pacific. Health experts however warn that Disease category 7% 44 Maldives 28% 11% 61% Bangladesh 8% Bangladesh 22 noncommunicable diseases are a growing problem. Deaths per 100,000 population; latest available data Communicable 13% 263 Bhutan 18% 0% 83% Bhutan 13% Bhutan 165 Noncommunicable 4% 122 Bangladesh 66% 2% 31% India 4% India 69 1,289 14% 769 Sri Lanka 49% 8% 44% Maldives Maldives 242 1,117 11% 1,016 1,092 South Asia 66 1,015 11% South Asia 985 Nepal 45% 17% 38% South Asia Nepal 8% Nepal 43 902 935 913 8% Sri Lanka 187 838 India 50% 17% 32% Sri Lanka 7% 101 730 748 752 735 748 771 670 711 713 703 704 683 670 687 702 685 667 675 604 623 598 620 623 647 599 607 587 560 526 18% 8% 74% 9% Cambodia 118 455 Thailand Cambodia 9% 51 6% Indonesia 91 313 Indonesia 32% 14% 54% Indonesia 5% 47 62% 4% 34% 4% Lao PDR 84 Singapore Lao PDR 5% 40 56% 6% 39% 7% Malaysia 621 Viet Nam Malaysia 6% 304 1% 27 74 102 72 95 112 104 58 89 109 59 79 66 Lao PDR 63% 20% 18% Myanmar Myanmar 12 166 144 166 173 175 153 122 1% 229 203 240 194 196 244 185 231 15% 44% 6% Philippines 129 263 266 Malaysia 41% Philippines 7% 79 387 343 373 344 359 363 338 376 54% 11% 35% 8% Singapore 1,833 444 478 461 Philippines Singapore 6% 937 713 Southeast Asia Southeast Asia 65% 12% 24% Southeast Asia 14% Thailand 328 Cambodia Thailand 10% 165 89% 4% 8% 9% 201 PRC FSM Myanmar Viet Nam Viet Nam Palau India 7% 76 Nauru Tonga Nepal Kiribati Samoa Tuvalu Bhutan Georgia Armenia Pakistan Vanuatu Maldives Sri Lanka Lao PDR Malaysia Thailand Tajikistan Mongolia Myanmar Viet Nam Cambodia Indonesia Singapore Azerbaijan Uzbekistan Philippines Kazakhstan Bangladesh Afghanistan Cook Islands Timor-Leste Turkmenistan Republic of Fiji FSM = Federated States of Micronesia, Lao PDR = Lao People’s Democratic Republic, PRC = People’s Republic of China Marshall Islands Kyrgyz Republic Solomon Islands Note: Percentages may not total 100% because of rounding. Papua New Guinea Purchasing power parity at international dollar rate. World development indicators database. Washington, DC, World Bank. World Development Indicators Database. www.worldbank.org/data (accessed 16 July, 2011). Central and West Asia East Asia Pacific South Asia Southeast Asia Sources: World Health Organization (WHO). 2011. World Health Statistics 2011. Geneva: WHO. ; WHO Indicator and Measurement Registry. http://apps.who.int/gho/indicatorregistry); E. van Doorslaer, et. al. 2006. E£ect of Payments for Health Care on Poverty Estimates in 11 Countries in Asia: An Analysis of Household Survey Data. Lancet; 368: 1357–64.; http://blogs.worldbank.org/developmenttalk/health-reform-a-consensus-emerging-in-asia Submitted by Adam Wagsta£ on 12 April, 2011 (accessed 16 July, 2011). FSM = Federated States of Micronesia, Lao PDR = Lao People’s Democratic Republic, PRC = People’s Republic of China. RESEARCH AND DESIGN: MARK BLACKWELL

14 Development Asia July-December 2011 www.development.asia

P14_15 The Big Picture.indd 1 10/21/11 3:57 PM More People Would Fall Beneath Poverty Line Free or Nearly Free Burden of Health Costs In some countries in Asia, Out-of-pocket health care expenses can easily strain a household budget, if Health Care Spending Is Considered portions of the population receive free or nearly free and the financial shock of a single expensive event can push a family into poverty. When the impact of health care costs on household resources is factored in, health care. about 78,000,000 more people in developing Asia would fall into poverty. For those already living in poverty, the effects can be devastating. Percentage of Population With Free or Nearly Free Who Bears the Cost Priority of Health Care Rising Costs Health Care Across developing Asia, the percentage of An indicator of the priority a government Spending per capita on health care rose Kyrgyz Republic Selected countries health care costs that must be paid out of places on health care is the portion of its across developing Asia from 2000 to 2008, 4.7% more People’s Republic pocket varies widely. overall spending dedicated to health care. often more than doubling. 6,000 more people of China 50% to 70% India 30% to 40% Portion of Health Care Expenditures, Government Expenditure on Health Per Capita Spending on Health Indonesia 30% to 40% by Source in 2008 as Percentage of All Government In international dollars as NOTE: The source study for this People’s Republic Philippines 30% to 40% Expenditure purchasing power parity chart used a poverty benchmark of China Thailand More than 70% Out-of- Other private Government of living on less than $1.08 a day. pocket sources 2008 2000 2008 2000 18.8% more Viet Nam 20% to 30% 4% Afghanistan 57 32,400,000 more people Kyrgyz Republic 45% 7% 48% Afghanistan 7% 16 3% 395 Kazakhstan 41% 1% 59% Azerbaijan 4% Azerbaijan Nepal % 100 42% 0% 58% 7 Georgia 433 Turkmenistan Georgia 7% 142 5.7% more 8% Kazakhstan 444 Tajikistan 69% 4% 28% Kazakhstan 9% 195 516,000 more people 12% Kyrgyz Republic 123 Uzbekistan 49% 1% 51% Kyrgyz Republic 12% 61 3% Pakistan 62 Pakistan 54% 14% 32% Pakistan 2% 47 5% 78% 1% 22% Tajikistan Tajikistan 95 India Afghanistan 7% 40 Household Resources Used Central and West Asia Central and West Asia Central and West Asia 9% Turkmenistan 124 Azerbaijan 73% 7% 19% Turkmenistan 6% 82 11.9% more Viet Nam % For Out-of-Pocket Payments 67% 3% 31% Uzbekistan 9 Uzbekistan 134 Thailand Georgia 6% 81 37,400,000 30.1% more Average; as percentage of 7.9% more % all household resources more people 15% 4% 82% 8 Mongolia 131 850,000 Mongolia Mongolia 11% 87 100,000 % 10 PRC 265 % more people Philippines Asia Asia Asia East East East PRC 44% 9% 47% PRC 11% 107 Bangladesh 5.1 more people PRC 4.1% Sri Lanka 3.7% more 12% Tonga 21% 4% 75% Cook Islands 361 % 445,000 more people 10% Cook Islands 244 India 4.8 8.3% more % Malaysia 0% 0% 100% Kiribati 17 304 % Tuvalu 14% Kiribati 145 Indonesia 1.8 % 60,000 more people 3% 0% 97% 15 % 251 4.4% more Marshall Islands Marshall Islands 21 Marshall Islands 299 Kyrgyz Republic 2.4% % 9% 0% 19 408 Cook Islands 91% FSM 11% FSM 208 Malaysia 1.4% 11,000 more 19% 440 Solomon Islands 4% 2% 93% Nauru 11% Nauru 554 Nepal 2.8% people % 9% 0% 90% Palau 17 991 Indonesia FSM 12% Palau 758 Philippines 1.9% 7% 70 10% 6% 85% Papua New Guinea % Samoa 10 Papua New Guinea 69 Sri Lanka 2.1% 8.7% more Pacific Pacific 10% 168 Kiribati 0% 16% 84% Republic of Fiji % Republic of Fiji Pacific 10 138 Thailand 1.7% 1,400,000 more people % Vanuatu 10% 6% 84% Samoa 15 Samoa 264 12% 149 Viet Nam 5.5% 14% 139 Republic of Fiji 16% 9% 75% Solomon Islands 18% Solomon Islands 81 12% 112 Palau 9% 13% 78% Timor-Leste 13% Timor-Leste 67 Tonga 14% Tonga 194 Papua New Guinea 8% 12% 80% 15% 164 Tuvalu 8% Tuvalu 266 Nauru 0% 21% 78% 6% 223 Vanuatu 14% Vanuatu 170 Asia’s Double Burden Timor-Leste 6% 11% 83% 10% 107 Communicable diseases are the leading cause of death in Asia and the Pacific. Health experts however warn that Disease category 7% 44 Maldives 28% 11% 61% Bangladesh 8% Bangladesh 22 noncommunicable diseases are a growing problem. Deaths per 100,000 population; latest available data Communicable 13% 263 Bhutan 18% 0% 83% Bhutan 13% Bhutan 165 Noncommunicable 4% 122 Bangladesh 66% 2% 31% India 4% India 69 1,289 14% 769 Sri Lanka 49% 8% 44% Maldives Maldives 242 1,117 11% 1,016 1,092 South Asia 66 1,015 11% South Asia 985 Nepal 45% 17% 38% South Asia Nepal 8% Nepal 43 902 935 913 8% Sri Lanka 187 838 India 50% 17% 32% Sri Lanka 7% 101 730 748 752 735 748 771 670 711 713 703 704 683 670 687 702 685 667 675 604 623 598 620 623 647 599 607 587 560 526 18% 8% 74% 9% Cambodia 118 455 Thailand Cambodia 9% 51 6% Indonesia 91 313 Indonesia 32% 14% 54% Indonesia 5% 47 62% 4% 34% 4% Lao PDR 84 Singapore Lao PDR 5% 40 56% 6% 39% 7% Malaysia 621 Viet Nam Malaysia 6% 304 1% 27 74 102 72 95 112 104 58 89 109 59 79 66 Lao PDR 63% 20% 18% Myanmar Myanmar 12 166 144 166 173 175 153 122 1% 229 203 240 194 196 244 185 231 15% 44% 6% Philippines 129 263 266 Malaysia 41% Philippines 7% 79 387 343 373 344 359 363 338 376 54% 11% 35% 8% Singapore 1,833 444 478 461 Philippines Singapore 6% 937 713 Southeast Asia Southeast Asia 65% 12% 24% Southeast Asia 14% Thailand 328 Cambodia Thailand 10% 165 89% 4% 8% 9% 201 PRC FSM Myanmar Viet Nam Viet Nam Palau India 7% 76 Nauru Tonga Nepal Kiribati Samoa Tuvalu Bhutan Georgia Armenia Pakistan Vanuatu Maldives Sri Lanka Lao PDR Malaysia Thailand Tajikistan Mongolia Myanmar Viet Nam Cambodia Indonesia Singapore Azerbaijan Uzbekistan Philippines Kazakhstan Bangladesh Afghanistan Cook Islands Timor-Leste Turkmenistan Republic of Fiji FSM = Federated States of Micronesia, Lao PDR = Lao People’s Democratic Republic, PRC = People’s Republic of China Marshall Islands Kyrgyz Republic Solomon Islands Note: Percentages may not total 100% because of rounding. Papua New Guinea Purchasing power parity at international dollar rate. World development indicators database. Washington, DC, World Bank. World Development Indicators Database. www.worldbank.org/data (accessed 16 July, 2011). Central and West Asia East Asia Pacific South Asia Southeast Asia Sources: World Health Organization (WHO). 2011. World Health Statistics 2011. Geneva: WHO. ; WHO Indicator and Measurement Registry. http://apps.who.int/gho/indicatorregistry); E. van Doorslaer, et. al. 2006. E£ect of Payments for Health Care on Poverty Estimates in 11 Countries in Asia: An Analysis of Household Survey Data. Lancet; 368: 1357–64.; http://blogs.worldbank.org/developmenttalk/health-reform-a-consensus-emerging-in-asia Submitted by Adam Wagsta£ on 12 April, 2011 (accessed 16 July, 2011). FSM = Federated States of Micronesia, Lao PDR = Lao People’s Democratic Republic, PRC = People’s Republic of China. RESEARCH AND DESIGN: MARK BLACKWELL

www.development.asia July-December 2011 Development Asia 15

P14_15 The Big Picture.indd 2 10/21/11 3:57 PM HEALTH

Double burden An explosion in infectious and noncommunicable diseases represents a worsening crisis for developing economies and health authorities

