Arquivo de etiquetas: Economia da Pobreza

Financiamento da saúde global e a erradicção da pobreza

A Agenda de Acção de Adis Abeba (AAAA), o resultado da primeira de três reuniões em 2015 tem como objectivo definir as condições de financiamento para os próximos 15 anos de desenvolvimento sustentável. Ficará conhecida pelo seu fracasso?

A terceira Conferência sobre Financiamento para o Desenvolvimento (FFD3), sucede ás reuniões de 2002 em Monterrey no México, e de 2008 em Doha no Qatar. Era vista como uma oportunidade para reafirmar a vontade do mundo de avançar uma visão de um futuro sustentável, próspero e partilhado, e para fazer planos sobre a forma como poderá ser alcançado e financiado.

A FFD3 foi decepcionante. Embora questões como a protecção social, a segurança alimentar, as necessidades de infra-estruturas urbana, a industrialização, o emprego, a protecção ambiental e dos ecossistemas, bem como a construção de sociedades pacíficas e inclusivas tenham sidos discutidas pelas Agenda de Ação de Adis Abeba, ele ignorou várias relações. Uma dela é a relação entre a saúde e desenvolvimento humano. Esta questão é essencial para atingir a dignidade humana que temos vindo a defender. Ela estará presente na próxima discussão dos Objetivos de Desenvolvimento Sustentável (ODS) que se realiza no próximo Setembro na Assembleia das Nações Unidas, e em dezembro, em Paris, na Conferencia Intergovernamental sobre Alterações Climáticas.

Nos 134 parágrafos, apenas um (parágrafo 77) foi dedicada à saúde. Há uma chamada de atenção para o Fundo Global e a GAVI Alliance para dar uma maior atenção ao reforço dos sistemas de saúde. Foi reafirmada a relevância da OMS, como entidade de definição de orientações globais. A Cobertura universal da saúde foi aprovada e foi destacada a necessidade de manter a segurança sanitária mundial. Foi ainda foi destacado a importância dos recursos humanos em saúde. Ficou expressa a necessidade de aplicar a Convenção-Quadro para Controle do Tabaco. Finalmente foi bem acolhida a criação de um novo mecanismo de financiamento global (GFF) para saúde das mulheres e das crianças.

É certo que o Secretário-Geral da ONU, Ban Ki-moon demonstrou optimismo no resultado de Addis Abeba na formação de um novo quadro global para o financiamento do desenvolvimento pós-2015. Mas foram muitas as vozes, sobretudo da sociedade civíl que sinalizaram a sua decepção. Algumas delas têm vindo a dar conta em outros postais. Algumas críticas apontam que o financiamento do desenvolvimento depende essencialmente do sector privado, enquanto outras apontam para a ausência de compromissos claros dos países desenvolvidos.

Segundo as vozes críticas este pode ser um precedente que fragilizaráa as negociações para os ODS pós-2015 e para a IPCC de Paris.

O financiamento da ajuda ao desenvolvimento em Saúde tem vindo a altera-se. Como sinalizou a Comissão Comissão do Lancet em , 2013 sobre “Investir em Saúde”, os países em desenvolvimento estão perante o desafio de eles próprias reduzirem a sua dependência da Ajuda ao Desenvolvimento e reforçaram a sua capacidades de canalizarem financiamento interno para os seus sistemas de saúde.

Agenda de Adis Abeba reforça esta tendência. Ela aponta para a a necessidade do reforço dos mecanismos de financiamento internos, por via da melhoria da cobrança de impostos, do combate à corrupção, e a expansão do sector privado na saúde. O reforço do mercado e a expansão do comércio global são os elementos chaves deste processo. A tradicional Ajuda ao Desenvolvimento, tal como a conhecemos, parece ficar consignada a acções de emergência.

Não foi contudo ignorado o objectivo de afetar 0,7% dos PIB dos paíse para a Ajuda ao Desenvolvimento, com a recomendação aos países dadores, a desenvolverem campanhas de sensibilização aos seus eleitores mais cépticos sobre a eficácia da ajuda. Prevê-se contudo que se verifique uma crescente procura de financiamento para uma nova agenda, com base nas questões das Alterações Climáticas. Isso criará uma nova agenda que obrigará aos diferentes governos dos países desenvolvidos a enfrentarem um desafio de aplicação de políticas austeritárias, ao mesmo tempo que se apela ao seu empenhamento na Ajuda ao Desenvolvimento. O destino comum da humanidade e o sucesso das medidas a tomar para conter as alterações climática obrigam a compromissos internacionais difíceis de conciliar com as agendas eleitorais internas, sobretudo na europa, onde se encontram populações mais envelhecidas.

Mesmo a questão do Fundo Global para Financiamento da Saúde das mulheres e das crianças (GFF), embora referido na declaração, os seus termos são ambiguos. Na avaliação dos ODM para o objectivo 5 (saúde materno infantil) estimou-se que há um deficit cerca de 33 bilhões de U$. é este valor que está proposto ser afeto a este fundo, gerido pelo Banco Mundial, através de doações públicas e privadas. Segundo o Banco Mundial apenas um bilião está previsto para os próximos 5 anos através de países Noruega, Canadá, Japão, EUA, e da Fundação Gates. O seja há um risco de que o financiamento fique aquém das necessidades estimadas para atingir os objetivos.

A ciência é uma outra área em que faz parta da Agenda da Ajuda ao Desenvolvimento. Há uma convicção geral de que é necessário incentivar a ciência, partilhar o conhecimento, investir em educação (sobretudo nas universidades), e na investigação com o objectivo de reforçar o campo das ciências da saúde e da vida.

