More Abidjan Thoughts

Observations from the past few weeks here in Abidjan:

• I had strep throat last week, and possibly malaria as well.  I'm better now, but this was a barrier to blogging the past couple of weeks.  
• Internet USB keys here are very convenient.  You can buy a USB key and insert it into your computer whenever you need internet and it provides you with a 3G connection.  I assume that this technology exists in the U.S., but I was completely unaware of it.  
• At the ministry of health, my direction is now pushing forward a plan to introduce "performance based financing" into the Ivorian health system.  This should be an exciting project and I imagine that it will be my core project during my time here in Cote d'Ivoire.  
• A lot of professional documents here are written collaboratively here.  In fact, at every government conference, workshop or commission that I've been to, the goal has been to produce, via group, some sort of document.  This is in stark contrast to the U.S., where documents are composed individually and circulated for editing, and where workshops and seminars are often a waste of time.  Here, the workshop is the most important work activity; everyone comes together, works hard, and produces a policy paper collaboratively.  Still, based on what I've seen so far, I'd probably choose the U.S. model for producing collaborative work.  I do like that the Ivorian model encourages such a high level of collaboration and participation.  But it does not encourage outside research.  It's a closed universe, where a group of people will sit inside a room drafting a strategic plan without bringing in outside research, thereby failing to take advantage of the wealth of easily accessible information available via internet.  It's possible that these judgments are premature.  I have only been to a handful of workshops and commission meetings so far.  
• Abidjan is generally pretty nice.  It is green, there is not too much garbage on the streets, there are lots of nice buildings.  Still, it's not quite as well kept as, say, NW Washington DC.  The main reminder is that my fingernails and the bottoms of my feet are usually dirty here.  Lots of dust flying around always.  
• In general, I've been positively surprised by the level of social capital here.  To get window curtains made, you go to the store, select your curtains and then come back in a week to pick them up.  They don't demand money up front, and it is quite possible that you would never return and they would be out the cost of the materials and the labor.  When we got our furniture made, we left a sizable deposit to allow the carpenter to buy supplies, and, while he wasn't a great carpenter, he did eventually deliver all of the furniture that we had ordered at the price he had quoted.  
• That being said, I left my cheap cell phone in a taxi last week, and the finder did not make any attempt to return it, despite text messages promising a reward.  
• There is no daylight savings time in Cote d'Ivoire.  Which makes sense, this being so close to the equator and all.  Days are always about the same length here.  Sunrise around 6am and sunset at 6pm.  
• There is an odd competition here among ex-pats to see who can pay the least for taxi rides.  I understand the desire to be well adapted to Ivorian culture, but I still don't really understand bragging about negotiating a particularly low fare with a cab driver.  Would you brag about how little you tipped your waiter at lunch?  Is there an ethical difference between the two?  

Partisan narratives and why America's government fails

Keeping with my kick of reading about making government work, I liked this from Scott Sumner on why the U.S.'s government often functions so poorly:

America has two political parties:

1.  One is so anti-government that they refuse to do serious thinking about how to make government work.

2.  The other is so pro-government that they refuse to make the tough choices necessary to make government work.

Book Review: The Anti-Politics Machine

This was an intelligent and thought-provoking book.  It is a terrific deconstruction of the institution of "development."  

The subject of the book is a development project in Lesotho.  It discusses how the Canadian International Development Agency (Canada's USAID) twisted a complex situation into a simple model so that it could apply its standard "development" prescriptions to the situation at hand.  The resulting project was a failure and the book examines exactly why it was such a failure.  

Adapted from the author's PHD dissertation, the book is a bit dry and plodding at times, but it is lucid and full of terrific analysis.  

Some of my favorite passages: 

Often, the question was put to me in the form "What should they do?", with the "they" being not very helpfully specified as "Lesotho" or "the Basotho".  The "they" here is an imaginary, collective subject, linked to utopian prescriptions for advancing the collective interests of "the Basotho."  Such a "they" clearly needs to be broken up.  The inhabitants of Lesotho do not all share the same interests or the same circumstances, and they do not act as a single unit.  There exists neither a collective will nor a collective subject capable of serving it.   

When "developers" spoke of such a collectivity, what they meant was usually the government.  But the government of Lesotho is of course not identical with the people who live in Lesotho, nor is it in any of the established senses "representative" of that collectivity.  As in most countries, the government is a relatively small clique with narrow interests... Speaking very broadly, the interests represented by governmental elites in a country like Lesotho are not congruent with those of the people and in a great many cases are positively antagonistic.  Under these circumstances, there is little point in asking what such entrenched and often extractive elites should do in order to empower the poor.  Their own structural positions makes it clear that they would be the last ones to undertake such a project. 