BY Bruce Heilbuth

raditionally, infectious other countries are just as compelling,” diseases, which claim so many he says. lives in Asia, mostly affected Moreover the problem is predicted to poorer countries while increase significantly along with aging noncommunicable diseases plagued populations, unplanned urbanization, Tricher nations. and unhealthier lifestyles. Globally, But the pendulum is swinging. deaths due to cancer are projected More and more people in the region to rise by more than 60% in the first are suffering from noncommunicable 30 years of this century, according to diseases like heart disease, diabetes, WHO projections; and deaths due to and cancer—a legacy of unhealthier cardiovascular disease are expected lifestyles resulting from people taking to rise more than 70% over the same less exercise, along with changing diets period. and, most of all, tobacco smoking, according to the World Health INFECTIOUS DISEASES Organization (WHO). ‘EVER-PRESENT’ Noncommunicable diseases are now “Unlike For the large numbers of poor in Asia, the leading cause of death around the communicable infectious illnesses such as hepatitis, world, with developing countries hit influenza, tuberculosis, dengue, hardest, according to an April 2011 diseases, which measles, and malaria remain an ever- report from WHO. Adults aged 35 to 60 tend to affect present threat. In fact they’re becoming in the WHO South-East Asia Region are people quickly, more prevalent, according to a recent dying from noncommunicable diseases Asia Business Council report. at a much higher rate than adults of noncommunicable The past 2 decades have seen more the same age group in developed diseases progress than 30 reemerging infectious diseases countries. much more slowly, and unexpected outbreaks of new “The region is in the midst of an ones. Global pandemics have included epidemiological transition,” says creating complex severe acute respiratory syndrome the WHO report. “While infectious health needs that are (SARS), HIV/AIDS, diphtheria, diseases are still highly prevalent, expensive to treat malaria, measles, polio, and H1N1 noncommunicable diseases are (swine influenza), while regional emerging as an important public health and can overwhelm epidemics have included H5N1 (avian threat, accounting for an estimated already stressed influenza). Those illnesses accounted 8 million deaths annually, or 22% of health systems” for about 15% of the 37 million deaths global deaths.” worldwide in 2009, the report says, and The starkest evidence of this shift can more than a third of them were in Asia – Shin Young-soo, World Health be seen in the Pacific islands where due Organization regional director for and the Pacific. to changes in eating and work habits, the Western Pacific By 2050, Asia’s urban population diabetes and obesity have become will increase by between 20% and 25%, epidemic, according to Indu Bhushan, according to the Asia Business Council, PICTURE CREDIT: AFP deputy director general of the Strategy which means 1.5 billion people will live and Policy Department and community in urban areas. This rapid urbanization, of practice leader for health at Asian which has led to overcrowding in Development Bank (ADB). “Data from big cities, could increase the risk of

16 Development Asia July-December 2011 www.development.asia

P16_20 Double burden.indd 1 10/21/11 3:04 PM HAZARDS OF CITY LIFE Rapid urbaniza- tion in the People’s Republic of China and other parts of Asia has led to over- crowding in big cities, which raises the risk of infectious disease transmission. The shift to an urban, sedentary lifestyle is also linked to the high incidence of obesity, diabetes, heart diseases, and cancer.

infectious disease transmission. A prime example of the potentially devastating effects of these illnesses is the 2003 outbreak of SARS, which cost Asian economies between $11 billion and $18 billion and brought a loss in gross domestic product of between 0.5% and 2.0%, according to the US State Department. The raw data from Asia are often astonishing. In 2009, for instance, India had the highest number of tuberculosis cases in the world (2 million new patients). In addition, about half of all Indians have silent or “latent” tuberculosis infection, says a OneWorld South Asia report.

MORE MISERY Noncommunicable diseases will reap as much if not more misery—and represent an equally large threat to national budgets. The rising tide is already straining healthcare systems, observes Shin Young-soo, WHO regional director for the Western Pacific. “Unlike communicable diseases, which tend to affect people quickly, noncommunicable diseases progress much more slowly, creating complex health needs that are expensive to treat and can overwhelm already stressed health systems,” he said in a recent speech. Since they’re closely linked to poverty, these diseases impede PICTURE CREDIT development. In India, eliminating noncommunicable diseases would increase GDP by between 4% and 10% according to the World Bank. Harvard

www.development.asia July-December 2011 Development Asia 17

P16_20 Double burden.indd 2 10/21/11 3:04 PM HEALTH

POVERTY’S HEAVY TOLL A ragpicker lugs a sack of recyclables in Mumbai, In- dia. The poor are the most vulnerable in Asia, not just to infectious illnesses but also increasingly to noncommunicable diseases, such as cancer, due to poor eating habits and other problems.

University health economist David Bloom estimates that chronic illnesses, such as heart disease and cancer, will cost the world an estimated $35 trillion over 25 years unless concerted action is taken. Which noncommunicable diseases pose the biggest challenges? Pick an ailment.

DIABETES Up near the top of the list is diabetes, which, like many others, is interrelated with obesity, unhealthy diets, and inactive lifestyles. Diabetes accounted for about 4 million deaths in 2010. By 2030, 366 million people will suffer from it, with the PRC ranked at the top of countries with the largest number of diabetics, followed by India, according to the International Diabetes Foundation. This represents a rise of more than two- thirds from 2010.

OBESITY Obesity and excess weight have his doctor has told him the cancer may population has adopted a Western diet, become increasingly worrisome be caused by passive smoking, his and with it the red meat and animal fat problems in the region, according daughter Yuli told The Jakarta Post. “His that are known to put people more at to WHO’s Shin Young-soo. More shop was full of cigarette smoke.” risk of colon and rectal cancer. than 1 billion people worldwide Ayung is, sadly, yet another victim The causal factors, as for other are overweight and this number is of the scourge of cancer, the incidence noncommunicable diseases, are many expected to increase by 50% by 2015. of which is rising dramatically in Asia. and interrelated. Physical inactivity is Childhood obesity is a particular In Hong Kong, China, according to an estimated to cause between 15% and concern, he says, especially among the AsiaOne report, the number of cases of 25% of breast and colon cancers, and is poor who often eat unhealthy foods bowel cancer has risen by about 3% a responsible for 30% of the worldwide because they’re cheaper. year over the past 20 years. heart disease burden, according to One way of gauging how big a killer WHO. PICTURE CREDIT: AFP CANCER colon cancer is in a country is to look South Jakarta cigarette shop owner for fast-food restaurants, says Hong THE SCOURGE OF SMOKING Ayung, 63, lies on his bed suffering Kong, China cancer specialist Jonathan But by far the biggest issue, all health from stage-three lung cancer caused Sham Shun-tong. The existence of experts agree, is smoking. by cigarettes. He hardly smokes, but fast-food chains is evidence that the “It’s a huge challenge,” Mary

18 Development Asia July-December 2011 www.development.asia

P16_20 Double burden.indd 3 10/21/11 3:04 PM Assunta, senior policy adviser to comprehensive legislation to reduce percentage points over the last quarter the Southeast Asia Tobacco Control [its] use,” says Assunta. The single of a century, and for young Australian Alliance, told the Australian Associated most important way of doing that, she adults (18- to 24-year-olds) they have Press recently. “Out of the 1.2 billion adds, is to increase tobacco tax, making more than halved over the same smokers in the world, 80% are from cigarettes pricier. period. developing countries or poor and low- The benefits of doing so are The Australian federal government resourced countries.” manifestly obvious as shown by the intends to go further, aiming to Part of the reason is that developing Australian experience. Over the past introduce plain packaging laws for nations, many of which have yet to 2 decades, Australian authorities have cigarette packs. “I think this is very impose cigarette advertising bans, are encouraging what Australia is doing,” “aggressively” targeted by the tobacco Ala Alwan, WHO director-general for industry, says Assunta. Indeed some noncommunicable diseases, told the governments in developing nations Australian Broadcasting Corporation even rely on funding from tobacco recently. “There is… the need for companies—given as “corporate social low and middle-income countries responsibility” donations—to fund to… implement similar interventions public services, including schools. if they want to see the rate of noncommunicable diseases declining.” THE WAY FORWARD Much of the work in reducing The morality of tobacco companies’ the incidence of noncommunicable behavior is the subject of separate diseases can be achieved by public debate. Meanwhile what can be done education and policies that support about the double burden of disease that lifestyle changes, according to WHO. exists in Asia on a scale never before By improving diet, increasing physical seen in history? activity, and quitting smoking, 80% of Raising the priority of heart diseases and stroke, 80% of Type noncommunicable diseases in health 2 diabetes, and 40% of cancers can be and development plans has been one prevented. Moderate physical activity of the key priorities of WHO. Urgent for 150 minutes a week could reduce action is needed now, it believes, to the risk of ischemic heart disease by reverse the threat. 30%, the risk of diabetes by 27%, and “The solutions are difficult but we the risk of breast and colon cancer by cannot avoid making a beginning,” between 21% and 25%. says ADB’s Bhushan, who believes the war needs to be waged on two fronts: POTENTIAL OBSTACLES public education, and policies that AVOIDING ADVICE A man smokes a A big potential obstacle, however, encourage healthy eating and healthier cigarette next to a “no smoking” sign in is urbanization, as Henk Bekedam, lifestyles. Jakarta, Indonesia. Tobacco products director for Health Sector Development The first step should include an are the greatest single cause of cancer at the WHO, observes. Smoking all-out war on smoking. If the health in Asia. and obesity are issues over which debate in the developing world is individuals can take control, he says, becoming less about killer viruses and but in reality it’s not easy. “As people more about killer products, then the steadily increased tobacco excises, move into urban areas, the bicycle they chief target must be tobacco, experts pushing the price of a pack of 30 to were riding is put against a tree and agree. around $20. they sit in trains, in buses; they don’t What makes the misery caused by The result? Whereas in, say, do regular exercise anymore.” tobacco-related illnesses so tragic is Indonesia where the prevalence of Another problem, according that they are preventable. Tackling the smoking among adults is over 45%, to Bhushan, is the political cycle. problem of tobacco—as opposed to fewer than one in five Australians Politicians are usually up for reelection infectious disease—doesn’t depend now light up, according to Cancer in 3 to 4 years, which is not much on scientists seeking an elusive Council Victoria. Smoking rates among time to make inroads into tackling vaccine. “You need to put in place Australian adults have dropped 15 noncommunicable diseases and have