Malgrado este convicção parece que a saúde deixou de ser uma prioridade. Veremos se as negociações que iram ter lugar em Dezembro, no Japão, para a constituição do GFF para a Saúde resultarão. Depois da centralidade das questões da saúde em Monterrey e em Doha, em Adis Abeba ele parece ter perdido protagonismo.

O Ebola centralizou muita da atividade de OMS e terá desviado a atenção da comunidade da saúde sobre as questões centrais da cobertura universal de saúde e do seu papel no desenvolvimento sustentável, na redução da pobreza e segurança alimentar. É necessário que esta questão volte a constituir-se como um assunto central da agenda, seja para reforçar os avanços alcançados nos ODM, seja para enfrentar os desafios do presente de criar sociedades mais resilientes. Uma visão do desenvolvimento humano sustentado depende de uma saúde global mobilizada.

Universal Health Coverage IV

Ten Recommended Steps to Health for All in the Poorest Countries

The period of the millennium develop goals since the year 2000 has been an exciting one for public health. Because public health is really proved its worth showing how a science based approach starting with epidemiology. Building health systems supported by international help in the form of Official Development Assistance.

Malaria is a not only a lethal disease but it’s a disease that spreads very widely. And in many parts of Africa is what’s called holoendemic. Endemic meaning that people are infected. Holoendemic meaning that the whole community, everybody is infected and basically the whole year round. So to control malaria is really it’s a great feat. And malaria is being controlled right now in Sub-Saharan Africa. Thanks to the focused efforts of the Global Fund to Fight AIDS to be malaria or the U.S. initiative of PMI and others alongside it. And because of the great advances in public health and in technologies that make it possible. Long lasting insecticide treated bednets.