In a similar vein: 

If the question "what should they do" is not intelligibly posed of the government, another move is to ask if the "they" to be addressed should not be instead "the people."  Surely "the masses" themselves have an interest in overcoming poverty, hunger and other symptoms of powerlessness... Once again, the question is befuddled by a false unity.  "The people' are not an undifferentiated mass.  Rich and poor, women and men, city dwellers and villagers, workers and dependents, old and young; all confront different problems and devise different strategies for dealing with them.  There is not one question -- "what is to be done" -- but hundreds: what should the mineworkers do, what should the abandoned old women do, what should the unemployed do, and on and on.  It seems, at the least, presumptuous to offer prescriptions here.  The toiling minters and the abandoned old women know the proper tactics to their situations far better than any expert does.  Indeed, the only general answer to the question, "What should they do?" is: "They are doing it!." 

This was also interesting: 

If one takes the "development" problematic at its word... the absence of growth in agricultural output... can only be considered an unfortunate mistake.  But another explanation is possible.  if one considers the expansion and entrenchment of state power to be the principal effect -- indeed, what "development" projects in Lesotho are chiefly about -- then the promise of agricultural transformation appears simply as a point of entry for an intervention of a very different character.  In this perspective, the "development apparatus in Lesotho is not a machine for eliminating poverty that is incidentally involved in bureaucracy; it is a machine for reinforcing and expanding the exercise of bureaucratic state power, which incidentally takes "poverty" as its point of entry. 

Things I learned this week in Abidjan

Notes from this past week:

• Animals are harder to remove from day-to-day life here.  There seems to be a lizard living in my air conditioner.  As I write this, there is a centipede crawling up the wall across the room from me.  My roommate found a lizard in her bed the other day.  If you look closely at any table or counter, you'll likely see very tiny African insects crawling around on it.  Happily, mosquitoes haven't been much of a problem though.  
• In a way, it's cheaper and easier to eat healthy here.  Processed supermarket food costs significantly more than fresh food from nearby markets.  The animals are always locally grown (there are chickens waddling around just about every block) and presumably antibiotic free.  The policies that create this -- lack of local food processing companies, high tariffs on foreign imports of processed food, tons of local food producers and sellers willing to earn low margins, lack of food safety monitoring -- aren't really replicable in a developed country.  
• All that being said, vegetable-based meals are not common and portion size is not helpful to the calorie conscious.  
• Eating out at a local restaurant (a maquis) is generally cheaper than making a meal at home, particularly if you're using western ingredients for your meal at home.  The main expense of going out to eat is time; you should count on spending at least 45-90 minutes for a meal.  
• Vietnamese spring rolls (nems) have been adopted into Ivorian culture.  They are cheap and plentiful here, and some Vietnamese places are run by Ivorians.  
• In the same way that a crepe in Washington, DC is expensive and of poor quality, a hamburger or pizza here is always (relatively) overpriced and disappointing.  The extra money that you're paying for a burger here isn't because you're paying for a deluxe burger but because you're paying for the cultural experience of "American food."  
• The lack of activity options doesn't really hurt my quality of life.  In DC, there are several soccer leagues, basketball leagues, kickball leagues and a dozen other sports that I could be playing any day of the week.  Here there is soccer on Wednesday in Deux Plateaux, volleyball on Thursdays at the American embassy and ultimate frisbee on Sundays at the Lycée Classique.  I would never play volleyball or frisbee over basketball in the U.S., but they are 90% as fun and the lack of choice can be liberating (I always just assume that Wednesdays here are for soccer, rather than trying to decide which day to play).  Likewise, with the social scene.  The plethora of nice bars and social activities in DC could be stressful, as it was disappointing not to choose the most fun Saturday night activity.  Here, there are a handful of ex-pat bars and usually just one or two activities per weekend, often with many of the same people.  You may or may not like going to see Diego's blues band, but that's what people are doing most Friday evenings here.  If you want to see people, you go and make the best of it.  
• I suppose this is all just a readjustment of my hedonic baseline.  I suppose that when I move back to DC, I'll enjoy the variety of options for the first couple of months, but then re-adapt.  

Why bureaucracy matters

This is my latest intellectual trip, especially the topic of public service delivery. It combines a lot of things I’m interested in – institution building, rule of law, making government work. I also like it because it touches on the existential question of all policy: what does government do well and how can it do this better? Where should government be involved and where not, and how can it function well where it exists? In the same way that people are starting to realize that the first rule of development should be to do no harm, I like applying this idea to all policymaking.  My current fellowship/job gives me a terrific platform to view this within the context of a developing country government.

Happily, I'm not alone here.  Chris Blattman thinks "'bureaucracy' will be the most topical development topic in five years," so I might as well get an early start.

Here’s a good passage from one of the foundational articles in this topic:

It is now widely appreciated that government failure may be as important as market failure, and the mere existence of the latter does not necessarily justify government intervention.  To the extent government intervention is called for, this does not automatically mean direct involvement of the state in economic activity and could entail indirect involvement through partnership with the private sector, and the “third sector” consisting of voluntary and community organizations.

And another:

The traditional model of state provision assumes away incentive problems, assuming that the government can stipulate and enforce a level of provision. It implicitly assumes that individuals who work in the public sector need little direct motivation to pursue the social good. Rewards therefore depended little on performance. The implicit assumption was that teachers, health care professionals and bureaucrats are publicly spirited and that this was enough. 

