The United Nations’ sixth sustainable development goal (SDG6) presses for equitable access to sanitation and hygiene for all by the year 2030. Yet, in 2022, 3.5 billion people lacked access to safely managed sanitation, confirming that the world is alarmingly off-track in reaching this target. The world would have to accelerate its efforts, and work up to six times faster to succeed.

Thus, there is an urgent call to funders, government agencies, and non-profit and civil society organizations to not only intensify current interventions but to remain constantly curious for alternative solutions for improved sanitation access. 

One of the main barriers to accessible quality sanitation is its high cost. When households do not have a big enough lump sum to build a complete and safe toilet, they often turn to lower-cost alternatives, including less safe latrines, shared latrines, and open defecation.

Financial interventions are therefore a popular method of increasing sanitation access, and are an alternative to other common interventions, such as behavior change programs (e.g., Community-Led Total Sanitation, which discourages open defecation) and market development (e.g., tax incentives to encourage enterprises to service rural areas).

Sanitation finance interventions aim to either make sanitation facilities affordable or provide financial incentives to encourage safer sanitation. In fact, multiple studies have found that interventions that provide monetary investments, subsidies, or sanitation infrastructure tend to result in more latrine coverage, access, and usage than either Community-Led Total Sanitation or education-only interventions.

Subsidies for sanitation

Early financing approaches in the 1980s often fully subsidized the construction of low-cost sanitation facilities. However, these approaches struggled to remain sustainable, due to the lack of funding for ongoing maintenance, difficulties identifying households in need, perceptions of corruption, the inability to meet user preferences, and the high cost of bringing fully subsidized infrastructure to scale. 

Given the limitations of full subsidies, many interventions now partially subsidize sanitation solutions, using a variety of mechanisms including: cash, vouchers, tax credits, or the provision of facilities themselves. Subsidies can be provided directly to households or to local governments, utility companies, or small-scale operators with the goal of reducing costs for households.

Sometimes, subsidies are provided as rebates or are output-based, meaning that they are only given after certain outcomes are met, such as the active use of latrines. Although funds are typically provided by external organizations, sometimes the funds from purchases by wealthier households are used to subsidize poorer households’ purchases.

Subsidies have successfully increased access to sanitation. For example, International Development Enterprises’ (iDE) Water for Women-funded WASH-SUP2 project and the EU’s GREEN Project found that offering 50% subsidies to households in rural Cambodia increased the likelihood that the household would purchase a latrine by 31%.

Microfinance for sanitation

Besides subsidies, nonprofit organizations have recently started to offer private investments to households to finance sanitation facilities. Households later repay the loan, as well as interest, to the lender. This approach is modeled on microfinance programs, in which Microfinance Institutions administer small loans to support entrepreneurial activities.

In the context of sanitation, microfinance programs have shown to be effective. In Cambodia, researchers from iDE found that households were four times as likely to purchase a latrine with a microloan than with a cash payment on delivery. However, research has also found that although households want to take out a loan to finance sanitation facilities, many (especially poor households) do not have access to microfinancing.

Community-led loans for sanitation

Despite their success in achieving increased latrine coverage, one limitation of sanitation microfinancing is that it often relies on ongoing external funding, which can come with high interest rates and short repayment periods. Community-led development techniques may provide another direction for sanitation microfinancing.

In 2019 and 2020, three Philippine Community-Based Organizations (CBOs), supported by Outreach International (OI) and Outreach Philippines Inc., implemented community-led sanitation loan projects. With community-designed and developed project proposals, they requested funds from OI to build sanitation units for 121 families.

However, instead of providing families with all the funds they needed, the CBOs subsidized 60% of the building costs, with project participants paying the remaining 40% back to the CBO over five years at a 3% interest rate.

The three CBOs have since constructed 118 latrines serving over 722 individuals. As of December 2023, participants have repaid 344,024.00 Philippine Pesos (₱)(US$6,254.98), or 56% of the expected repayment sum.

Using this financing structure, CBOs decided how to administer the loans and structure the repayment. One benefit of this autonomy is that CBOs could choose not only to fund the construction of new latrines, but also their repair and maintenance. The flexibility also allows CBOs to provide grace to households in extenuating circumstances, for example, they paused payments for six months in 2020 during the initial spread of COVID-19. Additionally, one CBO chose to collect payments once a year, while the other two CBOs collected it once a month.

In addition to flexibility in loan structure, community-led sanitation microfinancing allows repayments, as well as any interest accrued, to reside within the community group to spend on other concerns. Thus far, the CBOs have used this recouped capital to provide electricity to their community center and establish broader microloan programs, among other projects. Operating on shorter 2-to-3 month timelines, these loans provide smaller sums of ₱1,000 to ₱2,500 (US$18.18 to US$45.45). The CBOs have supported around 117 households across the three communities and accumulated interest worth ₱84,907 (US$1,543.76).

Community involvement

The importance of involving communities in the development of financing programs is further illustrated by the Sustainable Sanitation and Hygiene for All (SSH4A) program. Since 2008, when the development organization SNV began implementing the program, SSH4A has operated in 135 districts in 18 countries in Asia and Africa. One aspect of SSH4A includes finance mechanisms. In Tanzania, for example, SNV established a revolving fund for entrepreneurs to increase latrine production. Although initially successful, entrepreneurs chose to stop accessing the fund out of concern over defaulting on the loans. This shows how community participation can help ensure users’ concerns are addressed.

Reaching sanitation equity by 2030 requires global investment. Given that affordability is the main barrier to quality sanitation, interventions that alleviate the cost burden for households are an important component of plans to reach this target. Interventions must support sustainable access to sanitation, in order to maintain any gains made over time.

One way to ensure that our sanitation targets are sustainable is to invest in solutions that are authentically community-led. We have seen the benefits of community-led approaches in both our own research in the Philippines and that of others. We therefore hope that more attention is focused on locally driven solutions to sanitation challenges. Scaling these can lead to better outcomes than one-size-fits-all solutions.

