Traditional birth attendants and antenatal care in western Kenya

This paper examines the extent to which locally informed intermediaries can be exploited and provided with incentives to change the health-seeking behavior of pregnant women in rural Kenya. Despite Kenya being the largest and most advanced economy of East Africa, maternal and infant health outcomes are typical for those of other sub-Saharan countries, which lag significantly behind the developed world. There is evidence that antenatal care (ANC) is associated with improved maternal health outcomes, yet the majority of women in rural Kenya fail to meet recommendations for ANC timing and use, despite the availability of government subsidized healthcare. I examine whether a local intermediary, whose own incentives might oppose those of the government, can be co-opted to assist the government’s objective of increasing women’s ANC utilization.

I use a randomized controlled trial (RCT) to evaluate a program, which provides financial incentives for TBAs to encourage pregnant women to seek ANC at a formal medical facility. Competition between the TBAs and the formal clinics makes the effect of the program an empirical question, as there is no guarantee that the TBAs will respond to the incentive.

I find that living in a TBA treatment village increases the likelihood of attending the recommended number of visits by 20.7%. Women living in TBA treatment villages are 4.4 percentage points more likely to attend the recommended number of visits than women living in control villages, who attend the recommended number of visits 21.3% of the time. The results of this experiment, the first to study the extent to which TBAs can be motivated to encourage women to attend the prenatal clinic, could have important policy implications. The program’s success suggests that despite having a risk of losing clients, TBAs can be utilized as intermediaries of health facilities. Furthermore, finding that TBAs can induce pregnant women to attend ANC visits indicates that cultural norms, which discourage women going to ANC visits, can be overcome with relatively small financial incentives. By increasing the demand for formal maternal healthcare, TBAs’ encouragement of ANC attendance by women may help achieve improved maternal and child health outcomes.

That’s Georgetown’s Nisha Rai, in an excellent paper on the possibilities of integrating the use of traditional birth attendants with the formal healthcare system in Kenya (and developing countries in general). You can find a summary of the paper at the Bank’s Development Impact blog here.

If you know a policymaker in the health ministry of a developing country, please have them read this paper.

Garissa: #147notjustanumber

A vigil to remember and mourn the Kenyans who lost their lives in the Garissa terror attack.

Date: Tuesday, 7th April 2015
Time: 5pm-9pm.
Venue: Freedom Corner, Uhuru Park.

Bring flowers. Bring handwritten messages,we will have a board to pin them. Carry an umbrella. Dress Warmly,Black if possible. Park your car at All Saints Cathedral or the parking near Uhuru Park main dais. Security will be provided.

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A vigil to remember and mourn the Kenyans who lost their lives in the Garissa terror attack.

Date: Tuesday, 7th April 2015
Time: 5pm-9pm.
Venue: Freedom Corner, Uhuru Park.

Bring flowers. Bring handwritten messages,we will have a board to pin them. Carry an umbrella. Dress Warmly,Black if possible. Park your car at All Saints Cathedral or the parking near Uhuru Park main dais. Security will be provided.

Facebook page here.

Binyavanga Wainaina on remembering victims of the Garissa terror attack

Baragoi. Burnt Forest. Eastleigh. Kapedo. Kariobangi. Kasarani. Kiambaa. Kiambu. Kibera. Kisumu. Likoni. Mandera. Mpeketoni. Murang’a. Naivasha. Nakuru. Ruiru. Trans Mara. Westgate. And others.

Acts of terrorism in these places, whether perpetrated by criminals or the state, were quickly forgotten by Kenyans eager to move on and not deal with the uncomfortable truths around them. It is this reality that has motivated a section of Kenyans on twitter to post names and pictures of victims of the victims of last Thursday’s Garissa University terror attack under the hashtag #147notjustanumber.

Here’s Binyavanga Wainaina reiterating this point over at Africa is a Country:

We are not a nation if we can’t properly and fully memorialize each and every citizen we lose. I want to see the names ages and photographs of those who died in Mpeketoni. Those killed during PEV. Stories. Forgetting is not good. It is in these acts, our public commons reawaken. The politics of saying we are not ready to face ourselves, the fullness of our pain, is the same politics that allows us to ignore it when a Kenyan strips the institution they are given to run, strips it dry, dry, and returns like a zombie, a plastic rubber-band zombie in some new form, to govern somewhere else again.

I want a public again. I want some random church choir knocking on my door at easter to sing at my door. I want to see three million Nairobians flood the streets to cry, and sing, and hug because our children have been killed. I want to stop feeling that we live inside mostly the private. I want never to hear the word self-empowerment again.