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something to show for their efforts. the West. “There is a lack of long-term political More than any other Asian nation, commitment,” says Bhushan. “Given Indonesia exemplifies the scope of the the short democratic cycle, politicians Diabetes is costly to problem that confronts the region. The tend to focus on quick wins.” manage long term, number of cases in the country of 237 Still, as the Australian anti-smoking and demands a million is skyrocketing, according to experience has shown, cultural shifts newspaper reports. can and do happen. “Ultimately social and financial There were 21.3 million Indonesian cultures are man-made, and men can investment that diabetics in 2010, double the figure change their culture,” says Bekedam. many countries of a decade ago. “It’s alarming,” says There are signs of hope in the University of Indonesia endocrinologist Western Pacific, according to WHO. All will have difficulty Dante Saksono Harbuwono, who adds the countries in the region have now making unless they that research has shown Asians tend ratified the organization’s Framework quickly reprioritize to have higher insulin resistance than Convention on Tobacco Control Caucasians. and have introduced laws aimed at efforts and funding Diabetes is costly to manage long reducing its consumption, and already term, and demands a social and some countries are reporting declines financial investment that many in smoking. that engages all these sectors,” says countries will have difficulty making Hong Kong, China has instituted a WHO’s Shin Young-soo. “The private unless they quickly reprioritize efforts citywide smoking ban, and Singapore sector—those involved in producing, and funding, according to Samlee has banned smoking in eateries. marketing, and trading food—can Plianbangchang, regional director for Even Bollywood has acted. Crew take important steps to make our food WHO South-East Asia. members filming an anti-smoking healthier, while still enjoying healthy “More than 110 million Asians suffer movie will have to cough up a fine if profits.” from diabetes. These are not only older they are caught puffing up on the set. Action can be taken by city planners people, but also the youth,” he says. Kumar Mangat, the producer of “No and transport officials to create urban Five strategies can help reduce the Smoking,” told the Mumbai Mirror environments that promote healthier burden, according to WHO: he had hired a cameraman to catch and more active lifestyles, he adds. • Case prevention through offenders in action. Since lifestyle habits are ingrained early reductions in modifiable risk In the PRC, where around 3,000 in life, parents and family members can factors like obesity; people die every day from tobacco- help children develop healthier habits. • Screening coupled with related diseases, according to WHO, This message should remain at the pharmacological or lifestyle the more than 300 million people heart of all public education drives interventions; who smoke are no longer allowed to and policies, to encourage and make • Targeting individuals who have light up in what the government calls it easier for young and old alike to pre-diabetes; “enclosed public places.” make healthier choices, exercise more, • Improved diagnosis and control Health authorities in Asia obviously and eat better. Above all, the quit- of blood glucose in sufferers; applaud these efforts. Now, WHO smoking message should be promoted • Better management of believes, if the battle against obesity continually, WHO says. “It won’t microvascular complications, and noncommunicable diseases is to happen overnight, but it’s the only way including renal disease and be won, health sectors must join hands to go,” says Bekedam. retinopathy; and with others—agriculture, education, • Improved management of environment, the food industry, SKYROCKETING DIABETES: ‘WE MUST associated cardiovascular risks. trade, and transport. To that end, the REPRIORITIZE EFFORTS’ Even delaying the onset of diabetes United Nations General Assembly Projections for 2010 were that diabetes can make a big difference, in human will convene a high-level meeting in would account for almost 4 million and hard-cash terms, says WHO’s September 2011 to try to galvanize deaths worldwide, mostly in the Bekedam. “By making sure the illness action to halt premature deaths from developing world, according to WHO. starts at a later age, we can prevent noncommunicable diseases. The prevalence of the disease in Asia complications from diabetes,” he says. “We need a whole-of-government has increased by two to five times in “This is an issue health authorities and whole-of-society approach the past 2 decades, far higher than in must address as a matter of urgency.”■

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Human vs. Bug Most scientists believe that the next major pandemic will emerge from Asia. Can the region pull together and stop it in its tracks?

BY Floyd Whaley

semi-retired doctor in ill. He was feeling better when an FAST TRANSMISSION Commuters on the Guangzhou, the People’s invitation came to attend a wedding mass transit railway in Hong Kong, China Republic of China (PRC), in Hong Kong, China later in the wear masks to protect against a killer was working late nights month. On 21 February, he and his wife outbreak of severe acute respiratory at the outpatient clinic of the city’s took the 3-hour bus ride south from syndrome (SARS), which spread quickly AZhongshan No. 2 Hospital in mid- Guangdong province. Some wonder if throughout the territory and traveled to February 2003. The 64-year-old he had reasons other than his nephew’s other parts of the world. physician was caring for patients who nuptials for making the trip to one of PICTURE CREDIT: AFP had developed a strange, deadly form the most advanced medical centers in of pneumonia. Like other doctors Asia. countless three-star hotels that line the fighting the ailment, he wore a mask He arrived on 21 February and roads of Hong Kong, China’s tourist and gloves. checked into room 911 on the ninth district. The next morning, the elderly Despite his precautions, he became floor of the Metropole, one of the doctor woke up feeling ill and had to

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OUTSIDE ASIA A discarded surgical mask lies on the sidewalk outside a clinic in Toronto, Canada where over 100 cases of SARS were reported.

KILLER VIRUS A man walks through the respiratory tract infection. When his The sick doctor died at Kwong Wah Chinese Christian Cemetery in Hong symptoms worsened, he checked Hospital in Hong Kong, China on 4 Kong, China. SARS infected more than into the Prince of Wales Hospital and March. The strange ailment he brought 8,000 people from 30 countries on 6 infected dozens of health workers and into the Metropole Hotel, which continents and killed more than 800 other patients. travelers then transported at the speed people in 2003. On 26 February, another guest who of jet travel around the globe, would had stayed near the sick Guangzhou later be called severe acute respiratory doctor’s room on the ninth floor of the syndrome (SARS). The severe form forego the wedding for a short walk Metropole Hotel became ill. Johnny of pneumonia infected more than to nearby Kwong Wah Hospital. He Chen, a 48-year-old businessman 8,000 people from 30 countries on warned medical staff that he was from New York who left Hong Kong, 6 continents. More than 800 people contagious but offered few other clues China for Viet Nam shortly after Liu around the world died as a result. to his ailment. left the hotel, checked into a hospital SARS captured the world’s On 23 February, other guests who in Hanoi with a 3-day history of fever attention, but it did not surprise many had stayed on the same floor of the and respiratory symptoms. There, he epidemiologists—the medical scientists Metropole as the ailing doctor began triggered an outbreak of the mystery who study the transmission and control checking out of the hotel. Kwan Siu- illness in Viet Nam that infected more of epidemic diseases—who had been Chu, a 78-year-old Canadian woman, than 50 people. warning of such a scenario for years. began her journey back to Toronto. At about the same time, a 26-year-old They had seen it before. She soon became ill with a fever and former flight attendant from Singapore Since the 1918 Spanish influenza respiratory problems and passed it on named Esther Mok, who had stayed ravaged the world, infecting an to five members of her family and her on the ninth floor of the Metropole estimated one-third of the world’s doctor. They unwittingly spread it to during a shopping trip to Hong Kong, population and killing between 50 more than 160 other people in Canada. China checked into a hospital back in million and 100 million people, there PICTURE CREDIT: AFP The next day, a 26-year-old worker Singapore with respiratory problems. have been serious outbreaks of diseases at Hong Kong International Airport Doctors there were unaware of the such as dengue, cholera, typhoid, and who had visited a friend on the ninth strange new illness and she infected 20 leptospirosis. Many of these diseases floor of the Metropole developed a people in 5 days. were confined to one region of the

22 Development Asia July-December 2011 www.development.asia

P21_24 Human vs bug.indd 22 10/21/11 3:07 PM world and effective treatments were and entertainment venues; and With clinical precision, the birds are developed. More alarming has been the travelers cancel trips. As visitor arrivals restrained and a swab of their stool emergence in recent decades of new have dropped, hotel occupancy rates is taken before a syringe removes a diseases—such as HIV/AIDS, SARS, have fallen significantly.” Another ADB small sample of blood from their necks. the Nipah virus, and avian influenza— report estimates the economic impact The samples are carefully stored in a that spread quickly and baffle doctors of SARS in East Asia at about $18 cooler full of ice. The team then moves trying to treat the first cases to emerge. billion. carefully around the duck pond, taking In late 2003 and 2004, avian influenza samples of the water the birds drink A SEVERE BLOW (H5N1) dealt a harsh blow to the and their waste. In addition to the lives lost and the poultry industry. Millions of chickens The chilled samples will be suffering incurred, the economic were killed in an effort to control transferred within hours to the capital impact of such outbreaks can be the disease, and the United Nations Vientiane, where they will be tested for massive. A 2003 report from the Asian estimated that from 2003 through 2008, avian influenza. If any trace of the virus Development Bank (ADB) notes the poultry industry alone lost $10 is found, national and international that SARS led to reduced consumer billion. Unlike SARS, which spread health authorities will be alerted spending throughout the region, as from human-to-human contact, most and a trained response team will be people opted to stay home rather than cases of avian influenza in people have dispatched to the village to study and risk infection. spread through contact with infected contain the outbreak. “Services involving face-to-face live or dead birds. No known cases In small villages in Cambodia, Viet contact have been dealt a severe blow were traced to eating properly cooked Nam, and other countries throughout by the widespread fear of infection poultry, but a few cases were reported the region, similar actions periodically through such interactions,” the report in which people consumed dishes take place. A decade ago, no such states. “Tourism, transportation made from raw contaminated poultry quick, coordinated response in a (particularly airlines), and retailing blood. remote village would have been have been the hardest-hit sectors as In a 2007 speech to a health summit possible. Since the SARS outbreak, consumers shun shops, restaurants, in the United States, World Health countries throughout Asia, and Organization (WHO) Director-General around the world, have taken a hard Margaret Chan noted that the figure look at the possible source of the next could be much higher. “The most pandemic and how best to respond. respected scientific journals have One possibility is that it might come published scenarios of the havoc a from a few sick birds in a tiny Laotian pandemic could wreak under the or PRC village. From there, it could unique conditions of the 21st century. jump to a farmer, who visits a nearby The World Bank has estimated that public market, which spreads it to a pandemic could cost the world others who end up in the capital city, economy between $800 billion and $2 and then to those who bring it onto trillion, depending on the virulence of international flights. the virus,” she said. The best response is to isolate it on the tiny farm—or wherever it is first CRITICAL CONTAINMENT detected—before it finds its way to the On a small farm near the town of airport. That is one of key conclusions Thalat in the Lao People’s Democratic of the Asia Pacific Strategy for Republic, villagers have reported Emerging Diseases, the joint response unusual deaths of ducks on their farm. by countries in the region, as well other Not long afterward, a team of men nations around the globe and WHO. FLU CARRIER A duck farmer transports and women in face masks and rubber The strategy seeks to support countries poultry on his motorbike for delivery gloves spread out across the property. in the region, particularly developing PICTURE CREDIT: AFP in Lao People’s Democratic Republic’s As ducks squawk and scatter, several nations with limited capacity within capital Vientiane. Asian countries have masked men remove the birds from their health ministries, to detect, report, put in place surveillance and response the pond for capture while a technician and respond to possible emerging systems that monitor poultry for avian flu with syringes and vials waits on the diseases. Because diseases do not even in remote areas. shore. respect borders, the strategy calls for

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2008 WHO report. The effort underway in countries throughout the region is to gather information from rumors, media, ambulance workers, midwives, traditional healers, schools, village leaders, and nongovernment organizations. This type of information gathering is complemented by hotlines, e-mail, text messages, and radios in order to move tips about unusual incidents to the coordinating center in the capital quickly. Countries throughout the region, with the help of WHO, have also worked together to form trained response teams that know how to react properly to these reports. Cambodia has established 26 national, provincial, and sub-provincial rapid response teams and 154 district- level teams, according to WHO. Thailand created rapid response teams in every district in the country. In the Lao PDR, rapid response teams have responded to outbreaks of dengue, cholera, and avian influenza at the national, provincial, and district levels. In Myanmar, rapid response teams BUG-FREE FLIGHT Korean Air workers As the ADB report on the impact of trained to handle avian influenza were spray disinfectant inside an airplane to SARS notes: “Early identification and mobilized to help in the aftermath of prevent the spread of disease. Infected containment is critical, as any delays cyclone Nargis. India, Mongolia, and travelers can transport a disease at the will create greater costs later on.” Thailand have established areas in their speed of jet travel around the globe. Traditionally, public health officials national centers so they can coordinate have used indicator-based surveillance responses to outbreaks. to track disease. This includes weekly At the Metropole Hotel in Hong cooperation by countries throughout or monthly monitoring of sicknesses Kong, China, where the ailing the region. that are required to be tracked by Guangzhou doctor checked in with As part of the implementation of the law, such as cholera, yellow fever, the SARS virus, and helped spread it strategy, developed countries—with and plague. While indicator-based around the world, health authorities the help of WHO—have supported surveillance is useful for gathering conducted an exhaustive study to Asia–Pacific nations in developing and analyzing information about understand what took place. One surveillance and response systems. The known diseases, it has drawbacks key finding was that the doctor likely strategy has also worked to support in the fight against new infectious sneezed or coughed on guests at the greater transparency in the reporting diseases. Emerging diseases can come hotel, and they returned sick to their of unusual disease outbreaks. It has from unexpected sources and involve home countries. Authorities found not traditionally been the policy of unusual symptoms. Because they can that one case of SARS and one cough countries to quickly report medical spread rapidly, weekly or monthly or sneeze helped trigger a global problems to their neighbors. reports are too infrequent. epidemic. “One case brought down PICTURE CREDIT: AFP What took place on the Laotian “When it comes to the timely Hong Kong, China. One case brought duck farm is an important example of detection of outbreaks and important down Toronto,” noted Dick Thompson, the changes that have taken place in public health events, indicator-based a WHO spokesman at the time. “One disease detection in the last decade. surveillance systems often fail,” notes a case is a big number.” ■

