Monday, March 23, 2015

Cancer is an urgent public heath issue

Between 40,000 and 80,000 new cancer cased are diagnosed each year. According to a report published in 2010 and posted on the website of Kenya Network of Cancer Organization, 18,000 cancer deaths were reported in 2005. Cancer kills about 27,000 Kenyans every year, a majority of them in the prime age.

About 80 percent of reported cancer cases are diagnosed when it is too late. In 2006, 65 percent of women who were diagnosed with cervical cancer died. The National Cancer Control Strategy 2011-2016 admits that cancer is the third as a leading cause of death after infectious and cardiovascular diseases.

The proportion of the overall disease burden in sub-Saharan Africa attributable to cancer is rising, and the region is predicted to have a greater than 85 percent increase in cancer burden by 2030. Experts now believe that there is a relationship between the increase in cancer cases and the persistence of infectious diseases associated with the risk of malignancies. It is estimated that infectious viral and bacterial agents cause around 2 million cancer cases each year, most of them in Africa.

The National Cancer Control Strategy is unambiguous about what action is needed; screening, early detection and treatment; efficient referral systems, prevention, control of infectious diseases linked to cancer, enhancing access to cancer treatment services, human capacity development. But what really is going on, beyond having a strategy?

In my view, the dominant perception among health policy officials in this country is that cancer is not a serious public health problem. This perception has a significant influence on public health policy and resource allocation. That is why Kenya has only two cancer machines, both of them located at Kenyatta National Hospital in the capital city of Nairobi.

When the Cabinet Secretary Michael Kamau received the first consignment of 4000 tones of rails for the Standard Gauge Railway in January 2015, he said the government would push China Road and Bridge Cooperation to complete the 609-kilometer line before the next general election in 2017. We have not seen such urgency and zeal in addressing the plight of Kenyans suffering from cancer.

Simeon Munda, the Chief Executive Officer of Kenyatta National Hospital (KNH), revealed that 1,300 cancer patients are on the waiting list, with appointments stretching as far as 2017. Tens of thousands more cancer patients could wait beyond 2017 to receive cancer treatment at KNH.  

Cancer is an urgent public health issue, which demands immediate attention. Given that we have half decent population health records and that cancer is also linked with infectious diseases, my guess is that we are staring at a catastrophic epidemic.

Think about this. Bacteria that cause ulcers can cause stomach cancer. The parasite responsible for bilharzia can lead to bladder cancer. People infected with HIV have a substantially higher risk of some types of cancer. Three of these cancers, AIDS-defining malignancies are Kaposi sarcoma, cervical cancer and non-Hodgkin lymphoma. Moreover, people with HIV are five times more likely to be diagnosed with liver cancer.

We need national and county population-based cancer registries. This means that we must step up screening and diagnostic capacity at the county level. The registry system should be used to report on cancer incidence, cancer type, gender, age, socio-economic status, race/ethnicity, year of diagnosis, trends, survival and prevalence. 

The data will be critical to supporting cancer research to understand the specific causes and developmental mechanisms of cancers that are prevalent in our society, and specific to socio-economic, infectious disease and genetic risk factors. The data will also help build public awareness and provide evidence for advocacy for funding as well as put pressure on the government to implement the National Cancer Control Strategy 2011-2016 before it expires.

The conversation about cancer must go beyond the outrage about the breakdown or shortage of radiation therapy devices. It must be about the strategies and action needed to build a health infrastructure, leveraging both public and private investments to cope with the double burden of infectious and non-communicable diseases.

We must address the crippling shortage of healthcare personnel. Over 1,800 doctors and hundreds of nurses have resigned from the public sector since the management of health services was devolved to the counties.

Without enough doctors, nurses and community health workers the gains against infectious diseases will be reversed and we will certainly, not forestall the onslaught of cancer and other non-communicable diseases.

