MethodLogical is now at

MethodLogical is now at

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Monday, February 28, 2011



Amartya being Amartya

Posted: 26 Feb 2011 09:27 PM PST

Sen on how to compare India and China: not based on income levels or growth, but rather based on health and other objective measures of well-being. I was somewhat stunned by Bangladesh’s outperformance on those metrics, but that’s kind of par for the course with Sen’s writing – he’s great at finding this sort of story.


Via my ML co-contributor Seema Shah.

Friday, February 25, 2011



The news that wasn’t fit to print

Posted: 24 Feb 2011 07:52 PM PST

Today 1,500 women died due to pregnancy or childbirth related causes.

That's roughly one woman every minute.

Why isn't this in newspaper headlines? Why has progress on Millennium Development Goal 5 on maternal mortality been uniquely stunted in Africa and other regions?

One answer to these questions is that simply put, the status of women and women's health is not a priority. On a global level, it's easy for those in high-income countries to feel removed from the issue. Indeed, 99% of maternal deaths occur in developing countries; over half in Africa [Fig 1].

(UNICEF, 2005)

Within these high mortality countries, gender norms surrounding women's status and decision-making power have serious implications. Data from Ethiopia's 2005 Demographic and Health Survey demonstrate a fascinating "dose-response" relationship between women's status and her likelihood of accessing either antenatal, delivery or postnatal care from a health professional [Fig 2].

(DHS, 2005)

Women who participated in more decisions overall, who gave more reasons for refusing sexual intercourse, and less reasons to justify wife beating, all had higher access to these key services. A woman's ability to seek care, and have received education on the recognition of danger signs, is crucial for reducing maternal mortality. This is related to the etiology of maternal deaths.

The majority of maternal deaths are preventable with interventions we've known for a long time. Deaths are also highly concentrated.

Causes of maternal mortality in Africa (Kinney et al, 2010).

Over half are from direct obstetric complications that occur around the time of childbirth (hemorrhage, hypertension, sepsis, and obstructed labor account for 64% of all maternal mortality) [Fig 3]. Correspondingly, over half of maternal mortality occurs within 24 hours of birth. Severe postpartum bleeding, the most common cause of death, can kill a healthy woman within two hours if not properly attended.

Thus, reducing maternal mortality means ensuring women receive the right care at the right time. The literature conceptualizes three main delays that can occur to undermine this:

  • Delay 1: Delay in problem recognition and care-seeking (note: lack of decision-making power to seek care is an issue here)
  • Delay 2: Delay in reaching a health facility (e.g. lack of transportation or financial means)
  • Delay 3: Delay in receiving prompt and appropriate care at the facility

In Oromiya region, Ethiopia, where my current research is focused, virtually all women (95.2%) deliver at home. Only 5% of births are delivered by a skilled health professional, and roughly a third had an untrained traditional birth attendant as the most qualified person present, with the vast majority (~60%) with a family member or relative as the most qualified person present. About 5% of births occur with nobody present. This is partly due to extreme health worker shortages. Ethiopia has1 physician per 22,198 people—and most of these are concentrated within Addis Ababa and other urban areas. In addition, many women do not perceive a need for trained birth attendants, nor the need for early initiation of antenatal care or other pregnancy-related care. And in fact, there are many substantial missed opportunities with these services. Only 26% of women who received antenatal care were informed of signs of pregnancy complications. Furthermore, only about half of women who received their first tetanus toxoid (TT) injection were instructed on the need for additional vaccinations. Consequently, only a third of Oromiyan women have sufficient doses of TT to confer protection at birth. Finally, even if women do deliver in a health facility, only 25% of these have a functioning delivery room, and even fewer hospitals are capable of providing comprehensive obstetric care (performance of caesarean sections and blood transfusions).

Thus, overcoming the three delays not only requires behavior change and education within communities, but also skilled health providers, adequate supplies and equipment, and integrated referral systems. In other words: social change and a functioning health system.

It's perhaps no surprise why reducing maternal mortality is so difficult. This leads to an interesting realization however, which is that maternal mortality indicators are a way to capture progress on the harder-to-measure realms of gender equity and health systems strengthening.

The implications of maternal deaths on child survival and societal well-being are vast and long-lasting. Let's keep maternal health a priority. Every minute counts.

Do happiness measurements mean anything?

Posted: 24 Feb 2011 01:00 PM PST

A study of people with locked-in syndrome suggests not; the vast majority of those surveyed reported being happy.

If a terminal condition that permanently keeps you from moving anything but your eyes can’t make you unhappy, I doubt we’re measuring anything of importance. What if we do believe these measurements are accurate reflections of happiness? Then things are more problematic: this is a worst-case scenario of the Hedonic Treadmill, and happiness isn’t the measure of well-being we should be targeting.

To put it bluntly, if people are just as happy after developing locked-in syndrome as they were without it, should we stop treating or trying to prevent it?

Buying Equity in a First Grader?

Posted: 23 Feb 2011 09:28 PM PST

As part of a competition I am involved in with a group of Harvard Kennedy School classmates, I’ve been enjoying exploring ways in which organizations can creatively implement investment strategies that offer both financial returns and social returns. This idea, impact investment, is an increasingly popular concept because it is a sustainable model for achieving social returns (in contrast to philanthropic or charitable models).  Impact investing is also often called triple bottom line or blended value.  As described by Paul Sullivan of the New York Times, impact investing is an "emerging hybrid of philanthropy and private equity."

