ENDING GLOBAL POVERTY

A GUIDE TO WHAT WORKS

STEPHEN C. SMITH

PALGRAVE MACMILLAN         2005

PART VI

 

Chapter 3: Health, Nutrition, and Population (Cont.)

 

POPULATION AND FAMILY PLANNING:

CARE MAKES PROGRESS IN ETHIOPIA

There are more than ten times as many people living on the Earth as there were 300 years ago. But one of the huge success stories of recent decades is the decrease in the rate of growth of world population. The growth rate peaked in the early 1960s at about 2.2% per year, but has now been cut in half to 1.1%. This is the difference between the population doubling at a rate of every 32 years in the 1960s, and every 64 years today. Although the population is still growing, the number of people added to the Earth each year (the number by which births exceed deaths) is now getting smaller. After a peak of adding 87 million additional people in 1989, in 2002 the world added 74 million people, and this figure is getting progressively smaller. Still, most of the increase is occurring in developing countries that are often already facing growing environmental pressures.

In isolated villages of rural Ethiopia, population growth has been fast and knowledge of family planning minimal. There has been very limited access to healthcare. Women have little power in the family. Fewer than 19% of women in the country can read, and the percentage is even lower in rural areas. On average, a woman in Ethiopia will give birth 6 times, a rate of fertility almost unchanged for decades. Yet the environment is becoming increasingly stressed. The population, now at 65 million, is expected to reach 88 million by 2015. The hope of ending poverty in Ethiopian villages depends on decreasing fertility. The work of CARE’s Population and AIDS Prevention Project (POP/AIDS) in rural Ethiopia shows that this is possible.

This program began in 1996 with a mission to improve the health status of women and children. In CARE’s program, an extension agent (or profession trainer) lives in a village for several months, working in a cluster of between four and nine villages with a local peasant’s association. The goal is to help establish “a culture of family planning” and a framework for community health. The CARE agent begins by identifying and working actively with natural leaders in these villages – people CARE calls “opinion leaders” rather than “political leaders.” The extension agent works to persuade these leaders of the importance of family planning. The leaders in turn play a key role as “change-agents” by convincing others, partly by setting an example through their own behavior. The CARE agent and community leaders often meet, sitting together in a large circle outdoors, to discuss family planning, health issues, or other concerns raised by participants. With the assistance of these opinion leaders, the CARE extension agent then identifies an appropriate local resident who was respected in the community and would serve as the reproductive health representative after the extension agent had transferred to another village.

In the first months after moving on to another community, the CARE extension agent makes a few brief return visits for training. After that point there is follow up from the Ethiopian Ministry of Health, including programs to involve the representatives in immunization, in an anti-polio campaign, and in the distribution of Vitamin A supplements. The involvement of the ministry is intended to help promote program financial sustainability.

• CARE says it works with tacit approval of the official leaders, by making courtesy calls to officials, introducing visitors, symbolically demonstrating respect and acceptance of their authority.
• During a five-year project from 1996 to 2001, CARE extension workers trained and established 344 community representatives potentially serving some 260,000 villagers.
• Contraceptive use rose from 4% to 24% in the Oromiya region south of Addis Ababa. The program worked better where men were more actively involved.

As of the end of 2004 these village family planning representatives were still active and linked to nearby government health facilities for supplies and technical support. This linkage is an important phase in the assumption of responsibility for the program by the local government.

Ensuring that an adequate, steady supply of contraceptives for the village was available after the launch was very important to maintaining use. If costs of contraception cannot be kept very low, the villagers cannot afford them, so continued subsidies will likely be needed for some time. Consistent involvement by community based organizations and the Ethiopian government is needed to ensure the new “culture of family planning.” In this way, an escape from the high fertility trap might be secured.

HEALTH MAKES EDUCATION POSSIBLE:

DEWORMING IN KENYA (ICS IN BUSIA)

Worldwide, hookworm and roundworm each infect about 1.3 billion people, whipworm infects about 900 million, and schistosomiasis infects about 200 million. These parasitic infections can be debilitating. Severe infections lead to abdominal pain, anemia, protein malnutrition or Kwasiorkor, listlessness, and other complications. In Africa, millions of children live in communities where parasitic infections are nearly universal. If all children in heavily infected areas were given safe deworming treatment now available, we could control these infections for an estimated 49 cents per child per year.

In rural Kenya parasitic infections are endemic, including hookworm, roundworm, whipworm, and schistosomiasis. But with so little money available – annual government expenditure on public health in Kenya was only about $5 per person in the 1990 to 1997 period – and so many pressing problems, officials in aid agencies and in the Kenyan government doubted whether these treatments should be a priority. Now an action research project has shown clearly that deworming is one of the most high-impact and cost effective strategies for keeping children in school while improving their general nutrition and health.

• The program is run by the International Christian Support Fund (ICS), an NGO based in the Netherlands.
• ICS implemented its deworming program with cooperation from the Kenyan Ministry of Health, and is working with a Harvard-MIT research team led by Michael Kremer, assessing their poverty programs using the highest standards of rigor: randomised impact evaluations.
• In Busia district, 92% of schoolchildren were infected with at least one parasite, and 28% had at least three infections. The most heavily infected children were more likely to be absent from school on the day of the survey.
• The deworming program was one of the most rigorously evaluated poverty programs in the world, using randomised trial methods.
• The results showed it to be more cost effective than virtually any known program in increasing the level of primary school attendance among very poor children.
• The program cost per additional year of schooling was just $3.50, much less than the alternative methods used to increase school participation, such as subsidies to attend school.
• The result was a well-designed program, rigorously evaluated, with an unusually favourable cost-benefit ratio.
• Nangina Primary School had a sign painted onto a wall that reads: “OUR MOTTO: HARDWORK AND DISCIPLINE LEAD TO SUCCESS.”

ICS has had many benefits from participating in rigorous randomised trials that extend even beyond the knowledge it gains on program effectiveness. They have received many valuable ideas from the researchers, and have acquired an international reputation for innovation and careful program assessment. It is to be hoped that many other NGOs will follow their example.

Chapter 4: Basic Education