Monday, March 16, 2015

Plan to solve Nairobi’s traffic mess inadequate

Last week Cabinet Secretary Michael Kamau observed that it takes 45 minutes to fly from Kampala to Nairobi and 2 hours to drive from Jomo Kenyatta International Airport to Nairobi’ s city centre, a distance of 18 km.

The observation by Mr. Kamau is not extra ordinarily enlightened. Nairobi’s commuters have to endure endless and excruciating traffic gridlock. Commuters now think traffic jams are an inextricable feature of life in Nairobi. The immobility and frustration, and the cost to business and the economy are both indefensible and shameful.  It is an indictment of our urban planning and governance.

Nairobi’s traffic catastrophe has been years in the making. Our technocrats and decision makers have aided it consistently and deliberately for the past half-century.  And a passive and self-interested public has actively abetted it. Now the chickens have come home to roost.

Four factors have converged to create Nairobi’s traffic catastrophe. First is the expansion of major road arteries into Nairobi; more roads more cars. Second is a substantial rise in car ownership owing to two things; influx of cheap used cars into the markets and expanded access to unsecured bank loans. Third is unregulated expansion of high-density affordable housing in the sprawling suburbs, buoyed by road expansion and lack of land use zoning in contiguous counties. Fourth is a large and growing urban population; Nairobi is home to about 1 in 10 Kenyans.

Other factors that explain Nairobi’s unconscionable traffic gridlock include inadequate, 19th century urban road infrastructure, a total absence of any form of rational traffic management, lack of public transit system and the drop the price of gas.

Last week Nairobi’s Governor, Evans Kidero and Michael Kamau, Cabinet Secretary for transport and infrastructure admitted that Nairobi’s traffic congestion was a matter of great concern. There is task force and it has a plan in place to address the traffic mess. The plan includes: an intelligent transport system backed by a traffic management centre (How different is this from a similar system, with lights and cameras was installed in Nairobi in 2012); removal of all roundabouts between Waiyaki way and Mombasa road; review of PSV termini to reduce number of matatus entering the CBD, suspension of licensing of PSVs in Nairobi subject to demand analysis; expansion of existing roads and construction of bypasses.

In the long-term, under a memorandum of understanding, the national and county government will build a Bus Rapid Transit and a Light Rail Transit. Also in the works is the so-called institutional framework through the Nairobi Metropolitan Transit Authority to address Nairobi’s transit issues.

That the government is grappling with Nairobi’s horrendous and shameful traffic is laudable. The plan proposed to resolve the traffic mess is grandiose but myopic. The plan has been greeted with enthusiastic cynicism. The plan fails to put any burden on private motorist, and instead suggests, contrary to existing evidence, that matatus account for a large part of Nairobi’s traffic congestion problem.

The plan places no obligation on urban and regional planning and makes no reference to the role of the governments of the contiguous counties of Machakos, Kajiado and Kiambu, which account for a significant volume of commuter traffic into Nairobi. Moreover, the plan does not involve the private sector in providing solutions to Nairobi’s traffic mess. It is big on spending your money.

I offer four suggestions. First, we need a public private partnership to build and operate park and ride facilities 10 km from the CBD and reliable high occupancy bus shuttles into the city. This should be accompanied by the elimination of 40-60 percent of street level public parking in the CBD and a congestion levy for private cars entering the CBD.

Second, Nairobi County should enter into an agreement with neighboring counties to regulate the conversion of farmland to high-density residential use. Planning regulations should outlaw development of high-density settlements beyond 15 km from a major urban centre.

Third, a partnership among Nairobi County, the Rift Valley Railway (RVR) and the Kenya Railway Corporation could increase the capacity of RVR to modernize and expand its services, and get more private cars off the road.

Fourth, do not rush to replace roundabouts with four-way intersections. Globally, roundabouts have been shown to perform better and are safer than other intersection controls modes. What is needed is clever re-design and better controls at the roundabout.