The post Safe sanitation: global access is essential, but how do households pay for it? appeared first on Globaldev Blog.

The annual marking of World Malaria Day on 25^th April serves as a reminder that thousands of people still die each year from a disease that is both preventable and curable. In addition, the financial burden of the disease is estimated to push over 100 million people globally below the poverty line every year as a result of out-of-pocket health expenditure – which is healthcare costs that they must cover themselves.

The Kenyan government has introduced several initiatives designed to ensure that everyone has access to quality health services without suffering financial hardship. The Universal Health Coverage (UHC) programme is the most recent of these initiatives. It had been piloted in four out of 47 counties by 2022 but has not been rolled out nationally due to resource constraints. The National Health Insurance Fund (NHIF), which is in charge of implementing the UHC, offers rudimental financial security. However, the fund only offers limited financial protection, with the poor, those over 60 years old and patients with chronic illnesses having the least access.

Malaria is also a serious impediment to national economic growth. This article provides a clearer sense of the scale of the disease and its true costs to society – costs that strengthen the case for vaccines and other preventative measures. In turn, these measures will not only save lives and improve well-being, but will also prevent the economic damage inflicted by malaria on households and society. The insights in this article can assist policymakers in developing policy measures such as reforms in NHIF, coupled with carrying out research, especially in the area of malaria vaccination.

Malaria prevalence in Kenya

The World Health Organization states that nearly every minute a child dies from malaria in Africa. In Kenya, approximately 70% of Kenya’s population is at risk for malaria. According to the Kenya Economic Survey 2023, malaria accounted for the second highest disease caseload at 11.7% in 2022. Annual household surveys show a reduction in malaria parasite prevalence from 8% in 2015 to 5.6% in 2020. Among other factors, the World Health Organization attributes the downward trend in malaria prevalence to the introduction of the malaria vaccine in 2019. However, the declining rate has slowed down since 2017. This trend highlights the need for alternative sustainable preventable measures in order to reduce and eliminate malaria prevalence in Kenya.

The costs of malaria in Kenya: indirect and direct

Both individuals and the economy as a whole suffer direct and indirect expenses as a result of malaria. Direct costs refer to expenses incurred due to medically managing the disease, while indirect costs are expenses that are incurred due to other losses. These costs range from lost wages, through to lost productivity and expenditures including the need for childcare that would not otherwise be incurred.

A study on Kenya estimated that the direct economic cost of malaria to both government and households in children as young as five years old was approximately US$251 million in 2009. The total direct costs of malaria account for 43.5% of the total estimated cost while indirect costs, including deaths, make up 56.5% of total costs. Death contributes to indirect costs because the household and society loses the future lifetime earnings of the individual.

The direct health care cost results in higher out-of-pocket expenditure, especially where public service delivery fails. This expenditure eats into households’ disposable income, that they may have otherwise spent on products and services that better support the economy.

Researchers have estimated the indirect cost of malaria, where a 10% rise in malaria prevalence lowers monthly individual wages by 3.3% to 3.8%. In Kenya, malaria results in an annual loss of over 170 million working days. According to economists, malaria causes a “growth penalty” of up to 1.3% annually in some African nations. This loss over time, results in significant GDP disparities between countries with and without malaria. In the education sector, malaria is estimated to contribute from between 5% to 8% of all absenteeism among school-going children. This is equivalent to 50% of all preventable absenteeism.

Conclusion

It is critical that the methods aimed at eliminating malaria are expedited given its significant economic impact. It is evident that the majority of Kenyans cannot afford to pay out-of-pocket. The annual increase in funding for the health sector should be supported by data and prioritized towards access, uptake and use of malaria preventive interventions to reduce the socioeconomic burden of malaria. The impact of malaria vaccination cannot be understated and the national rollout of the malaria vaccine should be targeted to increase coverage from eight to all 47 counties.

The post The true social and economic costs of malaria in Kenya appeared first on Globaldev Blog.

Over 30 years have passed since HIV/AIDS emerged as one of the most significant global health threats. In that time, scientific advances in basic knowledge of the virus and treatment have made this once deadly condition a chronic one. While people receiving antiretroviral therapies (ARTs) can now expect to live longer lives, socio-economic barriers and geographical inequities make access to ARTs one of the biggest struggles for HIV care in low- and middle-income countries.

The United Nations ’90-90-90’ goals for combating HIV called for the following by 2020: 90% of people living with HIV (PLWH) know their status, 90% of people who know their status are receiving treatment, and 90% of people on treatment have a suppressed viral load. These ambitious targets have since been updated to the ’95-95-95’ goals by 2030.

A key focus lies on sub-Saharan Africa: while the region is home to only 12% of the global population, it accounts for over 70% of the global burden of HIV infections.

Historically, each country has deployed a different healthcare strategy for targeting HIV. In 2015, the World Health Organization (WHO) adopted a ‘treat-all’ policy, whereby all ‘people living with HIV’ (PLWH) should be initiated on ARTs regardless of immunological or clinical status. This policy has been implemented to varying degrees in sub-Saharan Africa.

Mozambique, where 2.2 million people are currently living with HIV, has one of the highest proportions of deaths attributable to HIV/AIDS in the region. HIV prevalence is higher among women (15%) than men (9.5%), with gender inequality and gender-based violence contributing to these differences.

There has been substantial progress in the treatment and prevention of HIV in Mozambique, particularly in preventing mother-to-child transmissions, yielding more than 90% ART coverage for pregnant women and reducing the vertical transmission rate to less than 12% in 2021.

But anthropogenic and natural events from 2013 have cast doubt on whether targets of ending HIV can be achieved by 2030. Indeed, Mozambique has experienced a variety of internal and external threats that have resulted in increased pressures on an already fragile healthcare system, particularly for HIV care.

Natural disasters

According to the United Nations’ Global Assessment Report on Disaster Risk Reduction, Mozambique is Africa’s third most vulnerable country to disaster risks. The country suffers from tropical cyclones, floods, and droughts that have intensified in the last decade. In 2013, floods displaced more than 180,000 people in the Gaza province, and in 2015, an additional 56,000 people were forced to resettle in the Zambézia province.