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Islands of Health Often isolated, sparsely populated, and resource-poor, Pacific island countries face special challenges in terms of health care

BY Frale Oyen

hen Lois Englberger arrived in the Federated States of Micronesia in 1997, residents on the island of Pohnpei had begun to Wabandon their traditional diet for packaged and tinned foods, which are high in fats, salt, and sugar but poor in nutrients. The vitamin rich, yellow-fleshed karat banana wasn’t available in the market. Green, leafy vegetables and the fiber-rich, giant swamp taro were fed to the pigs, while rice, instant noodles, and fatty meats had replaced the traditional island diet of root crops— breadfruit, taro, yam, and cassava— eaten with seafood, coconut, and a bit of fruit. The shift away from nutritious local foods, combined with a more sedentary lifestyle, had begun, leading A CALL FOR CHANGE Tongans attend a to expanding waistlines and an church service in the capital Nuku’alofa. onslaught of chronic health problems “In 1948, the US Navy Pacific nations fight mounting health such as diabetes, heart disease, and did a health survey and problems by preaching a return to hypertension. healthy living. “In 1948, the US Navy did a health found no diabetes in survey and found no diabetes in Pohnpei. Now, one in Pohnpei,” says Englberger, research three adults is diabetic. nations. Many of these small nations, advisor to the Island Food Community as well as the larger developing of Pohnpei, a nongovernment It’s terrible” countries in the Pacific, are seeing organization established to research their struggling public health services and promote a return to traditional – Lois Englberger, research advisor overwhelmed. to the Island Food Community of Pacific island diets. “Now, one in three If Pacific communities are to achieve Pohnpei

PICTURE CREDIT: LUIS ENRIQUE ASCUI adults is diabetic. It’s terrible.” the health targets set out in the Millennium Development Goals—the OVERWHELMED ISLANDS worldwide initiative to end poverty It’s a similar story throughout the diseases—such as malaria and by 2015—they will have to better focus Pacific. Often isolated, sparsely tuberculosis—continue to affect many their resources by targeting services populated, and resource-poor, island communities, dietary changes to those most in need and allocating Pacific island countries face special in the past few decades have added resources to priority programs and challenges in terms of health care. an additional devastating impact preventative health care, say experts. While traditional communicable on health outcomes in many Pacific They will need to find programs that

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CANNED CHOLESTEROL Processed foods high in fat, salt, and sugar have replaced traditionally healthy fare in the Pacific diet, which include fish, root crops, and vegetables.

FRESH CATCH A market in Samoa sells a variety of fresh seafood.

work in the special circumstances of which are among the highest in the in 2009, enabling early diagnosis of Pacific island communities. Pacific. Under the program, specialist drug-resistant strains of tuberculosis in nurses travel the country identifying the country. It also expanded the DOTS CONNECTING DOTS tuberculosis cases and raising program to nine outer islands with An example of an approach that is awareness of the disease. They are high tuberculosis burdens to relieve the working can be found in Kiribati. backed by community health workers pressure on the main hospital. The Tuberculosis Epidemic Control who make daily home visits to patients “All this work has meant that since Program in Kiribati follows a recently released from the hospital. 2007, tuberculosis cases in Kiribati management strategy known as DOTS The program used donor support have fallen from 745 (per 100,000) to (Directly Observed Treatment) to received from Australia to open 294 in 2010,” says Kiersten Dybing, lower the country’s tuberculosis levels, Kiribati’s first tuberculosis laboratory communications officer with the

LOVE PATROL

he Pacific islands are particularly subjects into people’s living rooms island communities. vulnerable to sexually and generating discussions about life Viewers relate to the actors—Pacific transmitted diseases and HIV/ issues—sex, relationships, and HIV/ islanders just like them, who, on the TAIDS due to migration and their AIDS. big screen, are living lives similar to involvement in seafaring. In some It has, for example, made it possible theirs. They relate to the issues because,

countries, innovative approaches are for a 60-year-old grandmother to for many, it is their story that is being PICTURE CREDIT: LUIS ENRIQUE ASCUI / AFP being taken to address the issue. talk about condom use and sexually told. In Vanuatu, the Wan Smolbag transmitted infections with her “Obviously a TV show on its own Theatre, a nongovernment grandson, say its producers. Hearing can’t do everything,” says Drysdale. organization, uses drama to raise the the characters discuss these issues on “But if it’s coupled with peer education profile and understanding of sexually screen “normalizes them and makes and improvements in services available transmitted diseases, a growing threat them okay to talk about,” says Robyn to people—counseling and one-to- in the Pacific. Its locally produced Drysdale, a public health consultant one interaction—it can play a big role television series, Love Patrol, has researching the effect the series has had in getting action and actual change been credited with bringing taboo on the attitudes and behavior of Pacific happening.” n

26 Development Asia July-December 2011 www.development.asia

P25_27 Islands of health.indd 26 10/21/11 3:11 PM 27 10/21/11 3:11 PM Asia n Development July-December 2011 2011 July-December “It’s unfortunate to have an “It’s unfortunate this message The challenge is to get Community involvement has been In Kolonia, the capital of Pohnpei, following suit. are Even the children “It’s so exciting to see that our work abundance of foods rich in vitamins of foods rich in vitamins abundance essential nutrients growing and other of it,” says and not take advantage here organization’s Emihner Johnson, the blessed have been “We acting director. we have. of what and should be proud foods don’t need to eat processed We that have a lot of chemicals.” Strategies to island residents. across at only local food include offering a governor’sworkshops and events, of Karat as the Pohnpei proclamation State banana, national Karat postal stamps, and the use of eye-catching as well as a local posters and billboards website and social media to promote the value of local food. central in convincing Pohnpeians that not only is a change of diet needed, of the And as word but it is possible. health benefits of consuming local the joining are more foods spreads, movement. small vendors sell boxes of cooked local foods, such as giant swamp taro, of a few for $1, a practice unheard proclamation presidential A years back. issued in June encourages the use of local foods at all government events; the Department of Health and Social the Federated States of of Affairs its offices has declared Micronesia zone”; and a an “imported food-free number of communities are growing banning carbonated drinks at their events. Sixth graders at the Calvary Christian Academy decided to set aside 2 days a of week as local food days. The group 30 has even taken it upon themselves underscoring their the word, to spread or message by giving gifts of fruit seedlings to family and ready-to-grow friends. to see that the children is paying off, the word taking up and spreading are about local foods,” says Johnson. This can be attributed in part to attributed in part This can be very complex dynamics are “There One solution being pursued is to deaths in the Pacific are caused by Pacific are deaths in the diseases. noncommunicable attitudes. Food existing norms and in important role and feasting play an does Exercise Pacific island culture. understand the not. So while islanders living, they may importance of healthy will or the means not always have the to make healthy choices. factors and going on, with many and social, cultural, influences, from economic factors to political and individual choices,” says Viliami Puloka, head of the Healthy Pacific of Lifestyle section of the Secretariat an organization the Pacific Community, the lives of dedicated to improving Pacific islanders. “Many individuals motivated to eat the right very are food and be physically active yet their buying power does not allow them to the healthy choices.” afford of the foods eating more to return traditionally consumed in the Pacific. The Island Food Community of Pohnpei advocates such a program. by the Nutritional analysis coordinated since 1998 found that Pohnpei, group one of four states in the Federated has an abundance States of Micronesia, of nutrient-rich, indigenous foods, including several varieties of bananas, yams, giant swamp taro, breadfruit, and pandanus. July-September 2011 July-September Asia – Viliami Puloka, head of the of head Puloka, Viliami – section Lifestyle Pacific Healthy Pacific the of Secretariat the of Community “Many individuals “Many to motivated very are and food right the eat active physically be power buying their yet them allow not does healthy the afford to choices” Development 24 STARTING THEM YOUNG Schoolchildren THEM STARTING attend an exercise class in Tonga. While infectious diseases will continue to be a significant burden in some communities, many believe diabetes, heart that controlling and hypertension— disease, stroke, linked to poor illnesses chronic diets and sedentary lifestyles—is biggest health by far the region’s to the World According challenge. 75% of all Health Organization, Australian Agency for International Australian Development. EATING LOCAL

PICTURE CREDIT: AFP P25_27 Islands of health.indd 27 HEALTH

Health for Hire Some developing countries are experimenting with turning over the provision of b a s i c h e a l t h c a r e t o o u t s i d e c o n t r a c t o r s . C a n o n e o f a s o c i e t y ’s m o s t i m p o r t a n t public functions be entrusted to external organizations?

BY Karen Emmons

nly 50 doctors reportedly of the government salary—typically WAITING LINE FOR HEALTH CARE survived the genocide low. Once private practice was made Women and their children wait for their in Cambodia in the legal after 1993, sideline private clinics turn in a long queue outside a hospital in 1970s. Pockets of turmoil became common; but for many years, Phnom Penh. continued for another 2 decades government doctors spent little time whileO the government, with outside in their public posts. A villager who assistance, struggled to rebuild its needed a day of costly travel to reach a coverage or quality of services to most health care system. In the rush of the public health clinic or district hospital of the country, especially the poor and 1980s and early 1990s to train the had no guarantee of finding staff, people in remote areas. needed cadre of medical professionals medicines, or working equipment. to staff clinics and hospitals, skills were Basic services, such as immunization, CONTRACTING NGOS IN CAMBODIA PICTURE CREDIT: AFP churned out with weak attention to were not consistently provided—one An experiment was proposed to bring quality. of the culprits behind the high child private sector or nongovernment As often happens in a country mortality rate. organization (NGO) operators in to emerging from war, morale among Cambodia’s public health system manage public health facilities, with public health staff reflected the size was failing to provide adequate results-based contracts introduced to

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P28_31 Health for hire.indd 28 10/21/11 3:16 PM MORE REWARDING A doctor checks the blood pressure of a child with dengue fever. Cambodia’s contracting model uses performance-based incentives to motivate health care professionals to provide high-quality services.

monitor the service and incentive pay offered to rehabilitate the attitudes and behavior of staff. The contract required management and technical support to help the public health system perform efficiently and to provide equitable primary health care services to rural populations. In Cambodia, three models were trialed simultaneously from 1999 to 2003 under the Basic Health Services Project covering a total population of about 1.26 million people. New health clinics were built and old ones renovated prior to the trial. Two variations of a contracting model were included. In one, the contractor managed all service delivery, hiring, firing, and setting wages of staff, and distributing essential drugs and supplies in the district referral hospitals and health clinics. In the other, the contractor managed and strengthened the existing system in the district referral hospitals and health clinics

with a small budget to supplement the held to the goal of targeting services pay incentives and operating expenses; to the poorest half of the population “Most NGOs have drugs and supplies came through the and performance at 160% to 450% of come to realize that regular government channel. In the the baseline levels had to be achieved their sometimes third model, the government continued within the 4-year term of the contract. to manage all the services. In the contracting model, individual capricious cherry- NGOs, universities, and consulting staff received bonus pay when various picking of limited (but firms responded to the competitive goals were achieved. photogenic) problems bidding. The contract winners were Twelve randomly chosen districts NGOs with previous experience in were targeted for the experiment, with in small populations Cambodia, such as CARE International, four included as a control group. Bids with limited time HealthNet International, and Save the from three districts were rejected due to commitments Children Australia. Each was randomly the inadequate technical capacity of the assigned a model. bidder. Thus the experiment focused contributes very little Eight objectively verifiable health on five districts in three geographically to sustained health care service indicators were used for well-spaced provinces; each district PICTURE CREDIT: AFP improvements” monitoring, which was done randomly had a population of 100,000 to 200,000 and regularly by the Ministry of Health people. – William Aldis, an assistant to track the contractor’s performance. Cambodia’s Ministry of Health professor on global health at Some patients were asked to comment devised a coverage plan specifying a Thammasat University in Bangkok on treatment received. All models were minimum package of preventive and