Community health workers who go into the communities, rather than waiting for sick people to carry their young. Often dying children many, many kilometers in their arms, hoping to arrive at a distant clinic in time. With the community health workers out in the communities, cases can be picked up much faster. Lives can be saved. A prick of the finger allows a community health worker to know within a few minutes whether that child is infected with malaria. And new medicines that replaced those fading, failing medicines like Chloroquine now based on Artemisinin. Very interesting story because Artemisinin is a molecule, extraordinarily effective in fighting malaria that was identified by Chinese scientists. How did they come to that? Because there was an ancient Chinese herbal treatment for malaria and for other fevers that came from a, a plant that the Chinese called (XXX) And that we know as Wormwood, or in its Latin, as Artemisia annua. And that was an ancient herbal remedy. But when the Chinese scientists went after it, the found out what is the active molecule and that we now call Artemisinin. When Artemisinin is put into medicinal form now, it’s enormously effective to control Malaria. And that’s one of the breakthroughs of recent years as well. If deaths of children under five have declined from 12 million back in 1990 to under 8 million in 2010, that’s a huge progress. But obviously, far from where we should be because most of those 8 million deaths are also preventable. We’ve gotten half way to building the primary health systems and we should take inspiration from that. And understand what it would mean finally to fulfill the commitments that was made already back at the founding of the United Nations and the World Health Organization. The commitment that was enunciated once again in Alma-Ata 1978. The commitments that was the motive spirit of the Millennium Development Goals of ensuring health for all and universal health coverage. Let me give ten basic recommendations of how we can move from the improved situation today. To the full breakthrough of universal health coverage and health for all within a short period of time, even within a decade. The first is a financial point. If we look at what the poor counties simply can’t afford on their own and need to be filled by official donor assistance. We can calculate how much aid should be directed at the health sector. Now mind you, I’m not talking about aid, year in, year out forever. I’m talking about an amount of aid that will shrink, as the poor countries develop, and reach a threshold, of income, where on their own, they can fund their own health systems. That threshold is reached probably somewhere around $1,200 per person per year, measured in current prices and market exchange rates. If you calculate the gap that the poor countries simply can’t manage out of their own budget, it’s around $40 billion a year Roughly $40 per person for a billion people that need that extra help. 40 billion how should we think about that is that a big number or a small number for the rich world. Well one way to think about it is that as we know there about a billion people in the rich world so it’s on the order of about $40 from each of us in the rich world, to save millions and millions of people in the poor countries. But $40 per person in the rich world is the bargain of the planet in terms of the lives that could be saved. Let me put in terms of the proportion of the rich world income. We know, that the average income of the rich countries is on the order of $40,000 per person per year. For the billion people in the rich world, it comes to about $40 trillion of income of the countries that give Official Development  assistance. 40 billion out of 40 trillion is one out of a thousand, it’s one tenth of 1% of our income. Or to put it another way it would be like saying for every $100 in the rich world take a dime put it aside, next $100, take a dime put it aside. One tenth of 1% of the income, would accumulate into a total fund of $40 billion per year.  So the starting point, number one, in the recommendation is a, annual flow of funds from the rich countries to the poorest. 40 billion a year right now. A number that would shrink over time. One tenth of 1% of high income world output each year. That would close the financing gap and enable millions of lives to be saved. Second recommendation. Put that money into highly effective organizations. My own recommendation would be to build the Global Fund to Fight AIDS, TB, and Malaria. Which has done such an outstanding job, into a Global Health Fund more generally and channel through it about $20 billion per year. So that the Global Health Fund could effectively support the basic health systems in the poorest countries. Letting those countries know that as they develop and lower disease will help them to develop. They will get less and less over time, because they will eventually graduate from the aide itself. Now third is that the low income country’s have to do their bit. They can’t fund their health systems just on their own. But they can make the valiant effort needed, they should contribute as much as feasible. And as I’ve mentioned, most fiscal experts that have looked at this regard 15% of the total budget as a stretch. But realistic and reasonable target for funding help. So the third recommendation is that the poor countries would be called upon to meet what became known as the Abuja Targets. Because of a meeting that took place in Abuja, Nigeria. The Abuja Target calls for the poor countries to devote 15% of their budget revenues to the health sector. The fourth recommendation is to finish up this job of comprehensive malaria control. Malaria is getting under control. You’d think I’m a little bit obsessed with it. And the fact in the matter is you’re right. Malaria is such a pernicious disease. Such a killer. Such a burden on development.  ut so much within reach of control that we do need to put the focus on it. And we’re close to getting the job done, but still underfunded roughly by half. So my third recommendation, fourth recommendation is that the world should adopt a plan for comprehensive malaria control. That would cost roughly, $3 billion a year. Which enable the poor countries to finish up the supply chains, the funding of community health workers, the rapid diagnostic tests, the medicines and so forth to really get the job done. Fifth recommendation. The leading donor countries should fulfill their longstanding commitment to providing universal access to antiretroviral medicines for individuals infected with HIV. And having the clinical indications for antiretroviral treatment. These medicines work. The treatment to poor people saves their lives. It’s been shown to be highly effective. More treatment would mean lower transmission of the disease because when an individual is treated with antiretroviral medicines. The viral load, that is the concentration of the virus in the body diminishes sharply. Making it much less likely for the virus to be transmitted from one individual to another. Sixth recommendation. That the leading donor countries should also fulfill their commitment to partnership with the poor countries. In funding following the global plan to stop TB, to stop tuberculosis. This too has a financing gap on the order of $3 billion a year, roughly $3 per person per year in the high income world. Roughly, cup of coffee at your favorite coffee shop in a high income country would be what is needed incrementally in order to build the requisite fund. Recommendation seven. That the world, especially the donor countries and their financing and the poor countries and their implementation, should guarantee access to sexual and reproductive health services. This would include emergency obstetrical care for safe childbirth, antenatal care for safe pregnancy, and contraception. Because many, many women around the world want to have fewer children. They want to use modern contraceptives. But they lack access or they lack the funds to, be able to afford it on a market basis. And so we need full funding of family planning services, contraception and emergency obstetrical care. Pregnancy safe management. And, again, at a very low budget. These services could be made universal. Eighth, the Global Health Fund would take up what have sometimes been called neglected tropical diseases. The neglected tropical diseases are diseases less in the headlines than malaria. Less in the headline than AIDS. The experts in those disease communities feel a little bit neglected because they are saying wait a minute, we also have powerful tools to fight deeply debilitating diseases. And yet, we are sometimes overlooked because our diseases that we’re studying and trying to control are not in the  headlines. And when I tell you the names you’ll say, you’re right, not in the headlines, never heard of them at least for some of them. But among these neglected tropical diseases are hookworm, that I presume most have heard. Ascaris which is a kind of worm infection. Trichuris another worm infection. Onchocerciasis, yet, another infection in the tropical areas that is absolutely a killer, but can be prevented and can be treated. Schistosomiasis, a disease in which a snail plays an important role in the life cycle of this disease. Filariasis, lymphatic filariasis, another vector borne tropical disease with, terrible consequences. Also controllable through bed nets. and, with, ample effort and organization, a disease whose burden could be reduced very, very sharply. And various forms and causes of blindness including trachoma, that is an infection of the eye that can cause blindness. And that can be prevented,ah, that is wide spread, a major cause of blindness. Also, we know, one could add though it’s not in the usual list of the neglected tropical diseases, is cataracts. Where advances in surgery allow for remarkably low cost replacements of the lens when individuals are blinded by  cataracts. And this is another case where communities especially elder, older people can be brought back to sight. With the tremendous benefits of course for themselves in the community at very, very low cost. So category eight, expand the Global Fund’s reach to these neglected diseases. Category nine, the Global Fund should establish special financing to complete the health systems. Not only the targeted diseases, but the training and deployment for example, of community health workers. This would be a crucial part of the, transformation from a disease targeted fund to a general global fund that’s providing a broad base of services. We have called at the United Nations for the deployment of a 1 million community health workers in Africa by the year 2015 as a major boost for achieving the Millennium Development Goals. Malaria control, it’s essential to get the community health workers out into the communities with their rapid diagnostic test with their Artemisinin in their backpacks. With their mobile phones for, getting advice from the clinics or being able to call an ambulance. When the community health workers are out there, the malaria burden, plummets. And finally, recommendation ten, is that there are now, a number of noncommunicable diseases. Typically that have been overlooked in many of these urgent MDG related efforts that also can be part of the primary health system. Dental care for example, treating cavities, something very basic, but often not present in poor countries. Eye care, mental health counseling and mental health interventions for the massive burden of depression for example which is pervasive around the world. Many cardiovascular diseases where people have undiagnosed high blood pressure, hypertension that can cause loss of life for adults. But if treated, brought under control can absolutely have the consequences meliorated or the adverse consequences controlled all together. A number of cancers can be addressed at very low costs. And of course, campaigns against tobacco use are part of any good public health system because tobacco remains a massive killer. That’s a behavioral challenge but it’s a behavioral challenge that we need to meet because it’s one of the most effective ways to save lives. Moral of the story, we’re close. It’s not so hard, the Millennium Development Goals have given a big spur to effort, we can now see a pathway to help for all. In the next phase of the Global Development Objectives, the Sustainable Development Goals. I would expect that universal health coverage will feature prominently in the next phase of goals. And we will have the opportunity indeed to complete what we have started. To finally achieve to realize health as a basic human right.