Although mixing social good with high returns seems like a sexy investment concept, impact investing is still in its infancy.  It is estimated that current impact investments amount to approximately $50 billion and is projected to grow ten-fold by 2014, but still only barely reaching 1% of all managed assets.  The existing impact investing players, such as Acumen Fund, Root Capital, and Grassroots Business Fund, have proven models of success with high and sustainable returns.  Non-profits such as Endeavor and Ashoka have also played a valuable role in supporting individuals who want to develop and implement their own impact investment ideas.

Many of the innovative models revolve around doing debt financing of export commodities, or tying the loan to some sort of productive asset (like a sewing machine, drip irrigation system, etc) such that future earnings can be used as a substitute for traditional commercial collateral.  But one idea I’ve been thinking about recently is quite different — why not invest in human capital directly, reaping returns from potential future earnings as a substitute for collateral or traditional loan re-payment?  Here’s the basic idea:

The need: The marginal cost of annual school fees, for example the 500-rupee cost ($10)  in Jalandhar, Punjab, of entering 8th grade in public (government) schools, is often the limiting factor for a high-achieving student from continuing their education.  The child’s family does not have commercial education loan options available that don’t require burdensome repayment in an environment of uncertain returns to education. There is a significant under-investment in education in many parts of the developing world, for a whole host of reasons — the cost of enrollment, the opportunity cost of lost earnings, the low quality of schools, and the uncertain economic returns to education.

The concept: Imagine if you could tell a first-grader in that all of their education costs will be covered for as long as they wish to study — through grade 10, through college, through law school, PhD — whatever thay choose — in exchange for a fixed percentage of their post-graduation earnings.  Essentially, transfer the risk of returns to education investment to a third party.  A company would establish and manage a social investment fund that invests in the secondary education of a diverse pool of students.  The fund would commit to financing all education costs, in exchange for a fixed percentage of the student’s future earnings.  The students face little risk of overly burdensome debt payments, students receive a flexible source of financing needed to complete their education.  Rather than a loan, education costs are financed up front in exchange for a form of “human capital” collateral.  Payments are zero when income is zero, and payments are low when income is low.

Any existing players? Lumni is the sole player in this space right now that.  Lumni focuses only on financing college-level education, and the typical contract involves a 4% repayment of future earnings for 120 months following graduation.  Currently Lumni operates both for-profit and non-profit funds in Chile, Colombia, Mexico, and the U.S., with over $15 million in commitments from 100 investors, financing almost 2,000 students to date. Since Lumni profits more when students earn more, they also have active career coaching, job search help, and other professional development functions available to their students.  Their model is depicted in the diagram below:

Can this model truly work at the secondary or even primary school level? Lumni is paving the way in college education financing, but what about applying their same model to primary or secondary education in the developing world?Definitely a host of obstacles arise.  Would it be possible to truly predict the future earnings of a first grader in rural Mali?  How would you factor in mortality rates, or school drop-out likelihood?  Would the model of repayment through future earnings too closely resemble an indentured servitude arrangement and receive negative public feedback?  Would students have perverse incentives to avoid repayment, or take lower-paying jobs during the repayment period?  I’m interested in any and all feedback.

Thursday, February 24, 2011



Cold Chains and the Weakest Link

Posted: 23 Feb 2011 04:05 AM PST

Bangladesh is set to start a trial of a new cholera vaccine. This is good news, as cholera is a nasty bug and, as we recently witnessed, capable of heightening geopolitical tensions. As readers of this blog will note, I have taken the bold pro-vaccine position in the past (sorry Jen). However, vaccines are only as effective as their storage.

Basically, most vaccines have to stay cold so bacteria and other microbes don’t grow in them.  To stay cool (and safe) from the factory to the patient,  vaccines require an effective cold chain. Basically this means a supply chain capable of keeping the product cold every step of the way (the WHO has a cool, if rather technical, page devoted to cold chains).

Brrrr... it's cold in here. There must be supply chain management in the atmosphere.

This isn’t a problem in most of the U.S., where vaccines are shipped cold from the factory, in refrigerated containers, and kept cool at clinics and hospitals. But it may be a challenge in places in like Bangladesh where infrastructure is not as developed. The result is either spoiled vaccines or vaccines that don’t make it to rural, isolated populations.

The purpose of this post is not to disparage the new vaccine or the Bangladeshi health system (how could I criticize anything that combines two of my favorite global health strategies, vaccines and fighting diarrhea?!). Rather, it is to underscore the need for physical infrastructure to complement health system infrastructure. Such a relationship requires cooperation not only between public health and development folks, but also between governments, non-profits, and corporations capable of large scale civil engineering projects.

Wednesday, February 23, 2011



Too much aid? A little perspective…

Posted: 22 Feb 2011 02:37 PM PST

Just heard the Dambiso Moyo argument about aid, yet again. It sounds like a lot of money when we say $1 trillion has been spent on aid over the last 50 years, and ask what we have to show for it.

I’ll be the first to agree that a lot of aid is misspent. But to me, the argument that misspending and unintended consequences are the entire picture of why aid has not achieved its goals is without perspective. The amount of money spent on aid simply isn’t that much for the admittedly overly ambitious goals that have been set. That quoted figure means $20 billion a year. For 1-4 billion people in poverty. That’s really not that much in the scheme of things.

We spend about the same amount ($18 billion) on 77.5 pets yearly and that is only the cost of feeding them, and only the cost numbers for pets in the US. That doesn’t even include healthcare or training for pets. Yes, I am hugely at the risk of inviting arguments about purchasing power from Jason, but will endlessly find any arguments that don’t take into account the gross underspending on aid into account.