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P28_31 Health for hire.indd 29 10/21/11 3:16 PM HEALTH

curative services. The service indicators Increase in coverage population of around 200,000. This were based on the priorities of the increase was nearly two and one-half Millennium Development Goals and among the poorest 20% times as large as that experienced in the World Bank’s Poverty Reduction of the population two control districts that continued to Strategy Papers and included child In a Cambodian experiment from 1999 to receive standard government service.” immunization, vitamin A provision, 2003 in contracting with nongovernment The Cambodian contracting model antenatal care, delivery by a trained organizations to run government health is also featured on the Eldis website, birth attendant, delivery in a health services in rural areas, contracted services one of the knowledge services from facility, knowledge and use of birth covered about 200,000 people of a total the Institute of Development Studies 1,500,000 in the experiment. spacing, and use of health facilities for of the United Kingdom. But there is a illness. More than caveat: “The effect of contracting on 25 percentage equity is still under question.” The site BETTER MOTIVATED points also noted that prerequisites for the The Cambodian results were evaluated strategy to work cover government several times and repeatedly praised. A capacity and political will to contract team of eight specialists from the Asian out, national capacity to monitor Development Bank, the World Bank, About contract delivery, and contractors 10 percentage Harvard University, the University with the capacity to fulfill contractual points of North Carolina, and a marketing obligations. research firm produced an extensive final evaluation, Contracting for NOT A CURE-ALL Health: Evidence from Cambodia, in While pointing out that government which they reported large increases in contracting of private organizations the coverage rates of health services in Experimental Control Districts: is an increasingly common tool to all districts, although the contracting Districts: Standard meet the growing demand for quality Contracting Government NGOs achieved higher coverage rates. reproductive health care in developing Services Services The immunization coverage rate in the nations, the World Bank also says on

contracted-out districts, for example, Sources: World Health Organization. 2005. Reaching the Poor with Health, its Health, Nutrition and Population increased from 25% in 1997 to 82% in Nutrition, and Population Services—What Works, What Doesn’t and Why website, “contracting is not a cure-all 2003. for ailing health systems, and there Their report included findings from exists relatively little systematic previous assessments. According to a the incentive pay costs, private out-of- evaluation of the contracting World Bank review, for instance, the pocket expenditures in the contracted experience in developing countries.” NGOs outperformed the government districts were found to be significantly Benjamin Loevinsohn and April districts in achieving higher coverage lower than those in the government Harding investigated 10 examples of rates and more equitable or more districts by 2003. contracting around the world, covering pro-poor distribution of services, with In singling out the model along between 50,000 and 30 million people, some nominal exceptions. The overall with several others in a summary of and concluded in their 2005 The Lancet efficiency of the health care system in good practices in health, nutrition, and report, “Buying results? Contracting for contracted districts was evaluated as population, World Bank analysts point health service delivery in developing better than in the government districts. out, “Contracting NGOs to manage the countries” that the practice for the In their report Improving primary health care system was found delivery of primary care “can be very Government Health Services through to be an effective means to increase effective and improvements can be Contract Management: A Case from service coverage and achieve a more rapid.” The Cambodian project was Cambodia where two districts were pro-poor distribution of services in the only randomized example in their evaluated for HealthNet International, rural areas of Cambodia.” study. Robert Soeters and Fred Griffiths Among the evidence, the World Calling the Loevinsohn and conclude that contractors were better Bank reports, “…the coverage among Harding conclusions “flawed”—also motivated because the renewal of the the poorest 20% of the population in The Lancet shortly after—Valéry contract was based on performance. of eight basic services rose from an Ridde, professor in public health Even though the contractors relied average of below 15% to over 40% in at the University of Montreal and on user fees to help recover some of two experimental districts with a total researcher at the Research Centre of the

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P28_31 Health for hire.indd 30 10/21/11 3:16 PM OUTPATIENT A young girl cares for cause the approach to fail: a culture her sick brother at a street corner in clash between the health ministry Cambodia. The country has taken "Quote here quote and NGO staff, changing the NGO measures to expand its public health here quote here quote program mentality from a tradition care system, such as contracting out here quote here quote of choosing where to work to taking health services to the private sector, responsibility for a whole population, but providing broader access to quality here quote here quote and funding cycles (or selling the health care, particularly to the poor and here quote here quote approach to donors) that enable long- those in remote areas, remains a major here quote here " term commitment. challenge. On the positive side, Aldis adds, Name Here “most NGOs have come to realize that Position here their sometimes capricious cherry- University of Montreal Hospital Centre Company here picking of limited (but photogenic) (CRCHUM), argued there is a lack of problems in small populations with convincing data to support contracting limited time commitments contributes and that more caution is needed before very little to sustained health going large scale. “The building of improvements. So they are more open health systems through contracting to the kind of collaboration attempted bodies is not based on the same in Cambodia.” values, and perhaps not on the same Meanwhile, Cambodia’s Ministry of paradigms, as that through trusting Health has moved beyond NGOs, but bodies,” he wrote. Contracting primary not the contracting practice. From 2003 Ridde refers to a 2001 book The to 2008 the contracting-out model was Challenge of Health Sector Reform: What care “can be very applied in an additional six districts. Must Governments Do? that describes effective and (the) In 2009 the practice expanded to the contracting experience in five improvements can be 30 “special operating agencies” in 8 developing countries and “shows that provincial referral hospitals and 22 there is not enough evidence about rapid” health operational districts, but NGOs contracting in general, or performance- were only contracted for a year to based contracting in particular.” – Buying results? Contracting train provincial health departments, Performance-based contracting has for health service delivery in health operational districts, and developing countries, The Lancet been adopted in fragile environments referral hospitals on managing such as Afghanistan, Haiti, and Liberia. contracts for health care delivery. To According to a health officer familiar the recurrent cost expenditure of the improve capacity and ownership, the with Cambodia’s contracting program, contracting-out model was 2.4 times model shifted to a form of internal the challenge is to align performance- that of government services and 1.5 government contracting between based incentives and other incentives times that of the contracting-in model. provincial health departments and with overall government compensation Thus there were also concerns about operational districts or provincial policies and reforms. Without the sustainability of services wholly referral hospitals. the performance incentive, “staff contracted out and the impact on In theory, the “special operating motivation would be lost,” says government capacity. agency” status gives hospitals the officer, who is also quick to say financial management autonomy the impacts have been deep, with A GOOD CONCEPT IN THEORY that enhances staff performance. The reduced absenteeism and considerable “Contracting with NGOs is a good special operating agency internally improvement in coverage especially in concept in theory and works if monitors health clinics and referral

PICTURE CREDIT: ERIC SALES remote areas. there is good will and flexibility on hospital performance but a systematic The final evaluation by the team both sides,” says William Aldis, an monitoring mechanism has yet to be of eight specialists noted that the assistant professor on global health put in place. use of eight indicators ran the risk at Thammasat University in Bangkok As Cambodia’s contracting model is of diverting effort from measured to who worked with the World Health refined, experts say it shows promise unmeasured outcomes. Organization in Africa and Asia. but there are many questions left to be Independent assessments found that He cites several factors that can answered. ■

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P28_31 Health for hire.indd 31 10/21/11 3:16 PM OFF THE SHELF

Researched and compiled by Maria Liza Solano

Unnatural Selection The Changing Body C h o o s i n g B o y s o v e r G i r l s , a n d t h e H e a l t h , N u t r i t i o n , a n d H u m a n D e v e l o p m e n t i n t h e We s t e r n Wo r l d s i n c e 170 0 C o n s e q u e n c e s o f a Wo r l d Fu l l o f M e n By Roderick Floud, Robert W. Fogel, Bernard Harris, and Sok Chul Hong By Mara Hvistendahl Cambridge University Press, March 2011, $32.99 PublicAffairs, June 2011, $26.99 his groundbreaking book looks at 300 years of he book Unnatural Selection human development in Europe and the United examines the causes States and puts long-term changes in height, of the skewed gender weight, morbidity, and mortality in an international ratio in Asia, where men Tcontext. It links the changing size, shape, and capability of greatlyT outnumber women, and its the human body—taller, heavier, and healthier—to economic consequences and demographic changes, which have implications for the across the globe. developing world and future health trends. The main culprit The Changing Body also talks about key issues such as is sex-selective whether longer lifespans contribute to greater productivity abortion, which or impose a heavier burden on society through higher health care costs and has resulted in 163 pensions. million females “Thirty years of research by leading economists, biologists, historians, and “missing” from demographers has confirmed the towering status of the high and mighty…. There Asia’s population. is a clear link between height and earnings. Increases in both, over the past 300 Author Mara years, are greater than over the three preceding millennia, demonstrating that the Hvistendahl’s research shows that changes are too rapid to be evolutionary. And the secret lies in nutrition.”—The the gender imbalance is increasingly Independent becoming a global phenomenon as it “For nearly three decades, the Nobel Prize-winning economist Robert W. Fogel is also affecting Eastern Europe and and a small clutch of colleagues have assiduously researched what the size and the United States where there are shape of the human body say about economic and social changes throughout significant immigrant populations. history, and vice versa. Their research has spawned not only a new branch of “Ms Hvistendahl’s distinctive historical study but also a provocative theory that technology has sped human contribution is twofold. She provides evolution in an unprecedented way during the past century.”—The New York Times n a history of the modern practice of sex-selective abortion, based on new and detailed research, and she helps readers think about its possible Arrival City chief of The Globe consequences.”—The Economist and Mail. How the Largest Migration in History “Despite the author’s intentions, Arrival City Is Reshaping Our World Unnatural Selection might be one of the “gives a vital most consequential books ever written By Doug Saunders resource to in the campaign against abortion. Pantheon, March 2011, $27.95 everyone who It is aimed, like a heat-seeking wants to learn missile, against the entire intellectual n Arrival City, journalist Doug about the pursuit framework of ‘choice.’ For if ‘choice’ is Saunders looks into the largest of the public the moral imperative guiding abortion, migration in human history: the good in an era of then there is no way to take a stand mass movement from rural to challenged or enfeebled nation-states. against ‘gendercide.’ Aborting a baby urbanI areas, and uncovers the stories With sharply written case-studies from because she is a girl is no different from of people living on the outskirts of the favelas of Rio de Janeiro to the aborting a baby because she has Down megacities—the slums or suburbs banlieues of Paris and the so-called syndrome or because the mother’s where newcomers start integrating ‘slums’ of Mumbai, Saunders shows ‘mental health’ requires it.”—Jonathan themselves into urban society. that the ‘arrival city’ of informal V. Last, Wall Street Journal n Saunders is the European bureau communities, where migrants from