Universal Health Coverage II

Poverty and Disease

The problems of health that are problems for all societies. In the rich world where health conditions are far better than in the poor countries. The problems of very high and rising costs of health care are front and center on the political and the economic agenda. In the poorest countries the challenges of course are also about finances but much more importantly about the tragic loses of life and the very high burdens of disease. Often from conditions that have been eliminated completely in the high income world.

921Poverty and ill health go together and we need to understand that linkage of poverty and ill health because understanding it enables us not only to. Address the challenges of heavy diseased burdens of pour countries but also gives us an added and important tool for breaking the poverty trap itself. We should expect two-way causation, that poverty Contributes to disease in many, many ways, but disease of course also contributes to poverty. An individual suffering from disease loses income. A community or country with a heavy disease burden similarly loses income from. Sickness in the population, lack of productivity, other burdens that arise in the economy when there is a large amount of unattended disease. How does disease contribute to poverty? Think about the, the following pathways. First through the adverse life cycle development of a, of an individual. If a young child survives illness but is buffeted by repeated illnesses when you. We now understand better that not only is that likely to set the child back in terns of readiness for school perhaps in terms of school enrollment or primary school completion. But that early bout of illness can have a lifetime effect on cognitive and physical development and on vulnerability even.

At adult ages to various kinds of diseases unexpected diseases. Cardiovascular disease can be affected by nutrition that is poor in early age. So human development across the life cycle. Is strongly affected by health and disease. Disease can have long term individual consequences. Disease burdens of adults in the labor force of course can have large and adverse results for an economy. Think about a village that has to harvest the crop. The crop may be the absolute lifeline for the village to enable it to eat throughout the coming year. But in many places, just at harvest time, there’s also the risk of a malaria epidemic. Malaria is a disease that is transmitted by the bite of a mosquito. The mosquitoes are breeding during the rainy season, the same time that the crops are growing. By the time it’s right to harvest the crops, it may be that the larvae have developed into mosquitoes now transmitting malaria infection. It’s not uncommon, therefore, that just when harvest time comes, the whole community is knocked out by malaria and can’t harvest the crops. Think of the consequences of that for poverty for devastation, for hunger, even for famine in the coming year. Of course, another economic consequence of ill health is the direct cost of health care itself, if a community can afford the health care. That eats up a budget, and it can be very, very expensive treating the diseases for very poor people. Even what would seem to be, modest outlays of a few dollars or a few tens of dollars, for a disease. Amounts that would hardly be noticed in the rich world can be the margin of survival for poor families that hardly have enough to eat to start with and may lose their last remaining monetary income to the effects of a disease.

922A disease burden contributes indirectly and over the long term to demographic problems. Remember how high total fertility rates can impede economic development, when the population’s growing rapidly, and when the community is supporting a lot of young children, and looking after them. And having to put them through school, and build new schools for a growing youth population. Who are not themselves earning income at the time, the burden of rapid population growth and a very young age distribution, I, is a huge hindrance for economic development. We’ve noted already on several occasions that a rapid voluntary reduction of fertility can be a big boost as it was in China to economic growth. But consider what happens when there’s a heavy disease burden. When out of every 1000 children born, 100 or 200 or 300 don’t survive to adulthood. Parents knowing of the high risks of children’s deaths. Therefore respond by having large numbers of children and if the household wants to be absolutely sure that there is a surviving son. For instance, for cultural reasons to perform the funeral rights or for very pragmatic economic reasons to support the mother and the father in their old age. Families may choose to have two or three or four sons to make sure that at least one survives but having two or three or four sons might mean having four or six or eight children as a whole. And so this is another indirect way often overlooked at how high disease burden is conducive to a perpetuation of poverty. Finally, one should note, investors are not so keen on investing into a high malaria zone or into a high AIDS region. Think of it that you are aware that your labor force could be very sick, could be dying young. A need to replace many, many workers as a hotel manager you’re aware that you’re trying to get guests to your hotel but after every rainy season there’s a malaria epidemic. It doesn’t seem very attractive for investment. You’re a mine manager. But you’re surrounded by infectious diseases like malaria. Well, foreign investors don’t like to head to those locations. This is yet another way how disease leads to poverty. But the arrow goes the other way as well. And I think that’s the direction that people perhaps most naturally consider how poverty contributes to disease.The answer that  trips off the tongue and comes to mind is can’t afford a doctor. And of course poverty does mean a much lower access or no access at all to medicine to modern doctors to basic health services, but there are many, many other ways that poverty contributes to a heavy disease burden.