More recently, in 2019, cyclones Idai and Kenneth devastated Beira, the second largest city, and the Nampula and Zambézia provinces. It is estimated that 1.85 million people were affected, 400,000 were internally displaced, and 19 health facilities were entirely or partially destroyed.

Humanitarian disasters can be devastating for PLWH. Inability to adhere to ARTs, malnutrition, opportunistic infections, and disease outbreaks can increase morbidity and mortality for this population. The loss of livelihood associated with disasters can also pressurize women and girls into transactional sex, increasing their risk of HIV exposure.

An estimated 350,000 PLWH lived in the regions affected by the 2019 cyclones, subsequently finding themselves cut off from primary healthcare services and incapable of accessing ARTs. Following the devastation, the Ministry of Health conducted a rapid needs assessment in affected areas. Results show that patients missed appointments and ran out of ARTs, in addition to records being destroyed and stocks of primarily pediatric formula and second-line ART drugs being disrupted.

Rapid mobilization of resources in Mozambique still took place. A study describes the successful reintroduction of previously implemented HIV services, which included a three-fold increase in the number of healthcare volunteers after the hurricane, and thus led to the creation of a new electronic data collection tool to avoid data loss and improve monitoring.

At the same time, NGOs operated in accommodation centers, where fixed health/HIV teams were deployed to provide testing and ART services for those who tested positive. Mobile clinics and community health workers were sent to hard-to-reach areas to locate HIV clients lost to follow-up.

While delays were reported, patients expressed positive opinions on the government’s response. PLWH and clinicians pointed out that the introduction of differentiated service delivery (DSD) in 2018 – a client-centered approach that simplifies and adapts HIV services to reflect patients‘ preferences, expectations, and needs – was very helpful in avoiding treatment interruptions. DSD included multi-month delivery (MMD) of ARTs of up to three months for stable HIV patients, community ART groups, and family-centered approaches.

Even if a comprehensive picture of the effect of cyclones on HIV care is not available, it is undeniable that consecutive disasters have left Mozambique’s healthcare system fragile. With the help of international funders and institutions, the government has safeguarded the continuation of flexible services for HIV care, showing the importance of DSD for patients and clinicians alike.

But despite high numbers of HIV infections, the first reports on cyclones Idai and Kenneth published by the WHO in 2019 did not refer to a potential post-displacement rise in HIV risks. Future disaster preparedness plans should highlight the importance of putting HIV services at the forefront, particularly since HIV care has not previously been included in Mozambique’s disaster and emergency management structures.

Covid-19

Another event that has hindered HIV service delivery is the Covid-19 pandemic. PLWH are exponentially susceptible to Covid-19 infections and subsequent complications, while also facing difficulty in accessing vaccines. Hence, HIV-endemic countries such as Mozambique have had to deal with mitigating exposure to Covid-19 for PLWH while focusing on efforts to provide much-needed HIV care. The WHO’s updated guidelines for HIV services during Covid-19 stressed the importance of DSD by adapting health services to meet PLWH needs.

Mozambique implemented swift policy changes to allow optimal ART delivery for those under treatment during the pandemic. Policy changes included eligibility for DSD after three months of ARTs, dropping eligibility criteria for suppressed viral load, including previously excluded groups such as pregnant and breastfeeding women, and expanding MMD by up to six months.

Mozambique has also increased community-based ART delivery efforts during the pandemic, with client-led group models supplying uninterrupted socially distanced ART delivery. Furthermore, MMD of ARTs has been integrated with other medicine dispensing programs.

While research is limited on the impact of Covid-19 on HIV services in Mozambique, early commentaries suggested disastrous consequences. But these negative predictions seem not to have materialized. Indeed, a study focusing on HIV program delivery shows positive trends in the number of people receiving ARTs (+12.6%) and the percentage of people with viral suppression (+7.6%) between January and December 2020.

Another report finds that Covid-19 had a transient negative effect on HIV services from January–March 2020 to April–June 2020, followed by rapid recovery and positive trends in HIV testing (+12.5%), people newly initiated in ARTs (21.2%), and the number of people on ARTs (9.9%) from April–June 2020 to July–September 2020.

These studies point to the expansion of DSD models and other innovations, including MMD of medications and ART distribution in the community, as the main reason for successful HIV outcomes. But while DSD has been identified as a vital strategy in HIV healthcare delivery, it is still unclear which models are most relevant in different settings and populations, due to a lack of evaluation and cost effectiveness studies.

While all these studies were mainly donor-based, no data are available on the country’s overall situation in government-funded HIV programs. Indeed, recent reports assessing the whole southern African region indicate a decreased number of tests and an increased percentage of positive HIV tests between 2019 and 2020, as well as decreased ART coverage. Studies are needed to follow up on long-term trends in HIV infection due to lockdowns, and to assess the overall HIV landscape after Covid-19 in Mozambique.

Conflict and Terrorism

The situation in the northern province of Cabo Delgado is one of the most volatile in Mozambique. In October 2017, an intense conflict erupted in the region, which has forced nearly 1 million people to flee the region. As a result of the ongoing conflict linked to an Islamic State (ISIS)-affiliated armed group, Al-Shabab, one-third of health facilities in the northern province were damaged or forced to close, leaving the population with limited health coverage.  

The province has an estimated HIV prevalence of 11.4% among adults. Disruptions to healthcare have uniquely affected PLWH. As a result of the devastation and closure of health facilities in the northern province, more than 2.2 million PLWH are not receiving any treatment. With women and girls at risk of multiple forms of gender-based violence in displacement settings and the increased propensity to seek transactional sex for survival, there is a heightened risk of HIV infections.

The government and NGOs have invested in mobile health services to ensure supply chain continuity for critical HIV commodities, ‘one-stop service delivery’ points for sexual and reproductive health, and gender-based violence services. Community health workers have also been trained to deliver messages on HIV/TB prevention and treatment and sensitization messages to reduce the stigma surrounding HIV.