Tuesday, March 10, 2015

Kenya’s economic growth is shallow

Kenya has made progress in the last decade. We are resilient. We bounced back when ethnic bigotry threatened to destroy our country. But the task of building a stable and prosperous society could never more urgent.

A report by the Institute for Security Studies revealed that with 40 percent of the population living in extreme poverty, Kenya is the sixth poorest country in Africa. Last week the World Bank declared that Kenya’s economic growth is among the fastest in Africa and GDP was expected to reach 7 percent in 2017.

This paradox is not inexplicable. Ambitious government spending in infrastructure, especially in energy and the standard gauge railway due to expansionary fiscal policy characterizes Kenya’s impressive headline GDP. But a majority of Kenyans remain poor, disconnected from the benefits of economic growth because Kenya’s manufacturing sector is stagnant and agriculture is comatose.

Kenya’s formal manufacturing sector is minuscule and the outlook is bleak. It employs 280,000 accounting for just 12 percent of Kenya’s labor force. Moreover, productivity of the manufacturing sector is depressing. The value added per worker in Kenya’s manufacturing sector is only $1.11 per day (about Sh. 100). Kenya’s average share of manufacturing value added in GDP is estimated at 10 percent, unchanged from the 1970’s.

A majority of Kenya’s farmers and agricultural workers are trapped in collapsing rural economies. The dysfunction of Kenya’s rural economy has been aided by poor infrastructure, especially roads, energy, water and essential social services such as health care and high quality schools. Low investment in agricultural research, compounded by broken extension services has contributed to low productivity and little innovation. Productivity in Kenya’s agricultural sector is estimated by the World Bank at about $1 per worker per day, compared to about $13 in Nigeria.

Kenya’s export sector has been sluggish for the past 25 years. Tourism has been buffeted by insecurity and poaching, especially over the last couple of years. About 40 percent of Kenya’s manufactured goods are exported to the East African Community. But our regional exports are under competitive pressure from imports from China and India. Furthermore, depressed economic output from the European Union has huge consequences for Kenya’s export sector as well as tourism.

A strong hand of the state through expansive fiscal policy underlines Kenya’s growth in the past decade. However, as exemplified by low productivity in both the agricultural and manufacturing sectors, the fundamentals for a broad based growth are feeble. Moreover, integrating into global financial markets through sovereign bonds makes Kenya vulnerable to external financial shocks. Hence, a large part of Kenya’s impressive GDP growth is not organic and is therefore unsustainable.

The path to economic prosperity takes more than a narrow expansionary fiscal policy vision.  Inclusive growth and shared prosperity demands careful social and fiscal policies that re-engineer’s Kenya’s flawed economic structure.

Of what value is an ultra modern railway line and a 10,000 MW energy capacity achieve when agriculture and manufacturing are declining? We must invest in higher education and research capacity to drive growth in productivity to boost output and competiveness. Our universities must be the engines of growth and structural transformation, through research-intensive programs, unleashing technological advancement and innovation.
Public universities are underfunded and burdened by intensive and mediocre teaching programs. We are woefully short of vital execution capacity. This is why we have Tony Blair leading Mr. Kenyatta’s Presidential Delivery Unit. And there are innumerable expatriate advisors in the civil service.

The same zeal for public spending on security, roads, railways and energy must be applied to building technological capacity, human capital and investing in smallholder farmers and pastoralists. Critical public research infrastructure must move to the university. Hence, research organizations like Kenya Agricultural and Livestock Research Organization, Kenya Medical Research Institute, Kenya Industrial Research and Development Institute should be integrated into research and teaching programs in public universities.

Sustainable and inclusive economic growth will not come inevitably through expansive fiscal policy. There is no such thing as trickle down from big government spending. Building inclusive prosperity demands careful, deliberate investment especially in research and teaching in our universities to shape public policy, drive technological advancement, spur innovation and raise productivity on our farms and rangelands, and on the factory floor.

