Rebuilding Foundations

An exploration of international development work in Africa

The Shackled Continent

One of the terms I might throw around in this blog is “evidence based decision making.”  It used to be a big buzz word within EWB, although it isn’t used much anymore.  It means to examine problems rationally and use quantifiable information to justify decisions.  That probably sounds like a simple concept, but often it’s hard – especially in Africa where information isn’t available on basic infrastructure. For example, how do you allocate water spending when you don’t know how many wells each town has?

Below is an excerpt from the book The Shackled Continent: Africa’s past, present, and future´ by Robert Guest, the African editor for The Economist.  I think it is an excellent illustration of the power of evidence based decision making.  Plus he’s a much better writer than me,

Dr Kasale was trying to make it easier for rural Tanzanians to get proper health care.  He was working on a ponderously named scheme with a simple premise: the Tanzania Essential Health Interventions Project (TEHIP) set out to show that even a tiny health budget, if spent rationally, could make a big difference.

Backed by the Tanzanian health ministry and a Canadian charity called the International Development Research Centre (IDRC), Dr Kasale and his colleagues carried out an experiment. They took two miserably poor rural districts, with a combined population of 700,000, and tried to find out how many lives could be saved by budgeting more logically.  The results were so startling that I flew to Tanzania to have a look.

The experiment was conducted in Morogoro and Rufiji, two sprawling slabs of bush the size of Belgium.  I landed in Dar es Salaam, the commercial capital, and drove out westwards to Morogo with Dr Kasale.  It was as beautiful as poor rural areas usually are.  Coconut palms glistened in the morning mist, dazzling sunlight played on green-cloaked mountains and every ten-dollar shack had a million-dollar view.

The people in Morogoro live much as they have since agriculture first reached Tanzania, growing starchy vegetables, eating what they need and trading the surplus, if any.

Before the experiment began, annual health spending in Tanzania was about $8 a head.  In Morogoro and Rufiji, IDRC added $2 a head to the pot, on condition that was spent rationally.  By this the donors meant that the amount of money spent on battling a particular disease should reflect the burden that the disease imposed on the local population.

This may sound obvious, but it is an approach that few health ministries take, in Africa or in the West.  In Morogoro and Rufiji, no one had a clue which diseases caused the most trouble, so TEHIP’s first task was to find out.  The traditional way of gathering health data in Tanzania was to collate records from clinics, but since most Tanzanians die in their homes this was not terribly accurate.  So TEHIP sent researchers on bicycles to carry out a door-to-door survey, asking representative households whether anyone had died or sickened recently, and if so with what symptoms.

These raw numbers were then crunched to produce a ‘burden of disease’ profile for the two districts.  In other words, researchers sought to measure how many years of life were being lost to each disease, with a weighting factor to reflect the collateral damage to families when breadwinners die.  They found that the amount of the local health authorities spent on each disease bore no relation whatsoever to the harm which the disease inflicted on local people.  Some diseases were horribly neglected.  Malaria, for example, accounted for 30 per cent of the years of life lost in Morogoro, but only 5 per cent of the 1996 health budget.  A cluster of childhood problems, including pneumonia, diarrhoea, malnutrition, measles and malaria, constituted 28 per cent of the disease budget, but received only 13 per cent of the budget.

Other conditions, meanwhile, attracted more than their fair share of cash.  Tuberculosis, for example, accounted for less than four per cent of life lost, but received 22 per cent of the budget.  No one wanted to cut spending on anything, but the research suggested the extra $2 a head would be best spent on neglected diseases for which there were cost-effective treatments or preventive measures.  As it turned out, the extra cash was ample: neither in Morogoro or Rufiji was the system able to absorb more than an additional 80 cents or so.

This tiny cash infusion smoothed the transition to a more effective approach to health care.  Health care workers, mostly nurses or paramedics rather than doctors, were given a simple procedure to show how to treat common symptoms.  An illustration: if a child arrives coughing, and with a running nose and a hot brow, the nurse is instructed to work through a checklist of other symptoms to determine whether it is merely a cold or something worse.  If the child is breathing more than fifty times a minute, for example, he is assumed to have pneumonia, given an antibiotic and checked again after two days.

In most cases the cheapest treatments are offered first.  Children with diarrhoea are given oral rehydration salts, which cost a few cents.  If the salts don’t work, the child is referred to a clinic and put on a drip.  For malnutrition, the first treatment offered is advice on breastfeeding.  When this is not enough, the child is prescribed cheap vitamin-A pills.  AIDS is tackled through education, condoms and antibiotics to heal open sores cause by other venereal diseases, which present the virus with an open door into a new bloodstream.

Knowing which diseases people are actually suffering from enables clinics to order the right drugs.  Previously, the government sent out the same package of pills to all dispensaries, which meant that popular drugs ran out while others gathered dust.  Non-malarial mountain villages used to receive as many malaria drugs as mosquito-infested lowland ones, and villages where no one had ever suffered from asthma received asthma medication.  ‘We did things blindly,’ a doctor in Morogoro recalled.

I asked people if their lives had changed since the TEHIP experiment began.  They all said they had.  A young peasant called Mustapha Dangeni told me that his two children used to be smitten with fever almost every month before he got a bednet.  Now, he said, they had been healthy for a whole year.  He and his wife found that, because they did not have to spend time nursing sick children, they could work longer in their fields, so they had produced more spare maize and millet.  They earned more money than usual, and did not have to spend any of it on anti-malarial drugs.  Mr Dangeni invited me to his hut to show me all the things he had bought with the extra cash: a radio, a bicycle, some rough furniture, better tools, and so on.  ‘Things are continually improving.’ He beamed, leaning topless against a sack of charcoal.

Guest, Robert. (2004) The Shackled Continent: Africa’s past, present, and future. Pan Books: London. Pages 240-244.

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One thought on “The Shackled Continent

  1. Interesting example case. It’s easy to forget how amazing it is that we have so much statistical information at our fingertips, relatively up to date, and in a format that’s easy to work with. And of course, it’s equally easy to forget that this isn’t the case everywhere.

    It makes me so happy that you are back to your ridiculously impressive blogging schedule! Hope all’s well with you, and looking forward to reading more 🙂

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