Thus far, no studies have emerged on how these mitigations have helped PLWH and on the development of HIV in regions affected by conflict. NGOs have sounded the alarm that a resurgence in violence in the northern province requires an enormous humanitarian response that is currently lacking, as well as stressing the importance of HIV monitoring.

Conclusions

UNAIDS recently warned that HIV global targets will be missed if progress falters in the fight against AIDS. At the 7th Global Fund replenishment, governments renewed their commitments to fight the three biggest killers – tuberculosis, malaria, and HIV – by raising $14.25 billion, the largest amount ever raised for the fund.

The lack of continuity of care for people living with HIV during disasters and crises has deleterious consequences, including worsening patients’ clinical conditions, halting clinical progress, and causing resistance to ARTs. Disruptors observed in global crises can be mitigated by training in preparedness, rapid mobilization of local services, and immediate reinforcement of existing structures.

Such actions have been seen during natural disasters, Covid-19, and conflict in Mozambique. They not only directly prevented complete disruptions in HIV care for patients, but also assisted in mitigating the disaster’s effects on the general health and wellbeing of the community. Expanding DSD, including HIV mitigation strategies as a pillar for disaster and emergency management, and monitoring HIV trends will be fundamental for the next steps in the country’s fight against HIV/AIDS.

The post HIV care in Mozambique after conflict, Covid-19 and natural disasters appeared first on Globaldev Blog.

According to the World Health Organization, one in eight people or 970 million people around the world were living with a mental disorder in 2019. This number rose dramatically during the first year of the Covid-19 pandemic with an increase of 25% in anxiety and depression. Yet relatively little attention is given by development practitioners to mental health. At GlobalDev, we decided to highlight the interactions of mental health and development with a series of columns on the topic. Here is what we have learned so far. 

As Marc Rockmore and colleagues put it in their piece Mental health challenges of development and the environment, “mental health disorders are a first order development concern.” Not only does mental illness lead to direct costs in general health, but it has also been shown that mental health disorders have an important impact on careers, labor markets, and earnings. 

The authors explain that early life exposure to substantial shocks are not an exclusive cause of adult mental health problems. In fact, research finds that events such as income fluctuations and climatic variations can also be a cause of mental disorders.

Mental health challenges of development and the environment

Similarly, in his article on Mental health and the Sustainable Development Goals, Crick Lund explains that depression, anxiety, post-traumatic stress disorder, and schizophrenia are socially determined and hence treating them without tackling the environment that causes them could be counter-productive. As he puts it, “why treat people only to send them back to the circumstances that made them sick in the first place?”

Lund calls for an integrated development agenda using mental health both as a means and a goal of international development. He illustrates this need as follows: “reduction of gender-based violence, cash transfers, housing improvements, improved education, and early responses to humanitarian emergencies all carry mental health benefits – and their impact and sustainability could potentially be enhanced with integrated mental health interventions.”

Mental health and the Sustainable Development Goals

Another major factor affecting mental health is exposure to conflict. In her article Evidence-based mental health interventions in post-conflict countries, Theresa Betancourt suggests using education and employment training programs as potential delivery platforms for mental health services. 

As she explains, one in six children live in countries affected by conflict – which can have grave consequences for their mental health, increasing the risk of depression, anxiety, and post-traumatic disorders. In addition, while conflict deepens the need for healthcare, it also wrecks healthcare infrastructure, leaving a majority of individuals suffering from mental disorders untreated. Hence, “integration of evidence-based mental health interventions into innovative delivery platforms such as youth educational, employment and entrepreneurship programs may be key to supporting young people’s daily functioning and interpersonal relationship.”

Evidence-based mental health interventions in post-conflict countries

We cannot mention mental health without talking about the pandemic. As mentioned earlier, during the first year of the pandemic, there was a 25% increase in cases of anxiety and depression. 

In their article, Mental health costs of lockdowns: evidence from curfews in Turkey, Onur Altindag and colleagues show that in the short run, restricted mobility led to a considerable decline in mental health through social and physical isolation, especially among the most vulnerable populations. 

Mental health costs of lockdowns: evidence from curfews in Turkey

The decline in mental health during the pandemic was also mentioned in several of our articles tackling food insecurity during Covid-19, resilience through the pandemic and the ways in which southern think-tanks have responded to the challenges linked to this period. 

Are you a researcher interested in writing about mental health and development for GlobalDev? Read our one pager and style guide and send us your proposal at editors.globaldevblog@gdn.int.

The post GlobalDev on Mental Health appeared first on Globaldev Blog.

Employment gives mothers the resources to strengthen their households’ food security, which in turn improves the likelihood of breastfeeding. Yet work demands after maternity leave tend to limit the attention that mothers can give to their infants. This column explores whether there is a ‘win/win’ scenario, potentially supported by legislation, which can promote a mother’s return to work and her ability to continue breastfeeding.

Breastfeeding has enormous benefits for both the mother and the child. For the child, breast milk contains nutrients with the required composition to meet the changing physiological needs of a growing infant. In addition, it contains antibodies that boost immunity and fatty acids that boost brain development. For the mother, sustained breastfeeding has been linked to reduced risks of ovarian and breast cancer, reduced post-birth bleeding, and reduced risks of type 2 diabetes and hypertension.

Is Kenya making progress in promoting breastfeeding?

Positive messages about breastfeeding seem to be appreciated by mothers in Kenya. In 2014, for example, at least six out of ten women in the country were breastfeeding their children exclusively for the first six months, while one in two women continued breastfeeding until their children were two years old. This means that over half of the children in Kenya (53%) are gaining the full benefit of breastfeeding, compared with the World Health Assembly’s target of 90%.

With all its benefits, why aren’t all mothers breastfeeding exclusively and why aren’t they breastfeeding for up to two years?

How does the transition to work affect breastfeeding?

Research shows that a mother’s working patterns significantly influence how long and how frequently she breastfeeds. In Kenya, working mothers generally have lower breastfeeding rates and shorter durations of breastfeeding compared with unemployed mothers. The main reason cited for this is the challenge of balancing breastfeeding demands and work.