…. I want thousands of names inscribed permanently in Uhuru Park. I want each name to have a story. I want to see the names. I want to see the names. Stories. I want to see the names. Photographs. It is not enough to send MPESA to Red Cross. I want to be a citizen of a nation that is not just Electoristan.

My heart is dull with pain, and I feel the pull to cover it all with that hard, now familiar Kenyan cynicism and move on, which really means suck the very remaining soul of it dry.

More on this here.

Kenya: Five Things About Al-Shabaab and the Somalia Question

Early Thursday morning militants from the al-Shabaab terror group stormed Garissa University College in Kenya and killed at least 147 students. The second worst terror attack in Kenya’s history lasted 13 hours and was made excruciatingly horrific by the fact that many of the victims remained in communication with their loved ones until the very last moments. Unbearable images of young students laying dead in their own pools of blood in classrooms will forever be etched in Kenyans’ memories. The attack echoed the September 21, 2013 Westgate Mall terror attack that killed 67 people. After Westgate many Somalia analysts insisted that such daring missions were the kicks of a dying horse, and cited successes by AMISOM and AFRICOM in taking back territory from al-Shabaab and decapitating the organization through drone strikes against it leadership.

Following Garissa, it might be time to reconsider this persistent narrative and overall Somalia policy in the Eastern African region. Here are my thoughts:

Screen Shot 2015-04-03 at 9.51.35 AM1. Regional powers do not want a powerful central government in Mogadishu: Since independence several governments in Somalia have espoused a dream of re-uniting all the Somali lands and peoples in eastern Africa (under “Greater Somalia,” see map). That includes parts of Ethiopia, Kenya, Djibouti, and more recently the breakaway regions of Somaliland and Puntland. A strong central government in Mogadishu would most certainly revive this old irredentist dream, despite the fact that the irredentist dreams of Somalia’s pre-Barre governments and the costly wars with Ethiopia (and proxy wars with Kenya as well thereafter) were the beginning of the end of stability in Somalia. Nairobi and Addis are acutely aware of this and that is part of the reason Kenya has for years maintained a policy of creating an autonomous buffer region in southern Somalia – Jubaland. The problem, however, is that a weak Mogadishu also means diffused coercive capacity and inability to fight off breakaway clans, militias, and terror groups like al-Shabaab.

The situation is complicated by the fact that Ethiopia and Kenya do not see eye to eye on the question of Jubaland. Addis Ababa is worried that a government in Jubaland dominated by the Ogaden clan could potentially empower the Ogaden National Liberation Front (ONLF), a separatist Somali insurgent group it has fought in its southeastern Ogaden Region.

2. The African Union and its regional partners do not have a coherent game plan for Somalia: To a large extent, African governments fighting under AMISOM are merely carrying water for Western governments fighting jihadist elements in Somalia. The West pays and provides material and tactical support; and the West calls the shots. Ethiopia and Kenya have some room to maneuver, but overall policy is driven by AFRICOM and the Europeans. The lack of local ownership means that African troops, especially the Kenyan and Ugandan contingents, are in the fight primarily for the money. Kenyan generals are making money selling charcoal and smuggling sugar (the UN estimates that al-Shabaab gets between US $38-56m annually from taxing the charcoal trade). The Ugandans are making money with private security contracts dished out to firms with close ties to Museveni’s brother. Only the Ethiopians appear to have a clear policy, on top of the general international goal of neutralizing al-Shabaab so that they do not attack Western targets.

What kind of settlement does Kenya (and Ethiopia) want to see in Somalia? (See above). What does the West want? What do Somalis want? Are these goals compatible in the long run?

3. The internationalization of the al-Shabaab menace is a problem: Western assistance in fighting al-Shabaab and stabilizing Somalia is obviously a good thing. But it should never have come at the cost of unnecessary internationalization of the conflict. Al-Shabaab has been able to get extra-Somalia assistance partly because it fashions itself as part of the global jihad against the kafir West and their African allies. Internationalization of the conflict has also allowed it to come up with an ideology that has enabled it to somehow overcome Somalia’s infamous clannish fractionalization (although elements of this still persist within the organization). Localizing the conflict would dent the group’s global appeal while at the same time providing opportunities for local solutions, including a non-military settlement. AMISOM and the West cannot simply bomb the group out of existence.