32 Development Asia July-December 2011 www.development.asia

P32_33 Off the shelf.indd 48 10/21/11 3:18 PM Poor Economics The Globalization A Radical Rethinking of the Way to Fight Global Poverty Paradox By Abhijit V. Banerjee and Esther Duflo W h y G l o b a l M a r ke t s , S t a t e s , a n d PublicAffairs, April 2011, $26.99 Democracy Can’t Coexist his book from the founders of the Abdul Latif By Dani Rodrik Jameel Poverty Action Lab at the Massachusetts W. W. Norton & Company, February Institute of Technology (MIT) shares the lessons 2011, $26.95 and insights learned from 15 years of studying the lives of the poor. TAbhijit Banerjee and Esther Duflo are pioneers in the use of randomized control arvard economist Dani trials in testing anti-poverty measures. Their research, which also involved Rodrik writes a sequel interviewing their subjects in the “back-alleys and villages” where they live, to his 1997 book Has sheds lights on how the poor can live on less than $0.99 a day and how they make Globalization Gone Too Far? decisions given their needs and the constraints that they face, and sheds light on HIn The Globalization Paradox, Rodrik how aid or financial assistance affects their lives. poses another question: is globalization Banerjee was educated in Kolkata, Delhi, and Cambridge. He is the Ford sustainable over the long term? He Foundation International Professor of Economics at MIT. He has been an honorary argues that democracy, national advisor to the World Bank and the Government of India. Duflo is the Abdul Latif self-determination, and economic Jameel Professor of Poverty Alleviation and Development Economics at MIT. She globalization cannot be pursued studied at the Ecole Normale Superieure in Paris, and MIT. simultaneously. The book “draws on a variety of evidence, not limiting itself to the results of Rodrik is Rafiq Hariri Professor of randomised trials, as if they are the only route to truth. And the authors’ interest is International Political Economy at the not confined to ‘what works’, but also to how and why it works. Indeed, Ms Duflo John F. Kennedy School of Government and Mr Banerjee, perhaps more than some of their disciples, are able theorists as at Harvard University. He writes a well as thoroughgoing empiricists.”—The Economist monthly column for Project Syndicate The authors “examine the myriad effects of poverty on people and societies, and a blog on economic development upending much of the conventional wisdom held by governments, aid and globalization, which is frequently organizations and NGOs, perceptions which in turn drive the way they provide cited by The New York Times, The financial assistance and humanitarian aid.”—The Washington Post n Economist, and other top publications. “The crucial message to take away from this important book, however, is that the worst thing we could do for the rural hinterlands to urban centres “Mr. Saunders’s optimistic legitimate cause of globalization right gather, presents not simply one of book, which draws on the work of now is to push it any further. In most the world’s most pressing problems. economists, sociologists and urban countries, plenty of work still needs It also offers us the most promising planners, feels as important in its way to be done to manage the economic solutions.”— Boyd Tonkin, Independent as was Jane Jacobs’s Death and Life of integration that has already developed “Arrival City brilliantly captures Great American Cities, published in and to ensure that the benefits become the breakneck pace of this ‘great 1961. It feels like a game changer; it more widely shared. Until that is migration,’ as the peasants of the should certainly be a policy changer. accomplished, poor world relocate to their own He makes it plain that these arrival pushing things megacities—and ours…. From Brick cities need nurturing, in the form further will Lane in London to the back streets of of transportation (paved roads, bus only create Dhaka; from newly gentrified Watts in terminals) security, sewage treatment, political backlash Los Angeles to burgeoning Istanbul, education and, vitally, citizenship for and set back he finds not hellholes, but a rich brew their people. They assuredly don’t need globalization’s of aspiration, entrepreneurship and restrictive zoning laws and xenophobic cause.”—Steven impromptu social organisation.”— stabs at urban renewal.”— Dwight Pearlstein, The Fred Pearce, The Guardian Garner, The New York Times n Washington Post n

www.development.asia July-December 2011 Development Asia 33

P32_33 Off the shelf.indd 49 10/21/11 3:18 PM PICTURE CREDIT: AFP 10/24/11 10:43 AM WEEKLY INSTALLMENT Representatives INSTALLMENT WEEKLY of a microlender in India receive payment from borrowers in weekly installments. Some critics are questioning the morality of making too much profit out of lending to vulnerable groups. First Lady Hillary Clinton told the First Lady Hillary Clinton of the most delegates it was “one that we could important gatherings in our world.” By 2005, have anywhere the United Nations (UN) organized of Microcredit. Year an International BY Karen Emmons Karen BY A global movement followed and A In 1997, the first Microcredit very small loans to very poor people very small loans to was to start very small businesses for the story after story, trumpeted, was Microcredit way it changed lives. the penicillin against poverty. to boast that these the story lines grew could send millions of loans micro of the people—including the poorest the poverty line. poor—walking across Summit launched a 9-year campaign 100 million of the world’s “to reach Then United States families.” poorest

n the 1970s, an idea emerged emerged n the 1970s, an idea Bangladesh and India that from would laterthe Nobel committee impossible: describe as appearing

ARTICLE Tiny Loans, Big Questions Loans, Tiny Borrowers, predominantly women, predominantly Borrowers,

M i c r o f i n a n c e—s e e n by m a ny a s a r e vo l u t i o n i n g r a s s r o o t s d e ve l o p m e n t—i s f a c i n g t o u g h s c r u t i ny I successfully lending money to people who lack collateral. The committee the 2006 Peace Prize to awarded and Grameen Bank Yunus Muhammad for doing just that, and changing lives as a result. who took into groups formed were for each other in place responsibility of collateral. The radical idea of giving P34_38 Tiny loans, big questions.indd 34 The following year, Grameen Bank As the microcredit—sometimes accepted its Peace Prize. also referred to in the broader context The global movement also became “We created of microfinance—crisis unfolds, a huge commercialized business. microcredit to fight microfinance’s “dark side” remains Hedge funds, private equity funds, the dominant story. Has poverty’s multinational banks, national banks, the loan sharks; supposed cure become part of the development agencies, philanthropists, we didn’t create disease? and nongovernment organizations microcredit to (NGOs), public and private, swarmed A DOUBTER RETURNS the idea. They zinged eye-popping encourage new loan In the 1990s, Feisal Hussain worked levels of capital into banks and sharks” in his native Bangladesh, organizing organizations, big and small, to dole community groups and making out to people whose previous options – Nobel Laureate and Grameen loans to poor women. It was in the had been to sell assets or borrow from Bank founder Muhammad Yunus early heyday of the microcredit high interest-charging moneylenders. movement. After 7 years though, he By 2009, microfinance had become left, uncomfortable with “the apparent very big business. According to Side of Microfinance, Microfinance contradiction between the rhetoric”— the microfinance data website, Isn’t a Magic Bullet, India’s Poor Reel that poor people would get a loan, Microfinance Information Exchange, Under Microfinance Debt Burden, Is make an investment, and rise out of that year 1,935 microfinance Microdebt Good for Poor People? poverty—“and the reality” of how institutions reported a gross loan Even Nobel Laureate Yunus was poor people managed their money. portfolio of $65 billion, lending to 92.5 recently quoted in The New York Times, In 2010, he returned, this time as a million borrowers. Microlending has a telling financial officials at the UN, “We technical adviser for inclusive finance wide reach in Asia and Latin America, created microcredit to fight the loan with the UN Capital Development with Bangladesh, India, and Mexico the sharks; we didn’t create microcredit to Fund (UNCDF) because the model three biggest markets. encourage new loan sharks.” had evolved from microcredit Individual tales of impoverished to microfinance, as had people’s PROBLEMS EMERGE borrowers echoed the nightmares expectations of what it could do. But then darker plots emerged—in of the American subprime lending “We know more than we did—it’s media reports, on blogs, in books. In a saga: taking on more loans to pay off not just credit,” says Hussain, referring recent documentary, a young mother others, public humiliation by collectors, also to the need for savings, insurance, in Andhra Pradesh set herself on fly-by-night operators, interest rates and money transfer. “We are more fire after loan collectors pursued her of 30%, 60%, and well over 100% on reasonable about what financial aggressively, publicly shaming her. the principal amount borrowed. A services can and cannot do than when When her husband rushed to her, his parsley farmer in Mexico, explained it was sold as a magic bullet—we clothes caught fire; both were dead a Businessweek story in 2007, took realize it wasn’t.” within 3 days. A 17-year-old girl, also a loan for a motorcycle to sell his In the never-ending polarizing in Andhra Pradesh, killed herself, produce farther afield but lost it after polemic on fighting poverty, the mistakenly believing any death in the missing payments. By then though, once-untouchable microcredit has family would absolve it of its heavy he had already repaid the cost of the increasingly come under closer burden of five micro debts. Families in motorcycle; but at 68% interest on the scrutiny and even attack. The criticism northwest Bangladesh were reported principle amount for 18 months, the hits at many layers, from the need for to be starving themselves or eating loan was nearly double the cost of the better lending behavior, regulation, only rice mixed with water to save bike. and transparency, to the original enough money for their next micro “This is unrestrained consumer premise that microcredit and micro- loan installment. A woman in the lending gone wild,” David Gibbons, entrepreneurialism would alleviate Bangladeshi capital, Dhaka had to sell chairman of Cashpor Micro Credit, poverty. her house to repay her micro loan. a nonprofit microlender to poor After more than a decade of women in India’s Uttar Pradesh and FALSE PREMISE glittering growth, headlines in 2010 Bihar states, told a Bloomberg Markets “Borrowing is not a solution for spotlighted a different story: The Magazine reporter in 2010. “It’s not poverty,” says Aneel Karnani, an Ugly Side of Microlending, The Dark about poverty reduction anymore.” associate professor of strategy at the

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University of Michigan’s Ross School average impact on poverty or household FAST GROWTH AND MISSION DRIFT of Business who believes encouraging income. (Although the trials in Kenya The hoopla around the prospect that entrepreneurialism among the poor on savings showed a positive impact hundreds of millions of people could is a “fundamentally flawed” method on women’s empowerment in the cross over the poverty line brought a for reducing poverty. Not everyone household.) The research suggested long line of social lenders committed has the drive or financial literacy to microcredit was not the powerful to the mission of social performance. be entrepreneurial, he adds, and most anti-poverty tool the years of hype had By proving that the poor could be are in petty trades or subsistence made it out to be. creditworthy, investors open to a new agriculture. “If you go to a village, Microcredit’s defenders believe frontier for capital performance joined there are too many women competing the findings aren’t sufficient to prove the queue for microlending—minus the in the same saturated business and, as anything because of the limited time social objectives. a result, they don’t earn enough to rise period studied—up to 2 years. Or When the model became out of poverty. some see the findings as evidence that commercialized and microfinance To Karnani, who also researches microcredit works, in a qualified way, institutions became for-profit, poverty reduction, it is “romanticizing by providing a cheaper alternative to which was accepted as necessary, the poor” and detracts resources the local moneylender. some donors, lenders, even NGO and dialogue from what does grow The findings also showed what many staff lost sight of the purpose. economies and provide jobs, which practitioners already knew: that a great UNCDF’s Hussain says the purpose he believes is what poor people many microcredit clients typically of microfinance is to include people want. “The real engine of economic spend their borrowed money not on who are poor in accessing financial development is small and mid-sized a microenterprise but on household services available to other segments of enterprises,” he says. expenses, paying off other debts, school society, with information and financial Other challengers include Ha-Joon fees, emergencies, and even televisions literacy training to hopefully make Chang, a Cambridge University or a wedding. better choices and ultimately to give economist, and Milford Bateman, them a chance to better manage their author of Why Doesn’t Microfinance vulnerabilities. Work, who in a joint critique also argue SMALL BUSINESSES A field worker of a “You want to build sustainable that microfinance is “based on an microlending company in India visits a institutions, but that can’t be the only attractive but false premise that poor loan recipient, who has used the money goal,” says Hussain. “You’re there for people can make themselves richer to start a sewing business. The idea a purpose—our starting point must be provided they have access to credit.” In behind microcredit is to lend money to the poor client and not the institution.” a blog on the Oxfam website, Bateman people who lack collateral to set up a The spate of debt-related suicides further protests that “the vast majority small business. in India over the past year triggered of existing entrepreneurs are forced to operate outside of the institutional and organizational structures required to raise the productivity of their efforts and upgrade their businesses.”