In a qualitative study of women of higher socio-economic status in Kenya, mothers indicated that returning to work after maternity leave was the main challenge to continued breastfeeding. They reported insufficient workplace support, such as spaces for expressing breast milk and lack of facilities for storing it.

But research among women of lower socio-economic status indicates that reduced household income led to reduced household food security, which in turn led to reduced breastfeeding duration and frequency.

This presents a dilemma. Mothers need employment for resources to support their households’ food security, which in turn improves the likelihood of breastfeeding. But at the same time, work demands limit the attention a mother can give to her breastfeeding infant.

Is there a win-win scenario that can promote a mother’s return to work and her decision to continue breastfeeding?

What legal provisions has Kenya made to support breastfeeding working mothers?

The government of Kenya has sought to address this challenge through the Breastfeeding Mothers Bill (no. 74 of 2019). The bill explicitly prescribes minimum standards with regard to space, equipment, and time that an employer should designate for breastfeeding mothers, as well as the penalties for non-compliance regardless of the size of the organization.

The bill builds on the Health Act (no. 21 of 2017), which legally requires employers to provide sufficient time and a lactation station – a private space where a mother can express and store breast milk. The bill goes further than the Health Act by explicitly prescribing conditions required to make up a lactation center.

For example, in addition to a room for expressing breast milk, the room can also be a breastfeeding room. This implies the need for support facilities such as staff to care for the baby when the mother is working, a baby changing table, and flexi-time to allow the mother to breastfeed.

The bill also explicitly states the amount of time required to allow the mother to breastfeed or express breast milk: a maximum of 40 minutes every four hours. The fine for non-compliance is a penalty of up to one million shillings, one year’s imprisonment or both. The bill also applies to public places such as restaurants, airports, and bus terminals with regard to suitable spaces for mothers to change their babies.

What’s next?

So far, the bill has undergone its first reading, but has not yet been adopted as an Act. A qualitative study of the legal measures that promote breastfeeding in Kenya indicates that provisions stipulated in the 2017 Health Act are more likely to be achieved by large to medium-sized enterprises, but they would be difficult for smaller enterprises with limited space and resources.

The provisions would also be difficult to implement in institutions that rely on casual workers and sales people. This would require innovative solutions crafted to suit the realities of the developing world. One example is the Mobile Creche, an initiative in India designed to offer daycare services for children whose parents work in construction sites based on the child’s age and needs.

Considering the level of investment that an employer would need to make, and the diversity of workplaces across the nation, it would be prudent to consider the bill from a position of implementation, even before it has been passed.

For example, how many workplaces have so far complied with the bill’s predecessor, the 2017 Health Act? What challenges do employers face in setting up such spaces? What is the main barrier: resources, awareness, or motivation?

And what about mothers: what is their experience of using spaces when they exist? What frustrations do mothers in different workplaces face in balancing breastfeeding with work? Would a lactation center address that challenge?

It would also be prudent to consider the bill from the point of incentives for the employer. One idea would be for governments to provide tax subsidies for employers that offer extended maternity leave support or flexi-time to working mothers.

The key message in supporting mothers in breastfeeding is that it will take the support of family, employers, government, and indeed, all of society.

The post Supporting the breastfeeding working mother: Kenya’s regulatory framework appeared first on Globaldev Blog.

How do public policies, and specifically pension schemes, affect the wellbeing of elderly retirees who decide to retire early? Do pension programs generate any potential downsides that policy-makers need to take into account? Are the large benefits that such programs can confer – such as better physical health, less stress, and more time for leisure – justified by the possible loss of quality of life due to speedier cognitive decline?

In a recent study, we find that people who retire early can suffer from accelerated cognitive decline and may even encounter the early onset of dementia. Our research examines the effects of a large retirement program in rural China.

Human capital and its potential depreciation

To most people, capital means a bank account, a thousand shares of Apple stock, or machines used in factories and business plants. But such tangible forms of physical capital are not the only type of economic capital. Formal schooling, a computer training course, and lectures on the virtues of punctuality and team management can also be a form of capital – ‘human capital’.

Human capital broadly encompasses the skills and abilities of individual workers in an economy. It has many dimensions: schooling, health, cognitive skills, and non-cognitive skills.

Human capital, and its connection to higher earnings and a better life, has long fascinated economists. Historically, however, economic research has mainly focused on the causes of human capital accumulation in early life.

Considerably less attention, if any, has been devoted to the causes and consequences of human capital depreciation in late adulthood. But recent evidence from neuropsychology suggests that the human brain is malleable and open to enhancement even in late adulthood.

Better understanding of the causes of human capital depreciation in later life has powerful economic consequences. Cognitive functioning is crucial for decision-making as it influences an individual’s ability to process information. Although some cognitive decline appears to be an inevitable by-product of aging, faster onset of cognitive decline can have profound adverse consequences on one’s life.

Therefore, examining the causes of cognitive performance in late adulthood is paramount. Better understanding of the causes of cognitive decline can help to craft better policies. It is especially important to understand the role that retirement policies can play in influencing cognition in old age.

Can early retirement speed up cognitive decline in old age?

Our study takes on this issue using data from China to examine the effects of a retirement program on cognitive decline among individuals who retire early.

China introduced the New Rural Pension Scheme (NRPS) in 2009 to ease demographic pressures and concerns about old-age poverty. This is a voluntary contribution-based retirement program: pensioners who reach the age of 60 and who have contributed to the scheme can receive a basic pension from the government and a portion from their own contributions to the account balance.

A new data source – the Chinese Health and Retirement Longitudinal Survey (CHARLS), which collects nationally representative data on individuals aged 45 and above – makes it possible to examine how early retirement influences several dimensions of cognitive performance.

Our analysis focuses on two critical cognitive domains: episodic memory, which captures fluid intelligence aspects; and intact mental status, which captures both fluid and crystallized intelligence.