GDP growth will not count until tangible wellbeing outcomes flow to farmers, pastoralists and the semi-skilled laborers who toil hard and long for this great land.

Tuesday, March 3, 2015

African Agriculture needs more than a Green Revolution

Four years ago, I visited a gutsy grandmother in a village in western Kenya. Ann was 75 years old then.

On a tour of a her half-acre estate we stopped at a vantage point, a termite mound on the edge of her farm, for a beautiful mid day view of her field and the village beyond.

Ann’s field, like her neighbors’, was planted with a local maize variety. In the village beyond, tin-roofed homes looked like shiny islands in a sea of yellow leaved maize. The maize was thin, with spindly stalks, and barely knee high.

Ann recounted memories from three-quarters of a century living on the land. She talked about a drier climate, barren soils and poor yields, denuded hills and scarlet rivers and frequent floods. She talked about the water hyacinth and the collapse of the native haplochromine fisheries.

Ann talked about hunger and malnourished children and the flight of young men from the land.
She remembered her youthful years when the water was clear, when fish were abundant, when the hilltops were green and lush, when the harvest was plentiful and her grandmother’s granary was filled to the brim.

“There are just too many of us, each scrambling for space to live, land to grow food, and pasture for our livestock. We toil harder on barren fields, for a paltry harvest, much less to eat and nothing to store. The big trees, the expansive grassland, the wetlands, the butterflies, the colorful birds and the wild animals of my grandmother’s folktales stories are no longer here. It is a very different world.” Ann remarked thoughtfully.

I have told this story before. But it is especially relevant today.

A recent study by the Institute for Security Studies revealed, unsurprisingly, that  40 percent of  Kenyans live in extreme poverty; earning or spending less than Sh.160 ($1.75) a day.  Over 90 percent of Kenya’s poor live in rural areas, where there livelihoods depend on subsistence agriculture and pastoralism.

Last week, Devolution and Planning Cabinet Secretary Anne Waiguru announced that 1.6 million Kenyans in 23 arid and semi-arid counties are faced with famine and will need assistance in the next six months. From my own experience, working in the coast and in western Kenya, a majority of rural households eat less than two meals a day 9 out of 12 months in a year. We know that nearly 40 percent of children born in Kenya are stunted.

In another continent-just an ocean away- and in Anne’s lifetime, a green revolution doubled cereal production. And even as the population increased by 60 percent, cereal and calorie availability increased by nearly 30 percent. The Asian Green Revolution stimulated the rural nonfarm economy, which in turn grew and generated significant new income and employment of its own. Real per capita incomes almost doubled in Asia between 1970 and 1995. Poverty declined. Malnutrition, as proportion of the population, retreated. And Asia prospered and Africa stagnated.

Ann’s story is an indictment on six decades of stagnation. It is an indictment on African governments. It is an indictment on the international development and research community. It is an indictment on Africa’s academic and research institutions. It is an indictment on all of us.
Although there has been some progress, it is neither deep nor good enough.

We have failed because a disproportionate number of African families are staggered by poverty and hunger. Over 40 percent of Africa’s children will not live their full potential because they are stunted. Africa rising will be stymied by unconscionable and grinding inequality, which is also an existential threat social and political stability. 

Africa needs more than an Asian style Green Revolution. Africa’s farming systems are far too complex compared to the narrow cereal production systems of the green revolution. Africa is the perched continent. Cheap mechanization is not feasible. Soils are inherently infertile and respond poorly to inorganic fertilizers alone.

Solutions for Africa’s agriculture must not be formulaic but integrated. It cannot be based on a big bet for maize alone like Bill Gates suggests in their 2015 Annual Gates Letter. Africa must leverage ago-biodiversity and ecological principles such as agroforestry to build resilience and harness natural capital. Africa also needs genetic intensification to enhance genetic fitness to adapt to climate change. Africa needs responsive fit-for-purpose institutions to support research, access to financial services, inputs, markets and value addition.


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