The Food’s Not Much, But the Lavatories Are Fabulous

image002.jpgI was startled during a meal at a non-luxury restaurant out in the boondocks in Ghana when my Ghanaian hostess suggested I check out the bathrooms. Lo and behold, they were indeed incredibly clean and hygienic. The reason seemed to be given by the following sign outside the lavatory. Apparently this private firm had won a lot of bathroom-cleaning contracts as a way to promote its own cleaning products for the homes of the Ghanaian middle class (I wish some entrepreneur in the US would think of this for our disgusting gas station bathrooms).

Now I’m not going to take a cheap shot and say this demonstrates the superiority of the private market to solve problems – especially when the private sector restaurant we were eating at was unable to supply most of the dishes that were listed on the menu (although those dishes that were available were fine). Maybe it’s a symptom of the information problems of a poor economy that the free market does well at supplying some goods (the frequently cited but still amazing penetration of cell phones and the internet into Ghana is another one), but misses out on others.

Of course, the “aid economy” is still much worse. Lacking any market or democratic mechanism to get feedback from the customers on what they want, there are even more extreme disparities between hits and misses on aid-supplied goods. One lightly used aid-financed road is a 4-lane highway in perfect condition, while the major Accra to Kumasi thoroughfare is a two-lane road riddled with potholes. Aid-financed buildings are always abundant, but some of the little things that make the buildings fully functional are missing. I saw a health clinic that was missing beds for the patients and tables for the nurse to work on (which was still much better than the well-documented problem of health clinics lacking medicines or health workers). The nurse’s solution was inventive – she kept moving one bed back and forth between the maternity ward, the post-natal recovery room, and the regular patient room, and she hijacked a table from the local aid-financed kindergarten. I am reminded of the old Soviet factory managers that creatively adapted to the perennial shortages in a centrally planned economy – much like the chronic shortages in an aid-financed economy.

It goes on. Food storage rooms are missing enough pallets to keep the food off the floor so it doesn’t rot. Some villages got a mass bed net distribution two years ago, but now some nets are torn, have been washed too many times because the village is so dusty, or some villagers missed getting nets altogether because they were absent on bed net distribution day. Moreover, the bed net villagers in an informal chat indicated other needs that seemed even more pressing to them than nets – they lack any reliable form of transport – to the capital, Accra, which is vital to them for business. Their only hope is to wait hours and hours by the road for some form of transport to come along. And more than anything they wanted – guess what – clean lavatories. There was not a single functioning lavatory in the village, and the villagers seemed well aware of the adverse health consequences of not having lavatories.

This is not to take away from the valiant aid efforts that did supply some critical goods, but it is clear the aid economy is a non-market system that has the same chaotic mixture of over-supply of some goods and shortages of others, common to other non-market systems. As the restaurant example above indicates, however, the free market is also uneven in supplying goods in poor economies. The difference is that we know in the long run, from the historical experiences of other countries, markets get more reliable and get wider and deeper coverage as a country develops (i.e. as transaction and information costs fall, and as markets get thicker with rising consumer demand). And for public goods, increasingly democratic systems with an active citizenry demanding services from their government create a kind of “political market” for public goods that does eventually succeed in creating better and more public services.

Unfortunately, history equally suggests that the non-market systems like the aid economy never do resolve their allocation problems of feast-or-famine. Aid may be a short-term expedient for some critical needs, but already in Ghana far more people are getting their needs met through private markets. Every visitor to Ghana or any other poor society has to be struck by the amazing number and diversity of small producers and retailers visible at every turn of the road – the “Royal Metal Works,” the “God is Able Provisions Store,” the “Urban Fashion and Business Center,” or the simple bald advertisement “Cement is Sold Here.” There is a lot more hope for the villagers and urbanites of Ghana from improved functioning of markets and of democratically-accountable public services than from the aid system. I’m willing to bet that the market will eventually compel the restaurant with the clean lavatories to have most of the items on the menu.

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Skepticism Takes the Day Off

When you see men voluntarily breaking rocks in the hot sun to build their village’s community center, you think they must really want it. I saw this on a visit to a project by The Hunger Project in the Eastern Region of Ghana. The Hunger Project believes in people helping themselves.


Sure the skeptic would naturally seek more systematic and rigorous evaluation, and could think of plenty of things that can go wrong in any aid project. But let’s give skepticism the day off and salute the people who work so hard to help themselves and those who help them do so, against tough odds.