You rest, you rust

The results indicate that the NRPS has a significantly negative effect on cognition among individuals aged 60 and older. Early retirement negatively influences all measures of cognition: immediate recall, delayed recall, and total word recall. The mental decline is equivalent to a reduction in general intelligence of the population of 1.7%.

Since retirement programs are geared towards ensuring the wellbeing of aging adults, this effect is alarming. What is worse, the biggest negative effect is on the measures of delayed recall, which neurological research demonstrates are highly accurate detectors of dementia.

Lessons for policy

What are the potential mechanisms that can account for the decline of cognitive performance among early retirees? The program boosted income for some people, and this could reduce incentives to remain in the labor force.

Reduced labor force participation could in itself lead to enormous benefits for people: reduced stress, improved personal diets, and improved overall sleep patterns. But working less could also create unintended adverse effects: fewer engagements in social activities and reduced mental acuity.

In short: you rest, you rust. The negative impact of early retirement far outweighs the positive effects.

These findings call for closer examination of the role that retirement programs can play in accelerating human capital depreciation in late adulthood. Cognitive impairments among the elderly, even if not severely debilitating, bring about a loss of quality of life and can have negative consequences.

Policies that aim to slow down cognitive decline in older ages are likely to generate large positive spillovers for society.

The post Early retirement: potential decline in cognitive function and human capital appeared first on Globaldev Blog.

How do Covid-19 restrictions imposed by governments around the globe affect our mental health? Early indicators suggest that the mental health cost of Covid-19 will be severe, with one study putting a $1.6 billion price tag on the treatment of pandemic-related mental health disorders for a single year in the United States. Symptoms of depression and anxiety are on the rise, prompting unprecedented concern among the public health community.

Since the onset of the pandemic, there has been a rapidly growing body of research evidence that documents the negative relationship between Covid-19 and mental health around the world, especially in developed countries.

Yet identifying a causal link and quantifying the relationship between exposure to Covid-19, limited physical mobility, social isolation, and mental health are challenging. Worsened mental health might be both the cause and consequence of social and physical isolation. The observed correlation does not imply a causal relationship because confounding factors such as earlier life events, childhood circumstances, and ability might influence exposure to Covid-19, social and physical isolation, and mental health outcomes.

To circumvent this problem of empirical evaluation and to assess the mental health toll of the pandemic, researchers have been creative. For example, one study draws on surveys conducted before and after US state-wide lockdowns to show that the mental health of individuals living in states with strict stay-at-home orders deteriorated more than those living in states without such tough restrictions. Two other studies document increased indicators of mental distress in Europe and the United States by using Google trends data and comparing pre- and post-lockdown search intensities related to pre-defined wellbeing terms such as ‘loneliness’ and ‘suicide’.

Our study uses a unique setting to overcome some of the empirical challenges in measuring the impact of mobility restrictions on mental health. We use a long-lasting curfew that is binding only for people aged 65 and older in Turkey as a natural policy experiment to mimic a ‘randomized controlled trial’, a widely used research tool for assessing cause and effect.

Turkey’s stay-at-home orders, imposed on the senior population and strictly enforced by the government, started in late March 2020 and lasted until mid-June 2020, making them one of the longest confinement policies to reduce Covid-19 mortality.

As we show in the study, individuals who are around the cut-off age of 65 at which the curfew becomes binding have no systematic differences in key characteristics and are thus comparable. We then conducted a phone survey, targeting the specific age group of 59–70-year-old adults to compare those who were just below the cut-off age and thus not affected by the stay-at-home orders subjected to those just above 65 who were affected. 

Panel A in Figure 1 shows that the curfew reduced the number of days that individuals had gone outside per week by around one day, corresponding to an approximate decline pf 43% relative to the control group. Similarly, it increased the probability of never leaving home by 24–30 percentage points, corresponding to a 150% increase relative to the control group.

Using a 20-item ‘self reporting questionnaire’ (SRQ-20) developed by the World Health Organization, we find that the curfew-induced reduction in mobility had a sizable positive impact on the probability of experiencing mental distress. Panel B of Figure 1 shows that we observe these effects both for somatic indicators, which capture physical symptoms of anxiety and depression, as well as non-somatic indicators representing more subjective assessments of anxiety and depression.

Finally, we examine potential channels through which a reduction in mobility leads to increases in mental distress. Our findings show that social and physical isolation plays a particularly important role in explaining the results. Mobility restrictions induced a substantial reduction in social interaction with friends and family, and a similarly large decrease in physical activity. At the same time, we find no evidence of a significant change in labor market outcomes or measures of intra-household conflict.

As policy-makers continue to weigh policy options in response to the pandemic, it is imperative to understand the potential costs of stay-at-home orders targeting certain sub-populations. This is particularly important for age-specific restrictions since many studies using a ‘susceptible-infectious-recovered’ (SIR) framework argue that it is possible to achieve better social outcomes through targeted policies that apply more aggressive lockdowns to individuals above the age of 65.

But since such policy responses increase the risk of a mental health crisis by placing already susceptible populations at higher risk of depression and suicide, these consequences would call for additional policy interventions to mitigate such adverse effects. These policy measures may include setting up mental health call centers, improving access to ‘telehealth’ services, and establishing on-the-ground local support services for at-risk populations.

Figure 1

The post Mental health costs of lockdowns: evidence from curfews in Turkey appeared first on Globaldev Blog.

Covid-19 threatens the lives and livelihoods of people globally. Following the outbreak, countries around the world took measures to lock down markets and restrict movements to prevent the spread of the virus. Although vital in containing the disease, these measures also cause a high cost to the poor and vulnerable in developing countries, as it disrupts their employment, earnings, and purchasing power.

Poor people in developing countries often rely on income from daily casual labor and the informal sector that only allows them to have little savings and food stock for the future. Besides, poor institutions and lack of social safety nets in the developing world often fail to protect the vulnerable during crises.