923One that I’ve mentioned already is the immuno-suppression that comes from chronic under-nutrition. Children who are not fed well, who lack basic micronutrients, have immune systems that are tuned down, that are not as effective, not as able to resist disease. Poverty also tends to mean a more dangerous physical environment. Poor families in rural areas typically don’t have reliable sources of safe drinking water or reliable clean sanitation. There’s open defecation it means that many diseases cycle through the body and are spread by open deification and the pathogen getting back into the ground water. And back into the wells and back into the water supply a diseases like cholera are spread in this manner. And so poor communities have poor infrastructure lack of access to the basic environmental conditions for good health. Poor people live in adobe huts with thatch roofs, often with a gap between the thatch and the walls a gap in which various insects can easily enter, mosquitoes bearing malaria or flies bearing other diseases or other insects that are coming and spreading disease. So even the physical structure of the housing can make a very, very big difference. Poverty is related to the ecological conditions of disease. Worm infections like hookworm or Trichuris or Ascaris are in warm, wet, tropical climates. Poor people living in the warm, wet tropics are subject to a much heavier helminth or worm infection. That’s part of the reason for their poverty, but it’s also the cause of poverty coming from the disease burden. Malaria is a disease of the hot tropics and, as a result the poor people living in that region have this extra burden of disease. One can say that it’s a condition of poverty, it’s really a condition of the geography associated with poverty. Poverty is also associated often with illiteracy, innumeracy the lack of ability of individuals to seek health in the right way or to understand what to do or how to fill a prescription or how to adhere to a drug regimen if that’s what’s needed. And so, health seeking behavior is extremely important for all of us. Poor people have a harder time with less education and less ability to fair out the right kinds of help. That’s why workers like community health workers can be so important to help poor people make the connections with the health system itself. And people living in poverty are very, very vulnerable to doing dirty and dangerous work. Young women who because of their extraordinary vulnerability, end up in sex trades, for example. And vulnerable to AIDS and other sexually transmitted diseases or to violence, and to other life threatening conditions of life, is another aspect of poverty itself. And so once can see this two way direction. Poor health leading to poverty Poverty leading to poor health. Whenever you have the arrows working in both directions, you have the possibility of a vicious spiral. Poverty, poor health. Poor health, even more poverty. More poverty, worse health. Worse health, even worse economic outcome. But whenever you have a vicious spiral you generally have the possibility of a virtuous spiral as well. Disease control raising income, higher income improved health, further improvement of health. Even yet further improvements of income in a virtuous spiral, exactly the opposite of the vicious downward spiral. It’s part of the effort of health the policy to break the vicious circle that traps people in a poverty disease trap and to make it a positive spiral of a health development upward spiral. So how can this be done? How can one intervene to control disease and thereby start the virtuous spiral? First of course is implementing what the health ministers called for back in 1978 in Alma Ata. They called for a primary health system for all, and implementing that basic primary health system is a crucial first step. Second is helping poor communities to have better nutrition. Part of that may not be directly in the health sector but in the agriculture sector. More productive farmers growing more food will support healthier diets. The community may generate a surplus that can be used for school feeding progr, programs for example. And therefore, agricultural interventions can play a role not only in agriculture and income, but also in reducing the disease burden. Local infrastructure, is another kind of investment not in the health sector per se but in safe drinking water and sanitation in. Power supplied which is vital for everything. Electricity to run the refrigerator in the clinic to keep the vaccine supply chain adequate to ensure that doctors have the facilities. Water to pump the irrigation water to improve agriculture. And a thousand other uses of electricity absolutely vital to improving overall health. Mobile phone connectivity, internet connectivity. We don’t think of those as health interventions per se. But communities that have access to phones have access to better health. They can call the doctor, they can call the health worker, they can call the ambulance and so investments in infrastructure extremely important. Education at all levels absolutely essential just so individuals understand how to seek help. But also, education raises incomes, we know that higher incomes for all the reasons we’ve discussed improve health outcomes as well. And local business development by raising the incomes of the community also cut that downward spiral of poverty and disease. How far do we have to go we have a ways but we’ve made also a lot of progress have a look at the data on the mortality rates of children under the age of five. Back in 1990, 12 million children under the age of five died. By 2010, the number was under 8 million. This is a huge, huge victory for public health. It is still 7.6 million too many. It’s still multiple and preventable tragedies, but there’s progress. There’s very substantial progress in reducing the mortality rates. If you look at the next graph, those same mortality rates are put in terms of numbers per thousand live births rather than the aggregate number of millions. And this is quite important as well. In 1990, on average in the world, 88 of each 1,000 children did not live to their first, to the fifth birthday.

By the year 2010, that rate had declined to 57. Per thousand. Still, a high number, still a number of deaths that can be cut sharply. But the under five mortality rate is falling sharply. Now remember, we also have an important clue where we need to put the extra special effort. If you look at the total number of deaths in the year 2010, the 7,600, more than 6,000 of those deaths were in just two regions, Sub Sahara in Africa and Southern   Asia. These are the epicenters not only of overall poverty but the epicenters of the disease burden and of the preventable and treatable diseases that could reduce this amount of suffering. And where are poor people succumbing to what kinds of conditions? That is shown by the estimates of the causes of deaths of children under five. And when you look at this chart, the 100% of that’s allocated in proportions to different diseases. What you see as the overwhelming message of this chart is this still very high burden of communicable, that is infectious diseases that can be spread from individual to individual. Diarrhoeal disease, pneumonia, measles, malaria, other infectious diseases, are a very large part of these deaths. What you also see are the number of deaths of children just in childbirth. As newborns, or neonates. And in the first four weeks of life. In the very vulnerable conditions just after birth. And so we see birth asphyxia. And the trauma, prematurity. A severe neonatal infections. A whole cluster of a causes of death related to childbirth and very often to the lack of sanitary conditions that face mothers giving birth. Threatening their own lives and threatening the survival of their children. Well, this is a, a good start for us in terms of understanding what to do. We have a poverty disease trap, each feeding on the other. Poverty feeding disease, disease feeding poverty. We know that this is heavily concentrated in Sub-Saharan Africa and in South Asia, we know that it’s heavily concentrated in diseases that are infectious and communicable. Or in conditions related to childbirth, or as a consequence in addition of chronic under-nutrition. So this gives us ideas where should the focus be how should we proceed? Building a primary health system that is responsive to those specific challenges is in essence the source and, and the starting point for addressing this wholly solvable but continuing crisis. We’ll now look at how that primary health system in a low income setting can best be designed

Why Did Some Countries Advance While Others Remained in Poverty? V

Which Countries Are Still Stuck in Poverty?