4. Kenya is the weakest link in the fight against al-Shabaab: Of the three key countries engaged in Somalia (Ethiopia, Kenya, Uganda), Kenya is the least militarized. It is also, perhaps, the least disciplined. According to the UN, Kenyan troops are engaging in illegal activities that are filling the coffers of al-Shabaab militants (charcoal worth at least $250 million was shipped out of Somalia in the last two years). Back home, Nairobi has allowed its Somalia policy to be captured by a section of Somali elites that have other agendas at variance with overall national policy. The Kenya Defense Force (KDF) risks becoming a mere pawn in the clannish struggles that straddle the Kenya-Somalia border. It is high time Nairobi reconsidered its Somalia policy with a view of decoupling it from the sectional fights in Northeastern Province. The first step should be to make the border with Somalia real by fixing customs and border patrol agencies; and by reining in sections of Somali elites who continue to engage in costly fights at the expense of ordinary wananchi. The government should adopt a strict policy of not taking sides in these fights, and strictly enforce this policy at the County level.

5. Kenya will continue to be the weakest link in the fight against al-Shabaab: Of the countries in Somalia Kenya is the only democracy with a government that is nominally accountable to its population and an armed force with a civilian leadership. This means that:

(i) Generals can run rings around State House and its securocrats: Unlike their counterparts in Uganda and Ethiopia, the Kenyan generals do not have incentives to internalize the costs of the war in Somalia. The cost is mostly borne by the civilian leadership. They are therefore likely to suggest policies that primarily benefit the institution of the military, which at times may not be in the best interest of the nation. And the civilian leadership, lacking expertise in military affairs, is likely to defer to the men in uniform. The result is makaa-sukari and other glaring failures.

(ii) Kenyan internal security policies are subject to politicization: With every al-Shabaab attack (so far more than 360 people have been killed) Kenyans have wondered why Ethiopia, which is also in Somalia and has a large Somali population, has remained relatively safe. My guess is that Ethiopia has done better in thwarting attacks because it has a coherent domestic security policy backed by unchecked coercion and surveillance of potential points of al-Shabaab entry among its Somali population.

Now, Kenya should not emulate Ethiopia’s heavy-handed tactics. Instead, focus should be on an honest assessment of how internal security policies in Mandera, Garissa, Wajir, Kwale, Kilifi, Mombasa, Nairobi, and elsewhere are playing into the hands of al-Shabaab. What is the best way to secure the “front-line” counties that border Somalia? What is the role of local leaders in ensuring that local cleavages and conflicts are not exploited by al-Shabaab? How should the security sector (Police and KDF) be reformed to align its goals with the national interest? What is the overarching goal of the KDF in Somalia and how long will it take to achieve that goal? How is the government counteracting domestic radicalization and recruitment of young Kenyan men and women by al-Shabaab?

These questions do not have easy answers. But Kenyans must try. The reflexive use of curfews and emergency laws, and the blunt collective victimization of communities suspected to be al-Shabaab sympathizers will not work.

I do not envy President Uhuru Kenyatta: Withdrawing from Somalia will not secure the homeland. Staying the course will likely not yield desired results given the rot in KDF and the internal politics of northeastern Kenya. Reforming the police and overall security apparatus comes with enormous political costs. A recent shake up of security chiefs and rumors of an impending cabinet reshuffle are signs that Kenyatta has realized the enormity of the insecurity situation in the country (and overall government ineffectiveness due to corruption). But will Kenyans be patient and give him the benefit of the doubt? Will the president be able to channel his laudable nationalist instincts in galvanizing the nation in the face of seemingly insurmountable security threats and ever more corrupt government officials?

Meanwhile 2017 is approaching fast, and if the situation doesn’t change Mr. Kenyatta might not be able to shrug off the title of “Goodluck Jonathan of the East.”

For the sake of Kenyan lives and the Jamuhuri, nakutakia kila la heri Bwana Rais.

A total of 19 incumbent African leaders have now lost elections

And as my adviser likes to remind me, the trend was started by Somalia in 1967.

Source: Mail & Guardian

Source: Mail & Guardian

More on this here.

H/T Onyango-Obbo.

How Goodluck Jonathan Lost the Nigerian Election

The Guardian reports:

Previous Nigerian presidents were too cynical to expose themselves to the unpredictable risk of a fair election. The election victories of PDP presidents during the past 16 years have been partially “assisted” by electoral malpractice. That changed when Jonathan nominated Professor Attahiru Jega as the chairman of the Independent National Electoral Commission (Inec) in 2010. Jega vowed to reform Nigeria’s electoral process to ensure free and fair elections.

The former university lecturer exuded calm authority and integrity. He has painstakingly prepared for the task over the past four years by studying the rigging methods used in previous elections, implementing an elaborate system of voter registration, training thousands of electoral staff, and introducing biometric readers to identify voters by reading their thumbprint.