Thus, economic lockdowns in developing countries threaten the poor in terms of livelihood, hunger, and economic welfare. It is estimated that more than a quarter of a billion people could face starvation during the pandemic, which could further increase their vulnerability to various diseases. Therefore, protecting the vulnerable from starvation and malnutrition during the pandemic is a new challenge that many developing countries now face.

In a new study, we provide evidence on food insecurity (lack of access to sufficient and nutritious food to meet dietary needs) within poor households during Covid-19. We conducted a telephone survey in April of 9,847 rural households in southwestern Bangladesh to find out which ones struggle with food security during the pandemic and how they cope with such adversity. We also followed up with 2,402 of them in May, almost a month after our initial survey, to understand how food insecurity within households deteriorates over time. Our survey households have very similar characteristics to average rural households in Bangladesh.

Bangladesh ranks very poorly in the global food security ranking (83 out of 113 countries in 2019 – worse than neighbors India, Nepal, Pakistan, and Myanmar) and the country has been adversely hit by the pandemic. For example, 13 million of its working population has already been permanently laid off from work and an additional five million people are expected to be in extreme poverty due to Covid-19. Thus, the food security situation in Bangladesh is similar to that in many other developing countries and requires immediate attention from policy-makers.

Most households experienced a negative income shock and were food-insecure immediately after lockdown

From our initial survey (wave 1), we find that 90% of the households have experienced partial or complete income loss following lockdown, more than 80% of the households experienced mild to severe food insecurities, and more than 50% of the households experienced moderate to severe food insecurities.

The findings show that households with no change in income are mostly food-secure, but food insecurity appears to increase with income loss (see Figure 1). Moreover, moderate to severe food insecurity is higher among households that experienced a complete loss of income than households that only experienced a partial loss of income.

Households that are primarily in occupations without job security, such as farm and daily casual laborers, were initially affected the most in terms of food insecurity. On the other hand, households that own businesses and are involved in public sector jobs are the least affected in terms of food insecurity. This suggests that households with higher job security tend to be more food-secure than households with very low job security.

Figure 1: Food insecurity and income loss during the first wave

Savings, loans, and food stocks are the main coping strategies

Figure 2 shows that households primarily rely on previous savings, food stocks, and loans to cope with income loss. In particular, households with higher savings and food stocks are relatively less food-insecure, and households are more likely to take out loans when they are more food-insecure. Moreover, household borrowings increased for severely food-insecure households, which took out more loans than households with mild to moderate food insecurities. Support from government was very low.

Figure 2: Coping strategies by food insecurities during the first wave

Food insecurities appear to be dispersing rapidly into groups that were formerly food-secure

Using the follow-up responses from 2,402 rural households (out of the 9,847 households from the first wave), we find that food insecurity among households deteriorated further during the pandemic and lockdown.

Figure 3 shows that the proportion of food-secure and mildly insecure households dropped in the second wave (roughly by 10 percentage points), while the number of severely food-insecure households drastically increased during the second wave (roughly by 30 percentage points), implying a probable shift.

Moreover, among the households that were food-secure in the first wave, roughly 88% of such households experienced a deterioration in food security: they became food-insecure from being secure. In contrast, among the households that were food-insecure in the first wave, only 1.5% experienced an improvement in food security (becoming food-secure from being insecure).

Our analysis suggests that food insecurities are dispersing rapidly into groups that were formerly food-secure. The traditional coping mechanisms such as using informal borrowing or lending, past savings, and help from friends, relatives or neighbors can work for only a short period of time. With no indication of improvement in food security among the affected households, the pattern of such transmission suggests that food insecurity would inevitably catch-up with the remaining food-secure households if drastic measures are not taken by policy-makers to arrest the spread at the earliest opportunity.

Figure 3: Food insecurity across the two waves

Concluding remarks

Despite reports in the national and international media, data are lacking on how food security is evolving during the Covid-19 pandemic, and how to target households most at risk of acute food insecurity. Our rapid household surveys present evidence of the relationship between income loss and food insecurity during the pandemic.

Overall, the results suggest that most rural households lost their income and only a few of them are food-secure during the pandemic. We also learn about the major coping strategies undertaken and the rapid dispersion of food insecurities across households.

Our study identifies households most at risk of severe hunger and food insecurity in an already vulnerable population. This should help governments, NGOs and humanitarian agencies to make effective decisions during emergencies in resource-poor settings, on the optimum content and duration of food support, and on ideal target recipients.

Food insecurity is affecting intake of nutritious food at a time when having such a diet is critical for staying healthy and maintaining a strong immune system to provide protection from coronavirus. Furthermore, food insecurity will not only further damage health and physical wellbeing but may also affect mental health and psycho-social wellbeing, particularly among women and children. Action is needed to identify and provide immediate support to households with a critical need for food.

The post Food insecurity during Covid-19 appeared first on Globaldev Blog.

Over one in five children under the age of five has stunted growth, technically measured as low height for a given age. Research has linked stunting with poor human capital development, health and labor market outcomes in later years, implying huge losses of human and economic potential.

The underlying causes of poor early childhood health and stunted growth are multifaceted, and there is a growing recognition that the rates of stunting observed across the globe cannot be explained by under-nutrition alone.

The role of hygienic environments, shaped through water, sanitation, and hygiene (WASH) practices, in particular has been increasingly emphasized. A hygienic environment can improve child outcomes through reduced incidence of illnesses such as diarrhoea, which is not only a primary cause of mortality but also diverts nutrients intake away from growth processes.

Furthermore, a hygienic environment can prevent the development of conditions such as environmental enteric dysfunction (EED), an asymptomatic infection that limits the absorption of nutrients, thereby constraining growth despite eating well.

Evidence from medical research indicates that nutrition and WASH practices should interact with one another in the formation of child health. But recent randomized control trials (RCTs) exploring this link have had mixed results.

For example, two large studies – the WASH benefits trials in rural Kenya and Bangladesh, and the SHINE trial in rural Zimbabwe – examined the interaction between nutrition and WASH by providing combinations of nutritional supplements and elementary WASH interventions, such as building toilets, providing handwashing stations and soap, and using chlorine to purify drinking water.