In our quest to understand sustainable development, and right now economic development we’ve focused on the modern era of economic growth We saw how the Industrial Revolution began in England and spread to all the world. Or, one should say, almost all the world because there are some places that still, even to this day, lack some of the basics, and lack some of the on-going economic growth that Indeed has reached almost all of the planet.

451We’ve been undertaking a differential diagnosis to understand how those, moving ripples of economic development have reached some places in the world, and failed to reach others. We’ve explored the role of the poverty trap. We’ve explored the role of geography. The role of culture. The role of, politics. Let’s put the pieces together. By focusing on those remaining areas in the world that are still stuck. Below the threshold of self sustaining growth. And, as we’ve used the idea of passing that threshold, looking at the $2,000 per person, per year threshold. As a marker for us. When we look at the map of global development. We see that those countries shown in red. On this map are the ones that, as of today, are still below that takeoff level. What do we see? We see that the remaining regions are, mainly, tropical Africa. And then, the number of land locked countries, Afganistan. Napal, Mongolia, Louse, and a few other parts of the world, and of course with out question we have to regard sub saharan Africa as the greatest challenge of development, the place in the world still with the highest poverty Rates, and with the biggest challenges in meeting basic needs.

452The good news is that in recent years especially since the year 2000, economic growth in sub Sahara Africa has picked up. There’s definitely progress, major advances in some of the key areas. Of disease control. Improved access to education, building infrastructre. But we’re still not yet in a sitatuion where there is self sustaining, rapid and dynamic growth, though one feels very much that it’s within reach. Let’s put our differential diagnosis. Perspective, therefore, on sub-Saharan Africa, and ask what we learn by taking that multidimensional view of a region to see what it implies for the priorities for economic and sustainable development. Africa has many distinct structural characteristics and many of these strustral charectarcistics are indeed sructeral problems for econmic development, if you look at the region of peverty in Africe That is below the Sahara Desert but above the southernmost countries. One is defining essentially the region of the tropics of Africa. Between the Tropic of Cancer at 23 Degrees north latitude in the tropic of Capricorn, and 23 degrees south latitude. And we know that the African tropics have many distinctive features that are relevant for economic development. Disease burden we’ve seen is very heavily concentrated in the tropic whether it’s malaria or other so-called vector-borne diseases, or worm infections that debilitate people, and that hold back whole societies. We’ve seen that.

453Agriculture can be very difficult in tropical conditions. Often water scarcity, with the very high temperatures, drought   propensity, soil nutrient depletion can be extremely pernicious in the tropical context. So this is one feature that needs to be addressed. Nothing impossible about these challenges because diseases like malaria are fully controllable, but they need to be controlled. We’ve seen that Africa has a distinctive feature of the most land-locked countries of any continent in the world. Roughly one in three African countries. Is land locked. 15 out of the 49 countries of Sub Saharan Africa. That’s a big problem. Why is that? Well, part of the reason is the colonial legacy. Remember that nature doesn’t draw national boundaries. Politicians do. And when the politicians divided up, Africa they divided it up into little parcels often cutting natural ecological areas dividing ethnic groups by artificial boundaries leaving a legacy. Of great difficulty making it hard for populations even to reach coasts. In many parts of Africa, the coastal physical environment is rather hostile. And in East Africa.

The eastern coast tends to be very dry. The trade winds come up to the coast from the east. They do not provide precipitation right on the coast, but as the highlands in the east coast carry those trade winds into higher altitudes, Then the rain is distributed in the interior, what’s called orographic rain fall, or rain fall that is caused by the uplift of the mountains, in this case, the highlands of East Africa. This means that the high population densities in East Africa are not at the cost but are in landlocked interior countries like Rwanda, for example, or Uganda. Where there is much more rainfall than one would find in their port of Mombasa, Kenya, which is in a, a much drier region. So, the distant from the ports has to do with history, it has to do with political boundaries It has to do, some historians think with the long legacy of even slave trade which caused populations in their self defense to move more into the interior. It has to do with the fact of rainfall being more propitious and able to support food production Often away from the coast and in the interior of the continent. We know that in many, many, other ways, the colonial legacy has played very difficult role. Have a look at the map of European colonial rule In Africa as of 1914. The first thing you see is the entire continent with the exception of of Ethiopia, was colonized. Africa was divided among the European powers, and the story of how it was divided is a rather shocking story. Actually, Africa was one of the last continents to succumb to European imperial rule. That may seem strange because Africa was very poor throughout history, therefore very vulnerable.

454As exemplified by the slave trade. So why wasn’t it colonized earlier? Europeans attempting to move to the interior of Africa in the earlier parts of the 19th century to colonize, succumbed to malaria and other tropical diseases, the disease burden actually prevented europe from colonizing africa until the latter part of the 19th century. Then what happened? Well, you could perhaps describe it to tonic water. Tonic water is water with quinine. But quinine is a natural preventative or curative to malaria, and when quinine was discovered and then mass-produced by the British and then by the other imperial powers, That enabled Europe to dominate Africa through military means. The Europeans were brutal vis a vis the Africans, but strangely polite and diplomatic among themselves. They sat down at the conference table at the famous Berlin Conference. Of 1884 and 1885 and said gentelemen, because of course was only gentelmen around the table, lets deivide africa in a very civilized way, civilized fro us without any civilaty vis a vis the fricans, and by 1914 you had a map of Africa that was divided in all of these arbitrary political divisions. This has left a legacy of wrong borders of high land lockedness of European domination over many of Africa’s natural resources. So that the resource earnings have been extracted and end up in tax havens around the world rather than the treasury coffers of Africa itself, the European powers did not provide education. Indeed there’s a documentary record showing we don’t want to educate the local population that would be a political Risk for us. And so when African governments achieved independence, often there were just a handful of people with a high school, much less a university, education. The infrastructure, physically, that the European powers left behind was also strangely deficient.