The article has lots of other little tidbits worthy of further exploration.  For instance:

Persson and Tabellini argue that proportional representation and parliamentary systems provide better  incentives for provision of public goods. 

Such an argument may help to explain (among other reasons) why Americans seem to get so little bang for their taxpayer dollar compared to, say, Germany.

Improving human resources in the health sector

The focus of my work conference this past week was on "how to improve human resources in the health sector."

There are several problems with human resources in Cote d'Ivoire's health system, but the main one is that there simply aren't enough people.  Not enough doctors, nurses, midwives, or health officials.  A lot of people left during the crisis this past decade, and the existing schools and training institutions are poorly equipped to fill the gap.

The schools are already overburdened and there is concern that increasing the ratio of students to teachers would decrease quality to unacceptable levels.  The Ministry of Health would like to create more schools and hire more staff for existing schools, but there are a lot of competing demands for funding.  They will probably be able to open a couple of schools and hire some more teachers, but not enough to produce the number of health sector personnel that is needed.  So what to do?

One option that was discussed is accrediting private schools to train health workers.  But a number of people were skeptical that this could work in a country of Cote d'Ivoire's level of development.  They cited recent privatizations of health training in Senegal and Benin as examples of why accrediting private institutions would not work in Cote d'Ivoire.  I was curious about the factual basis for these concerns.  Does a country need to attain a certain level of economic development or administrative sophistication before such public-private partnerships can function effectively?  Information on this topic is not easy to unearth.  The Center for Global Development discusses in a recent report on Partnerships with the Private Sector in Health:

Policies, such as those related to contracting or accreditation, that engage and influence the private sector are complex and challenging They require specialized skills and new practices built on experiences in other countries and basic principles of economics, regulation, business, and other fields The technical assistance available to public officials in developing countries, however, typically offers little support and expertise on private-sector engagement. 

The language is quite general, but it suggests that accreditation can be challenging for less experienced administrative bodies.  The opposing (libertarian) argument would be that it's unclear why the government should be so much better at creating effective schools and training institutions for health workers.  I don't yet have enough experience in developing country economies to know how strong this argument is.  On the one hand, if a private institution is churning out poor quality workers, won't hospitals and clinics stop hiring such workers?  On the other hand, I imagine the picture is much more complex than that.  From what I've seen, the Ivorian bureaucracy has a complex relationship with diplomas, trainings and other qualifications that I don't yet understand at all.  

I will revisit this question in a couple of months.  It seems that there are two main questions to be answered: 1) Could private accreditation of health worker training improve the human resources situation in Cote d'Ivoire? 2) And if so, what is the best way to institute a private accreditation program for health workers in a developing country?  This ASCP article provides some useful background on the latter question.  

Working at the Ivorian Ministry of Health

Notes from my first week of work at the Ministry of Health:

• I arrived at work on Tuesday morning and the electricity was out.  They didn’t really know what to do with me, but one of the women in the office was about to leave for a week-long conference, so they sent me with her.  The conference was in Agboville, 90 minutes north of Abidjan.  I was told to go home and pack my bags and Noelle would pick me up in two hours. 
• The conference was about how to improve human resources in the Ivorian health system.  There were officials there from several different branches of the Ministry of Health, as well as from the WHO and Abt Associates, who sponsored the meeting. 
• The meetings were a bit stressful at first, as my French comprehension is still not totally up to par, and I had trouble following some of the more technical conversations.  Also, I’m the only non-African here.  It’s an odd feeling; I attract a lot of attention whenever I walk into a room.  Everyone is polite enough to pretend like it’s nothing out of the ordinary, but it’s interesting to feel the vibe of the room change when I enter.  It’s a bit of a lonely feeling and I imagine it will increase my empathy for outsiders when I return to the U.S. 
• It’s worth noting that Abidjan doesn’t feel like this.  White people are noticed, but there they are common enough that you usually don’t get more than a brief second glance.  This is supposedly rare for Africa.  Sheila says that even in Accra she attracted significantly more attention. 
• By the end of the week, everyone had become much more comfortable with me.  I got invited out to dinner in town on our last night, and I had some nice conversations on Thursday and Friday. 
• There was a refreshing and admirable level of honesty at these meetings  -- it is common for government officials at an official meeting to say something like “our system of financial motivation for health workers is completely worthless,” and everyone will nod in agreement.  U.S. government would function better if public officials were so honest.  
• On Wednesday morning, we had a presentation on “Results-Based Management” (“Le Gestion Axée sur les Resultats”).  The presenter attributed the concept to Peter Drucker and his 1964 book “Managing for Results.”  The presentation cited the fact that the Canadian government adopted this concept in the early 1990s. 
•  We seem to be writing the official 3-year plan for how to improve human resources in the health sector. 
• In French, to make a text comprehensible to the population is to "vulgarize" it, which says everything.  
• At lunch, I found a hair on my plate.  I spent a moment trying to decide if it was mine before realizing that I was the only person within 25 miles with hair like that.