A salute to Dr. Naana Agyemang-Mensah, the hard-driving Director of the Hunger Project-Ghana, who works long hours to mobilize communities to help themselves. To the midwife in the birthing room in the completed community center, who lowers the mortality risk for mother and baby. To the microcredit bank in the community center, who gives loans to the members and makes sure they repay. To the food bank volunteers, who store food for the hungry season until the harvest.

Another salute to Professor George Ayiteey, whose Free Africa Foundation distributes insecticide-treated bed nets to the dusty remote villages I visited today. To G.B.K. Owusu, the local coordinator, who follows up with the chiefs and residents of each village to make sure the nets are reaching them (see net in use below).


And finally, once again to the men at work in the hot sun to build their own community center – a better image for aid than the stereotypical helpless child.

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A Tale of Two Refrigerators

In 2001 in southern Sudan, it was a time of peace between wars. It was a time ripe for treating diseases that kill thousands of children every year. It was an opportune time for measles vaccination to halt outbreaks of one of the world’s most preventable diseases. The Measles Initiative, founded by the WHO, UNICEF, the CDC and the American Red Cross, was created to address this significant challenge. In the rural county where I ran an NGO, over 1,200 young children died of measles over four months in early 2001. The death toll was devastating to our school children and their families: local villagers did not have the resources to combat the outbreak except to bury the dead.

When we reported the outbreak to the WHO, the officials we corresponded with expressed shock and dismay that our communities had no access to a vaccination program to stop the spread. But the WHO was caught in a Catch-22 of their own devising: they were unwilling to allocate resources and send doctors unless they could be certain the outbreak was measles, but they couldn’t be certain it was measles without a clinical diagnosis by qualified medical personnel.

Our NGO shipped out videotape of the infected children to one of the Measles Initiative partners. A medical doctor and global measles expert said the video was some of the best footage of children with measles he’d ever seen, but unfortunately Sudan wasn’t on the list to have a measles eradication program that year and he couldn’t be certain without seeing the patients. Even with the clear video footage, a senior WHO official still wouldn’t attribute the children’s deaths to measles nor send an investigative team. So, as far as we know, the children who died in eastern Upper Nile state in 2001 were never counted in the WHO’s official measles statistics.

Worse yet, the WHO wouldn’t supply vaccines to inoculate children and stop the outbreak without a refrigerator to store them, and the remote communities where we worked had no refrigerator and no reliable power source. UNICEF, we were told, would provide a fridge if the number of diagnosed deaths from measles was significant. But with no qualified medical personnel to diagnose a “significant” number of deaths in our area, we didn’t qualify.

In cooperation with Save the Children (US) and funded by USAID, our NGO set up a medical clinic and put qualified African medical staff in place. Training on running a vaccination program was provided and record-keeping started. The communities waited impatiently for the vaccination program as more children died in subsequent outbreaks. There were hundreds more deaths diagnosed from measles each time. Our NGO was repeatedly told it was “near the top” of the waiting list, but years passed with no refrigerator and no vaccines.

Another outbreak of measles started in mid-2008. In desperation, our NGO raised private funds to purchase a refrigerator and fly it into the isolated area where we worked. Within a few months, our new refrigerator was in place and ready to hold the free vaccines that the Measles Initiative promised to qualified organizations. We have found that “free” is a relative term in Africa, however. We quickly learned that a small number of vaccines were available to us at a regional distribution center, a $5000 air charter flight away.

Just last week, a second refrigerator was delivered, this time courtesy of Save the Children (US), nearly seven years after the original request was made. According to locals, thousands of children have died of measles in the mean time, but the major aid agencies still cannot work together to provide truly free vaccines. Seven years later, this community has two empty refrigerators and still no means to keep their children dying from measles. The refrigerator excuse is gone but the vaccines are effectively out of reach.

Even a time between wars is not the best of times for the poor in rural Sudan. As it turned out, it has been a time of bureaucratic “defer and delay” from the UN aid agencies who failed to provide the vaccines needed to save vulnerable children dying from a preventable disease. After seven years, Save the Children (US) is making the most progress, which is disappointingly slow.

It makes me wonder if the 90% drop in measles infection rate between 2000 and 2006 claimed by the WHO is accurate, or if the children who are dying are just too much trouble for them to count.

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