455Have a look at, a comparison of the map of the Indian railway system, built largely during the British colonial period in India, with the map of Africa’s railway system built largely during the period of colonial rule. In India you see a full grid. And that was because a unified colonial power, Great Britain, created a unified infrastructure, partly to extract India’s natural resources, including its cotton. As inputs to the cotton mills of England. In Africa, where the conditions were harsher and more difficult and the political divisions existed, the European colonial powers did not sit down together after the conference in Berlin and say, Now let’s construct a railway network. They each one constructed just a line from their port to the diamond mine or to the gold mine or to the plantation, and so the rail systems in Africa is not a full grid, but is just spurs that go to a few locations. And this has much greater burden for Africa. When India had its agricultural revolutions, so-called Green Revolution of the 1960s, this railway line played a crucial role in bringing fertilizer into the interior and bringing grain from the interior to the national economy. But in Africa, the rail can’t sere that purpose it doesn’t exist. It still has to be built. Even in the 21st century. So the legacies of colonial rule in Africa have been very, very tough. This isn’t an explanation of everything My point, again and again, is, don’t take a single factor. You cannot blame it just on colonial rule. We’ve seen, you can’t blame it just on, quote, corruption, because in many parts of Africa, the levels of corruption are comparable to far richer countries. In other parts of the world. You can’t blame it just on culture, though culture matters. It matters for gender, it matters for fertility. It matters for commitment to education. You can’t blame it just on geography, but geography surely has player a role in the burden of disease, in the vulnerabilities of agriculture. Of the high transport costs. Differential diagnosis doesn’t necessarily give you a simple answer. Simple answers are often highly simplistic answers. We need accurate answers, and the differential diagnosis helps with accuracy. It identifies several of the challenges that need to be addressed, even though Africa And, other countries still stuck in poverty. May face added burdens. They also have the opportunities for technological breakthroughs. Unimaginable, until recently. Now, when you go, even to the remote African villages across the continent. Maybe with few exceptions, but as a general rule, mobile phone coverage is there, broadband is on the way, information technology, is already transforming these very low income villages very low income regions Bringing in knowledge, market information, data empowerment and the potential for breakthroughs in help, in education, in business development. In other words, when we make the differential diagnosis, we identified the political and the cultural and the geographic. Phenomenon when we identified that heritages of the colonial period and the shortfalls of the infastructure. We are not overcome by pessimism but we are motivated with an agenda. An agenda which is targeted. A specific, a balance of public and private investment At areas for social mobilization, public awareness, the role of parents to help their children to make breakthroughs as well, that is the key for sustainable development.

Why Did Some Countries Advance While Others Remained in Poverty? I

The Idea of Clinical Economics

We’ve seen how modern economic growth diffused through the world. It started in England. It spread out [COUGH] like the ripples of waves on a lake surface. But, why did it go to particular places? Geography matters a lot, proximity to already rich markets matters. The conditions of the natural environment, the government policies all matter. I’d like to take a deeper dive today into this question. What happens within individual countries that determine whether that country gets on a path of rapid economic growth and development, or whether it remains mired in poverty.