All three trials find no impacts of the WASH interventions on child height, when implemented as standalone interventions (for example, building toilets only), or in combination. Further, none of the trials find evidence that nutritional supplements and WASH interventions interact with one another in shaping children’s height.

Additional analysis of the data from the trials highlights the difficulty of quantifying this interaction through RCTs: implemented interventions must first generate a sufficiently large improvement in a child’s hygiene environment. The elementary WASH interventions implemented in the trials may not have achieved this.

In a new study, we take a different approach to the same question, this time using high frequency longitudinal data from the Philippines from 1983 to 1986 to estimate the individual and combined contribution of nutrition and WASH to the formation of child height and weight in the first two years of life. Our analysis accounts for the fact that nutritional choices and WASH practices might be based on shocks and preferences that are unobserved by the researcher, which would lead to incorrect estimates if ignored.

We find that protein intake and better WASH individually lead to better child height and weight outcomes. Furthermore, improved WASH generates a small but robust and statistically significant improvement in the effect of protein on child height and weight.

A child at the 10th percentile of the distribution of WASH practices would be 2.57 cm taller by the age of two years if he or she were given an additional egg a day between the ages of six months and two years. For a child at the 90^th percentile of the WASH distribution, the increase would be 2.73cm.

This result provides one explanation for the puzzle of stubbornly high stunting rates in some countries, despite significant income growth.

A question remains though, of why our study finds evidence of a positive interaction between WASH and nutrition, whereas the RCTs do not. There are additional features of our study that are likely to explain some of this difference.

• First, households in our sample predominantly live in urban rather than rural areas. In these more densely populated contexts, better elementary WASH practices, and interventions of the type implemented in the RCTs, could reduce pathogen exposure sufficiently to translate into measurable impacts on child health.
• Second, the interaction effects that we identify are small in magnitude. Detecting such an effect size requires extremely large sample sizes in an RCT framework, which can be difficult to achieve if interventions are randomized at the village level, as was the case in the earlier trials.
• Third, for ethical reasons, RCTs can only encourage, rather than compel, participants to change their behavior. Imperfect compliance with interventions compounds the problem of a lack of statistical power.

Taking this research together, our study suggests that better child health can come from a combination of improvements in both nutrition and WASH behaviours. These might come from a variety of innovative approaches to encourage sustained improvements in WASH infrastructure and behaviour, and reduce children’s exposure to pathogens, in both rural and urban contexts.

The post Children’s health: potential benefits of improving nutrition and hygiene appeared first on Globaldev Blog.

As the global Covid-19 crisis unfolds, the measures to contain the novel coronavirus are also being felt by migrant workers across the world, who are trying to make their way back home or unable to travel to work. The International Labour Organization (ILO) estimates that in 2017 there were 164 million migrant workers – people who had left their home countries in search of work globally in farms, healthcare systems, and much more.

For example, Guatemalans make up a significant part of Canada’s seasonal agricultural workforce, and countries like Germany rely heavily on migrant workers for planting and harvesting activities. In South Africa too, workers from Southern and Eastern Africa are likely to occupy many of the lower-paid jobs.

The ILO estimate does not include migrants working within their own countries: for example, in India alone, millions of people from rural areas work in the cities to be able to care for their families. These migrant workers work as casual labour on daily wages, mostly on construction sites around the country, to meet the voracious demand for real estate by the middle class and the rich.

Implications of border closures and lockdowns for migrant workers

In many countries, the borders are now closed to non-residents in a bid to curb Covid-19 transmission and limit the number of imported cases. National lockdowns are being announced around the world. This affects migrant workers in different ways.

First, loss of income and returning home can mean a move back to abject poverty for workers as well as their families – remittances sent by migrants are a vital economic lifeline for millions of families trying to make ends meet. The World Bank expected remittance flows to low- and middle-income countries in 2019 to have reached $550 billion, making them the largest source of external financing. While the sums of money transferred as internal remittances are on average smaller, these are the ones that tend to reach more households and poorer people.

Studies of past economic crises in major migrant destinations have shown how remittances drop and migrant families need to seek alternative income sources. Those sources might not be available if migrants’ home countries are also being struck by the crisis.

Second, a challenging situation can be made even more difficult by migrants’ legal status and the conditions under which they work. Workers often live in crowded accommodation, where they can be exposed to the virus. Informal or irregular migrants especially often lack access to healthcare or insurance: many live in fear of falling ill without the support provided by family and kin.

As India announced the nationwide lockdown, many migrant workers flocked to the trains leaving the cities for the villages, choosing travel over the insecurity and financial burden of having to pay for rent or food as work opportunities and transport links were grinding to a halt.

What is to be done?

The answers to these challenges as well as to the longer-term problems facing economies worldwide lie in lifting travel bans for migrant workers with seasonal work visas and in implementing measures that effectively protect workers from Covid-19 while containing its spread.

Host countries and local authorities should look at providing access to safe accommodation that would allow migrant workers to be able to self-isolate. Access to healthcare services and insurance in case of illness, as well as to basic income support, should also be guaranteed. Portugal recently set an example by providing migrants with full citizenship rights for the period of the Covid-19 crisis.

While lockdowns may be necessary in some areas, policy-makers must also consider alternatives that would not lead to the working poor (of whom many are internal migrants) being deprived of their livelihoods for prolonged periods. For example, mass testing of the working-age population could speed up the return to work of those who have already developed immunity to the virus.

Other immediate actions include sharing information about Covid-19 in the most commonly spoken languages among migrants. Partnering with migrant recruitment agencies can be key to the success of such campaigns, as these agencies usually have direct contact with migrants and know their situation and needs.

Basic rights for migrant workers

The Covid-19 crisis highlights once more the vulnerability of migrant workers to informal contracts, exploitative employers, unsafe work conditions, and restricted access to basic services. The campaign for basic rights for migrant workers must continue to ensure that no one is left behind.

The post Migrant workers in the Covid-19 pandemic appeared first on Globaldev Blog.