Jonathan created the environment for the emergence of these changes and gave Jega the freedom and authority to conduct reforms that led to a credible election. But by giving Jega a free hand to play fair, he allowed Jega to craft the weapons that were used to oust him from power.

If Nigeria stays on the path towards greater democratic consolidation, Jonathan’s “accidental presidency” will forever remain as one of the variables in the process.

Nigerian President Goodluck Jonathan’s Concession Speech

I thank you all for turning out en-masse for the March 28 General Elections.

I promised the country free and fair elections. I have kept my word. I have also expanded the space for Nigerians to participate in the democratic process. That is one legacy I will like to see endure.

Although some people have expressed mixed feelings about the results announced by the Independent National Electoral Commission (INEC), I urge those who may feel aggrieved to follow due process based on our constitution and our electoral laws, in seeking redress.

As I have always affirmed, nobody’s ambition is worth the blood of any Nigerian. The unity, stability and progress of our dear country is more important than anything else.

I congratulate all Nigerians for successfully going through the process of the March 28th General Elections with the commendable enthusiasm and commitment that was demonstrated nationwide.

I also commend the Security Services for their role in ensuring that the elections were mostly peaceful and violence-free.

To my colleagues in the PDP, I thank you for your support. Today, the PDP should be celebrating rather than mourning. We have established a legacy of democratic freedom, transparency, economic growth and free and fair elections.

For the past 16 years, we have steered the country away from ethnic and regional politics. We created a Pan-Nigerian political party and brought home to our people the realities of economic development and social transformation.

Through patriotism and diligence, we have built the biggest and most patriotic party in Nigerian history. We must stand together as a party and look to the future with renewed optimism.

I thank all Nigerians once again for the great opportunity I was given to lead this country and assure you that I will continue to do my best at the helm of national affairs until the end of my tenure.

I have conveyed my personal best wishes to General Muhammadu Buhari.

May God Almighty continue to bless the Federal Republic of Nigeria.

Source: The Daily Post

A call for “politically robust” evaluation designs

Heather Lanthorn cites Gary King et al. on the need for ‘politically robust’ experimental designs for public policy evaluation:

scholars need to remember that responsive political behavior by political elites is an integral and essential feature of democratic political systems and should not be treated with disdain or as an inconvenience. instead, the reality of democratic politics needs to be built into evaluation designs from the start — or else researchers risk their plans being doomed to an unpleasant demise. thus, although not always fully recognized, all public policy evaluations are projects in both political science and political science.

The point here is that what pleases journal reviewers is seldom useful for policymakers.

H/T Brett

UK passes bill to honour pledge of 0.7% foreign aid target, and a note on SDGs

The Guardian reports:

The international development bill passed its third reading in the House of Lords on Monday and will now receive royal assent. Britain met the 0.7% target for the first time last year when it spent £11.4bn – or 0.72% of its GNI – on overseas aid.

The 0.7% commitment was established by the UN in 1970. In 2013, only five other countries – Sweden, Norway, Luxembourg, Denmark and the United Arab Emirates – had met or exceeded the 0.7% aid spending target. The Netherlands had consistently met the target, but fell short in 2013.

All well and good.

The question, though, is what proportion of the 0.7% will finance various jobs programs for UK (and other Western) nationals working in the global development industrial complex (or in other sectors that benefit from tied aid) versus actually going to poverty alleviation in the developing world.

Source: Daily Nation

Source: Daily Nation

And speaking of the global development industry, here’s a nice quote from the Economist newspaper on SDGs:

Developing countries seem to think that the more goals there are, the more aid money they will receive. They are wrong. The SDGs are unfeasibly expensive. Meeting them would cost $2 trillion-3 trillion a year of public and private money over 15 years. That is roughly 15% of annual global savings, or 4% of world GDP. At the moment, Western governments promise to provide 0.7% of GDP in aid, and in fact stump up only about a third of that. Planning to spend many times the amount that countries fail to give today is pure fantasy.

The backers of the SDGs concede from the outset that not all countries will meet all the targets—an admission that robs the goals of the power to shame. The MDGs at least identified priorities and chivvied along countries that failed to live up to their promises; a set of 169 commandments means, in practice, no priorities at all.

A set of 169 commandments also means fundraising opportunities for everyones’ pet issue. But it also means extra meetings, workshop, and clueless tied aid expats consultants for developing country Civil Servants to deal with; and little time for the boring things that actually contribute to sustainable improvement of human welfare.