LACK OF EVIDENCE For many years, there was no credible evidence to support either side of the argument. Most impact evaluations

were conducted by microfinance PICTURE CREDIT: ARIEL D. JAVELLANA organizations. A few years ago, development economists associated with the Massachusetts Institute of Technology’s Jameel Poverty Action Lab and Innovations for Poverty Action carried out randomly controlled trials in, India, South Africa, and the Philippines and found there was no

36 Development Asia July-December 2011 www.development.asia

P34_38 Tiny loans, big questions.indd 36 10/24/11 10:43 AM a controversy revolving around that includes financial literacy training microcredit, particularly in Andhra in five countries. He says this helped Pradesh state where over-indebtedness perpetuate over-indebtedness. is rife. Politicians hunting for populous A report of 123 alleged harassment leverage seized on the suicide stories cases released by India’s Society for and encouraged a boycott campaign Elimination of Rural Poverty found at and loan default. The Andhra Pradesh least 54 deaths related to microloans government made registration of and notes the “unbearable harassment” microfinance institutions (MFIs) the borrowers endured by aggressive mandatory, outlawed coercive collectors. One collector suggested collection methods, and put onerous that the struggling borrower resort to reporting requirements on MFIs, prostitution. bringing the industry to a grinding Poor regulatory structures or credit halt. India’s central bank has been bureaus within countries where forced to step in to help keep microcredit is available have stirred up microfinance institutions from going concerns about whether microcredit bankrupt. has created “debt traps” that push poor The volatile situation has been households further into poverty. exacerbated by the government’s deprived-sector lending requirement NO TRANSPARENCY (that banks direct a proportion of all When NGOs working for the loans to the poor), pressure among new poor ratcheted up their ambitions, and existing microfinance institutions OUT OF CONTROL Women’s groups and transitioned to commercial banking, (including self-help groups set up politicians call for greater regulation of and made millions of dollars from by banks) to build portfolios, and microfinance institutions in India, where their initial public offerings, there was inexperienced credit collectors and over-indebtedness has pushed some outrage at making money off the poor. borrowers. borrowers to distress. Profit, Roodman believes, “builds David Roodman, a senior fellow at dynamic and innovative institutions the Center for Global Development, a that provide useful services to poor research organization in Washington, people.” The challenge is making DC, who is finishing a book on the “How much is too growth in the industry moderate and history and impact of microfinance, limiting enterprises so it doesn’t grow attributes the troubles in Bosnia much when you’re too fast. “Without that regulation, it can and Herzegovina, India, Nicaragua, making that profit off hurt people and the institutions can go Pakistan, and potentially the of poor women is a under.” Philippines to the bubble-inducing As interest rates soared beyond speed of microcredit growth. He recalls question that many of levels considered usurious in the a village he visited in Andhra Pradesh us believe needs to be United States so too did hostility where women jumped from having defined. Without that toward microcredit. “How much is two loans to five in one year. The flood too much when you’re making that of credit and inexperienced employees, definition, we can’t profit off of poor women is a question he says, don’t allow borrowers time answer the question, that many of us believe needs to be to gradually learn how much they can ‘what differentiates defined,” says Chuck Waterfield, chief repay. executive officer of MFTransparency, a New lenders and even staff of older microfinance from nonprofit organization promoting “the microfinance institutions became moneylending?’” integrity of microfinance as a poverty “lazy” about expanding their markets alleviation practice.” PICTURE CREDIT: AFP and instead pushed new loans on —Chuck Waterfield, “Without that definition, we existing clients of other microlenders, chief executive officer of can’t answer the question, ‘what MFTransparency, a nonprofit says Vinod Parmeshwar, brand differentiates microfinance from organization manager for Oxfam America, which moneylending?’” promotes a savings and loans model Of course non-collateralized loans

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P34_38 Tiny loans, big questions.indd 37 10/24/11 10:43 AM ARTICLE

to poor people are higher risk, and money from investors for lending, the loans to people in areas with no less will financial institutions do the banking services are costlier. Chang hard work of building up a savings and Bateman also argue that without business, including obtaining legal a big injection of government or aid permission to take savings.” funds, microfinance institutions have to charge very high interest rates. ONE TOOL IN THE BOX In his microfinance work with What little evidence is on hand communities across 10 countries for indicates that many of the not-so-poor Plan International, Muhammad Awais can borrow, grow, and walk across the finds that microcredit clients accept the poverty line. But not everyone who high interest rates. “People also value borrows leaves poverty. Defenders say the service ,” he says. it’s not a cure-all, just one tool in the But Waterfield believes that box. when dealing with the bottom of “It has stuck around and succeeded the pyramid, “it’s not an exchange in the market with millions and of equals … you need to behave.” millions using it, although maybe some This includes limits on how much of them would be better off without it,” profit is made, lending practices says Roodman, who likens microcredit including keeping clients from over- to prescribing drugs—healthy in indebtedness, and transparency of appropriate doses, but possible to interest rates so that all MFIs no longer overdose. hide the true cost of the loans to the In his 2010 commentary Does borrowers. Microcredit Really Help Poor People, His organization has collected data Richard Rosenberg, a senior advisor from the majority of MFIs in more NOT THE SOLUTION Critics of with the World Bank’s Consultative than 20 countries and posts on its microfinance contend that poverty Group to Assist the Poor, refers to website the price each charges for cannot be solved by borrowing money. Portfolios of the Poor: How the World’s loans. The transparency work feeds They point out that the poor would need Poor Live on $2 a Day. It is a collection into an ongoing Smart Campaign for credit less if they had a way to safely of “diaries” from rural and urban commitments to a code of conduct as save. households in Bangladesh, India, well as initiatives on certifying MFIs and South Africa that used up to 10 similar to fair trade products, such types of financial resources (loans as the seal of excellence promoted by including Bangladesh and India; the from family, friends, moneylenders, the Microcredit Summit, all aimed to economic realities in other countries informal savings, and loans clubs) and distinguish those practicing mission require different rules. He suggests liked microfinance for its reliability principles, which Waterfield believes up to 15% return on equity is “green- in helping them “cope with the is most of the industry, from those that light” acceptable, while 15%–25% is in unreliability of their income and their are not. a “yellow-light” area and beyond 25% lives.” There are also expectations that is unacceptable. The authors conclude, “Whether technology advances, such as banking Profit helps expand the far-smaller or not the microfinance movement through mobile phones or smart cards, volume of public subsidies and grants was right to stress loans for could also bring down costs, but to the ultra poor—the very bottom microenterprises, or has been too

possibly at the expense of responsible of the pyramid. However, the power slow to embrace savings and other PICTURE CREDIT: ARIEL D. JAVELLANA lending. of private sector profit needs to be services, its greatest contribution is, Yunus believes lenders should pay combined with the financial counseling to us, beyond dispute. It represents a 10%–15% above the cost of the loan, support and graduation programs that huge step in the process of bringing which can still make interest rates the public sector offers. reliability to the financial lives of poor high. The Grameen model, which There is also the position that poor households….” recycles all of its loan payments, caps people would need credit less if Adds Rosenberg, “People not only its interest rate at 20%. Waterfield says they had a way to safely save. Says take out loans, but they repay them that rule works in only a few countries, Roodman: “The easier it is to get with high reliability.” ■

38 Development Asia July-December 2011 www.development.asia

P34_38 Tiny loans, big questions.indd 38 10/24/11 10:43 AM Knowledge Shared

“Development Asia is a good magazine. It is very useful for me as a lecturer on economic development theory.”

Made Antara, Lecturer University of Udayana Denpasar, Bali, Indonesia

“It is an enriching experience to read your magazine. The articles and information are excellent. Keep up the good work.” Rajesh P. Khambayat, Faculty Consultant Colombo Plan Staff College for Technician Education Metro Manila, Philippines

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www.development.asia A publication of the Asian Development Bank

Knowledge shared AD.indd 68 10/20/11 4:50 PM PROFILES IN DEVELOPMENT

What works Ya l e U n i ve r s i t y e c o n o m i s t a n d p r o f e s s o r D e a n K a r l a n i s t r y i n g t o b r i d g e t h e g a p between academia and development to understand why projects succeed (or fail)

BY Jade Lee-Duffy

wo years ago on the can make drastic improvements for mountainous Philippine those involved. island of Mindanao, representatives from Green MAKING IT WORK Bank of Caraga were on the lookout for Born in New York’s Bronx Tsmokers. Standing on the street, bank neighborhood and raised in Florida, staff members were asking anyone Karlan grew up reading about people puffing away on a cigarette if they helping others and changing lives. would participate in a smoking survey. In 1992, the economist volunteered For those who agreed and wanted in El Salvador with a microcredit to quit smoking, they were then asked organization to assist in developing to put the money they would normally their software systems. spend on cigarettes every week into a “I’ve always been interested in bank account. At the end of 6 months, development because I know I’m lucky they took a test to show if they were in this world, and because I thought I smoke free. If they were successful, could make a difference,” says Karlan, the now nonsmokers would get their who earned a doctorate in economics money back. But if they weren’t, the from Massachusetts Institute of money would automatically be given MEASURING IMPACT Dean Karlan Technology (MIT) in 2002, and a to a local orphanage. measures how lives have been changed master of business administration This health- and money-saving by development programs and projects. and a master of public policy from the initiative was one of many beneficial, University of Chicago in 1997. life-changing programs led by Yale During his 2-year stint in El Salvador, University economist and professor more likely to stop smoking than a Karlan was struck by how little the Dean Karlan, who is also the founder control group. organization understood the impact and president of Innovations for Most recently in April, Karlan along of giving money to small enterprises, Poverty Action (IPA)—a nonprofit with researcher Jacob Appel launched and what little evidence they had to organization in New Haven, a new book, More Than Good Intentions: guide them on the best way to run their Connecticut that designs and evaluates How a New Economics is Helping to programs. Surprisingly, says Karlan, programs in developing countries. He Solve Global Poverty. The book draws their only form of data collection was focuses on bridging the gap between attention to today’s most celebrated to ask recipients questions like: “How academia and development policies development approaches. For example, has your life changed since receiving in practice through evaluating which do microloans really transform the the loan?” programs and projects work (and do lives of the poor? Findings include Invariably, most recipients would

not work) to reduce poverty and help a study in Bolivia, Peru, and the say their life had improved. However, PICTURE CREDIT: DEAN KARLAN those in need. Philippines, which revealed that quick, Karlan jokes, “The striking thing was For the smoking-cessation project, cost-effective reminders from banks that they could have asked, ‘have you officially named the Committed Action such as texts and direct-mail messages gotten older since receiving a loan’ to Reduce and End Smoking (CARES) helped the poor generate savings. and of course the answer would be voluntary commitment savings Karlan also highlights that simple ‘yes.’ Would the organization then program, Karlan’s efforts resulted in and pragmatic changes in education, conclude that their loans caused aging? volunteers being 30 percentage points banking, agriculture, and health care You need to measure how lives have

40 Development Asia July-December 2011 www.development.asia

P40_41 Profiles in development.indd 1 10/21/11 3:30 PM FIELD WORK Karlan (center) interviews farmers in Ghana.

changed compared to how lives would ground to learn what actually works have changed had the loan not been and what actually does not through offered.” “Some aid works, careful rigorous testing.” “The organizers were well some are wasted” Aimed at the large foundations, intentioned, and smart, but they just the World Bank, government didn’t have the right data to answer organizations, as well as the general questions about their impact.” to taking research and putting it public, the book is told through The key to finding out if a into action, making sure things that individual stories backed by primary development program works, have been proven successful are research. “[Readers] aren’t emotional says Karlan, is to carry out impact taken to scale by bringing them to about standard deviation, so we don’t evaluations. “We need a causal link implementing organizations.” just tell statistics, but bring them to between improving lives and how Today, IPA has expanded to 500 life with rich stories to provide human to set up a program,” says the 2007 employees in 46 countries. context for the research.” Individual recipient of the Presidential Early stories include a young Ghanaian Career Award for Scientists and GOOD INTENTIONS named Anthony who scraped by to Engineers from the United States. “It’s In More Than Good become a teacher, then after 4 months the same approach for prescription Intentions, Karlan takes still hadn’t been paid; a microloans drugs, which fight colds or prevent a firsthand look at story on Mercy, who had repaid dozens diseases; by doing randomized trails, various development of loans and even helped others make we can learn which ones are achieving programs across the payments who had come up short; their goals and which ones are not.” developing world. and a flower seller named Vijaya While Karlan has been teaching From India and from Chennai, India whose alcoholic economics full-time at Yale since Bolivia to Kenya and Ghana, husband squandered any money she 2004, he also finds time to be a board the economist visited classrooms, earned. member and research fellow of the MIT hospitals, farmers’ huts, and vendors’ Karlan says the book weaves back Abdul Latif Jameel Poverty Action Lab; market stalls to test the impact of a and forth between the issues and and cofounder and president of stickK. program. struggles that people are facing. And it com, a free website that helps users “Everybody hears that governments reaches out to people in the developing lead healthier lives. are corrupt and aid is wasted or does world, say at a small nongovernment In 2002, when Karlan established harm,” says Karlan. “But there is organization in Indonesia, who want IPA, his goal was to make the leap another view that says aid works. Of to find out which types of ideas are from academic theories and research course, the answer is in the middle. proven to be effective in addressing the into the real world. “To produce Some aid works, some are wasted. fight against poverty. research and fieldwork, we needed Some programs are corrupt. Others are By working beyond the walls of Yale

PICTURE CREDIT: DEAN KARLAN a long-term presence on the ground, not. The question is, which programs University and publishing his new and to have staff who had the skill work and which do not. And what book, Karlan has created an impact and knowledge on how to do these methods and approaches are corrupt of his own. “If I just responded to my types of impact evaluations,” he and which are not.” academic incentives—to just publish says. “We needed more than a few “The heart of the book is about academic papers, it wouldn’t change professors and a revolving door of leaving the shouting match of the the world, so I needed [IPA] whose grad students working on projects, but ivory tower, about getting beyond mission is to change the world. And a real institution that was committed the rhetoric, and instead going to the that’s what I did.” ■

www.development.asia July-December 2011 Development Asia 41

P40_41 Profiles in development.indd 2 10/21/11 3:30 PM RECONNAISSANCE

LABEL-CONSCIOUS SHOPPER A customer checks out the label of a milk carton at a supermarket in the People’s Republic of China. Shoppers in many parts of Asia are becoming more selective.

SEAL OF APPROVAL The Fairtrade logo tells consumers that this can of black tea from Sri Lanka was made in an environmentally sustainable manner and Shop Fair Do you want to be an ethical shopper? Just look for the fair trade or similar label. Or is it that simple?

BY Margo Pfeiff

ade in China. Grown in in the past 2 decades, been gaining forced labor, or gender discrimination Guatemala. Imported from momentum worldwide. It works by involved at any point along the India. A modern shopper offering developing country producers product’s supply chain. Mneed only browse clothing racks better trading conditions by paying The fair-trade concept is said to have or supermarket shelves to see that them an above-market price for their started in 1946 with the commissioning developing countries are increasingly goods which, these days, can include of needlework in Puerto Rico for sale becoming the world’s gardens, sewing anything from coffee, sugar, tea, in the US at stores that became known rooms, and factories. bananas, honey, rice, fruit, and cotton as Ten Thousand Villages. These days, While consumerism in wealthy to timber, sports balls, even gold. That fair trade is a global movement with countries helps stoke the economies of ensures not only fair-trade prices and genuine items carrying certification developing nations by creating jobs, it practices, but also a safety net in bad markings, a logo that guarantees it also has downsides. It can negatively years when commodity prices drop. went from producer to retail shelf impact the environment and burden Producers can obtain advances for in accordance with international producers. In 2010, Indonesian palm goods before they are harvested, and standards set by the Fairtrade Labeling oil, which is widely used in food and the cooperatives to which they must Organizations International (FLO) cosmetics, was added to the United belong are paid a premium that goes system. FLO is the largest and most States Department of Labor’s List into a fund for communal programs widely recognized standard-setting of Goods Produced by Child Labor such as helping implement better and certification body and it is or Forced Labor. It’s hard to be a farming techniques, or contributing to responsible for regularly inspecting shopper these days without feeling that the community’s health or education and certifying producer organizations someone is being taken advantage of facilities. in more than 50 African, Asian, and so that we can sip that bargain bottle For the consumer, certified fair trade Latin American countries. PICTURE CREDIT: AFP of wine or enjoy a bouquet of exotic products offer a guarantee that the In 2009, FLO-certified products flowers. producers’ working conditions are amounted to almost $5 billion globally, The most successful option for good, their environment is used in a up 15% over the 2008 figure; an ethical consumerism has been fair sustainable manner, and basic human estimated 6 million producers and their trade, a movement that has, especially rights are respected with no child labor, families benefitted from approximately

42 Development Asia July-December 2011 www.development.asia

P42_43 Reconnaissance.indd 1 10/21/11 3:25 PM 75 million dollars distributed that year 32% from 2007 to 2008 and by another benefiting in the same way due to for community development projects. 23% to 2009. entrenched power structures in the Fair trade is booming as more and It seems a win–win situation coffee industry.” In 2010 the results more consumers, willing to pay a for everyone: developing country of a 10-year study of 327 Nicaraguan higher price for products they believe workers get a fair deal, producers and coffee producers was released by are helping create a better life for corporations can increase profits with the University of Hohenheim in Third World producers, jump on the feel-good social justice as a marketing Germany which found that “organic bandwagon. Celebrities like Sir Paul tool, and consumers can fill their and organic/fair-trade farmers have McCartney and Annie Lennox actively shopping carts while feeling they are become poorer relative to conventional promote the concept in the United helping the less fortunate. producers.” Kingdom, a fair trade leader. But fair trade also has its critics. Fair trade coffee accounts for a small The biggest annual event to raise According to Britain’s Adam Smith percentage of the coffee market, but awareness of fair and ethical trading Institute, a conservative think-tank, demand has increased and producers values is World Fair Trade Day only 10% of the premium paid for can’t keep up. One controversial result when celebrations are held in cities fair-trade products actually reaches is that the quality of fair-trade products worldwide every May, sponsored by the producer. The balance winds can be uneven since farmers are the World Fair Trade Organization, a up in the pockets of the retail chain. often able to sell their higher quality global group that identifies registered The Institute’s Marc Sidwell sees the specialty coffees—like organically fair trade organizations. In Asia, where movement as a type of subsidy or grown beans—on the free market for fair trade has recently begun picking marketing ploy that prevents growth, a better price than fair trade pays. up momentum among consumers, keeping poor farming families poor. They then unload their lower quality festivities took place in the Philippines Fair trade’s reputation has been beans at the fair-trade price. Unable to and focused on getting shoppers to tarnished in recent years. Danish obtain the volume it needs, Java giant switch to shopping fair trade with filmmaker Tom Heinemann visited Starbucks has even created its own slogans like “I am a shopper against more than 20 fair trade tea estates in program called C.A.F.E.—Coffee and child and forced labor,” as part of their Bangladesh, India, Kenya, and Sri Farmer Equity—to encourage suppliers “100% Guilt Free Shopper” campaign. Lanka for his documentary The Bitter by giving them a price premium if In fair trade’s early days, consumers Taste of Tea in which he found that they conform to environmental and in search of clear-conscience shopping few workers had benefitted from social responsibility standards. But had to traipse to a few far-flung hippie fair trade’s community-enhancing the system is multi-tiered, complex, and hemp-filled and handicraft-laden premiums. He also addressed issues and doesn’t always deliver the quality specialty stores or church basements of quality control, transparency, and promised. sponsored by nongovernment adherence to conditions by reporting While some dismiss the fair trade organizations to pick up their quinoa that fair trade quality inspections were movement as marketing hype more or cocoa. Today, with customers announced in advance. “The estate aimed at making the consumer feel demanding increased access to fair owners can tell the workers not to be comfortable than creating real progress trade products, the concept has gone critical,” Heinemann told The Times of in Third World farms or factories, mainstream. Companies want to be London in 2009. “It is a harsh system— it’s clear that fair trade has played a seen as socially responsible, so ethically [the workers] are deeply afraid of the significant role in raising consumer produced goods are stocked on Wal- owners because they can lose their awareness about the plight of Mart shelves, and both McDonald’s job.” producers in developing countries. By and Dunkin’ Donuts are serving some Since coffee is the biggest player in making shoppers more selective about fair-trade coffee. the fair trade game, the heat is on that what they toss into their supermarket In fact, when people think of fair industry to lead the way. Gavin Fridell, trolleys, fair trade does improve lives, trade, they usually think of coffee. It author of Fair Trade Coffee: The Prospects even if it is only for a small fraction of is not only the movement’s biggest and Pitfalls of Market-Driven Social producers. traded commodity but it is also Justice, states there are about 670,000 “Companies jumping on the social the world’s second most valuable independent producers of FLO certified responsibility bandwagon are making commodity after oil. Seattle-based coffee, only 3% of the total number of genuine efforts to be better corporate Starbucks, the biggest coffee chain world’s coffee-growing families. citizens,” says Gavin Fridell. “But their worldwide and the biggest buyer of “Although some coffee growers efforts, while certainly better than fair-trade-certified coffee, purchased are experiencing the benefits of doing nothing, tend to be limited and 14 million pounds of certified organic fair pricing,” Fridell says on his structured to meet the corporation’s coffee in 2009. In the US, imported website, “the lion’s share of coffee needs at least as much as the social certified fair trade coffee increased by growers remain obstructed from ever justice goals.” ■

www.development.asia July-December 2011 Development Asia 43

P42_43 Reconnaissance.indd 2 10/21/11 3:25 PM ON THE RECORD

Compiled by Maria Liza Solano

“Commodities like pills, vaccines, and bednets, and the cash to buy them will not have an impact in the absence of delivery systems that reach the poor. When the overarching objective is poverty reduction, if you miss the poor, you miss the point.”

Margaret Chan, Director-General of the World Health Organization

“The survival of one billion people—the weakest and most vulnerable on the planet— depends upon us finding answers now to hunger.”

Former United Nations Secretary General and Nobel Peace Prize winner Kofi Annan, who now chairs the Alliance for a Green Revolution in Africa

“Vaccines are an extremely elegant technology. They are inexpensive, they “Gender-dominated are easy to deliver, and they are proven to environments are not protect children from disease.” good... particularly Bill Gates, cochair of the Bill & Melinda Gates Foundation, in the financial sector at the World Health Assembly in Geneva last May where there are too few women... I “If corruption does not get solved honestly think that effectively, the party will lose the people’s trust and support. The entire party there should never be should stay alert and fully appreciate the too much testosterone long-term complexity and arduousness of the fight against corruption, and make in one room.” more efforts in fighting corruption and building a clean government.” Christine Lagarde, the first woman to head PICTURE CREDIT: AFP the International Monetary Fund, in an Hu Jintao, President of the People’s Republic of interview with The Independent early this China, at the Communist Party’s 90th anniversary year in July

44 Development Asia July-December 2011 www.development.asia

P44 On the Record.indd 1 10/21/11 3:26 PM With some solutions for climate change

...you simply add water

Climate change endangers us all. A great way to fight it is harnessing renewable energy. ADB provides funding and assistance for clean-energy run-of-river hydropower plants across Asia. They range in size from 5 to 100 megawatts.

Eco-friendly, these plants keep rivers flowing. Electrify urban and rural areas. Supply power for people and industry. And switch Asia on to a low-carbon path.

ADB. Investing in climate change solutions for Asia and the Pacific.

www.adb.org

ADB Climate Change Posters_DA2 203x273.indd 1 13/04/2010 11:25:50 AM