411There are lots of reasons that, or good explanations for why some countries advance and others get stuck. But what’s true is that those good reasons don’t all apply to all places. The real art of economic development is to make good judgement what’s happening in this particular place. Not on average, but if there’s a country that is facing an economic crisis, if your country is stuck in poverty, Or stuck in instability. What needs to be done here and now. How do we make a diagnosis? Well, I, I was lucky, in, in, my own work and thinking about this because I got to watch close up a wonderful diagnostician. Do her work. Thats my wife. Shes a clinical pediatrician, and when she sees a young child with a fever, she doesn’t say oh that’s it I know what that is all fevers are the same. Of course she does something completely different. Her training and knowledge and experience shows her as a trained medical doctor that there could be a thousand reasons for that fever. And in order to give a good prescription there has to be a good diagnosis. And what the doctors call it is differential diagnosis. Well I’ve come to the view that in economic development, and in sustainable development more generally, we also need to have a clinical approach. In my book The End of Poverty, I called it clinical economics[1]. And I said the world of a  good practicing clinical economist is to make a differential diagnosis just like a good medical doctor. And the fact of the matter is that as medical doctors go through their checklist what could be the cause of that fever. Is that an infection, is it something more serious. And they look at the evidence, they look at the lab results, they do the interviews, they try to understand from the parents and from the child, what’s happening. And then they draw a rich diagnosis. So to we as. The practitioners of sustainable development need to make such a differential diagnosis. On my checklist, as I presented it in the end of poverty, I suggested seven items on that checklist. Each with many categories to work through. What could cause a country to be stuck in poverty or stuck without economic growth? Let me mention the seven. First, could be what I call a poverty trap. Second, it could be bad economic policies, governments just making terrible mistakes. Choosing the wrong kind of strategy, closing the borders when international trade would make more sense, going for central planning under communism when a market system would be much more propitious for economic development. A third it could be that the government is broken in some manner, and most often, it’s bankrupt. Many governments around the world, and throughout history, have gotten into a fiscal mess. They’ve spent too much, they’ve taxed too little, they’ve got into wars that they shouldn’t have done and couldn’t afford, and ended up with a massive fiscal crisis. A fourth is physical geography. Maybe the country is stuck. Because it’s landlocked, high in the mountains, facing a terrible disease burden. Malaria for example. You might say, well if it’s geography, what can you do about it? You can’t change your geography. But the fact of the matter is you can change the consequences of your geography. If a country is landlocked, it needs to think about transport, and the kinds of industries that it’s promoting. If it has a heavy disease burden like malaria because of its tropical environment, it has to think about specific disease control. So while geography might not change, the results of geography are often subject to the human resolution. A fifth kind of failure could be ru, the lack of rule of law, massive corruption. That corruption[2], when it gets out of hand, can completely frustrate the normal processes of governance and therefore of economic development. A sixth. Problem could be cultural barriers. In fact, it’s very often said, if a country isn’t performing well, something’s wrong with the culturee. More often than not, I think that’s glib and simplistic, but sometimes cultural factors can really make a difference. And last. It’s geopolitics. By geopolitics, I mean a country’s relations with it’s neighbors, with it’s foes, with it’s allies. Because countries can suffer geopolitically. Of course, countries that fell under imperial domination in the middle of the 19th century and were under colonial rule for a century or more. Our powerful examples of what geopolitics can do to frustrate economic development. Clearly these seven factors and the many sub-factors that would fall under each of these categories does not necessarily apply in any particular condition. It’s a checklist for a diagnosis to ask what in particular counts in this particular place from the point of view of the strategy of economic development or of sustainable development more generally. In my own experience of more than 25 years of working with countries all over the world, It’s really struck me how different parts of the world in different counties in different times have extremely different conditions that they need to confront to get out of the rut, and the idea of always prescribing the same medicine, for a doctor it would be a disaster, the same is true. A foreign economy. I worked in Bolivia in the middle of the 1980s. That country had a hyperinflation. Prices were rising thousands of percent per year. When you did the differential diagnosis you could see that the government was broke. The government was printing money to pay its bills. And therefore what was required most of all was to get the budget under control in short order so that this fever of hyperinflation could be broken. That involved in part cancelling some of the debts that Bolivia’s government owed to international banks. That was part of the solution. Maybe in other countries, that wouldn’t have been necessary but in Bolivia’s case, it was. 1989, when Poland was in the transition from communism to a market economy, the great challenge was to allow supply and demand, markets and trade to work once again. Because the central planning mechanism had collapsed. When I began working in Africa, in the middle of the 1990s, the conditions obviously were completely different, from those of Poland, or Bolivia earlier, indeed other parts of the world. Africa was in the midst of a massive AIDS pandemic. It was in the midst of a massive resurgence of Malaria. Many places were so poor, that the most basic infrastructure, grows. Power, water, and sanitation did not even exist. I’ve found some. Economic officials from international institutions prescribing exactly the same medicine that, that they had said was needed in Poland or in other places. And it amazed me. Do a differential diagnosis and you see the problems in Tanzania or Ghana or Mali are completely different. From those in Poland. Do expect that these conditions will differ across history within a country, and certainly at any time across countries of the world. Now, one of those possible diagnoses is a poverty trap. Since we want to focus on the poorest of the poor to help. The poorest places get out of poverty. It’s important for us to focus on this particular case. It does not apply to most parts of the world. The idea of a poverty trap is rather straightforward, even if it’s sometimes overlooked. The idea is that any. Economy in the 21st century needs certain basics in order to be able to achieve economic development. It needs the basics of roads, of ports for trade, of electricity. Of safe water and sanitation for the people of access to basic health care so that the population is not burdened massively by disease and of education for children. Pretty basic list, and most of the world is able to secure that. But the poorest of the poor countries often cannot. Because the amount of finance that’s needed just for those very basic goods could be out of reach of the government. Let me give you an example. Suppose that you look at the basic cost not of, of fancy systems for health and education, roads and power. But of a very rudimentary system to help a poor country get started in economic development. Say that the cost of that, when you add it up, is $200 per person per year. Consider a poor country, say, $500 per capita as we’ve seen in the case of Malawi, for example. The budget for Malawi might collect 20% of the national income for public provision of goods and services and investment in infrastructure. Well, 20% of $500 per capita means that the government would be collection $100 per person per year. But we just said that the minimum needs are $200.00 per person per year. So the government of Malawi may be staffed with wonderful people and they know just what to do, they’ve made a great differential diagnosis, they even have plans on the shelf for schools, for clinics, for roads, for power, for water and sanitation. But how are they going to pay for it? They are trapped in poverty. Because they know what to do, they know the investments that need to be made, but they don’t have the money for it. There are two ways to break the poverty trap. One way is to borrow that extra money, and then have the economic growth that results. Help to pay off in the future. If global capital markets worked well, that would be a remedy. But private markets and public lenders say, well, that’s a poor country. That’s too much of a credit risk. We can’t lend to it, even if our loans would trigger the development that would allow them to repay. So the capital market solution doesn’t work all that well. The alternative is to get a boost of help. A short term boost, sometimes called aid or sometimes called official development assistance. So that a country like Malawi can fight Malaria, or build the classrooms for it’s kids. This is a pretty proven method and it really works. During the last dozen years or so as the world has been organized to help countries in extreme poverty fight extreme poverty. There have been special institutions set up like the Global Fund to fight AIDS, TB, and Malaria. And when money is put into that fight, you get tremendous results. Alas, even though the evidence is strong that it’s possible to break a poverty trap by that kind of target investment, and there are some positive results along the way. We haven’t quite succeeded yet in the world accomplishing that, in part because the concepts of what’s needed, the diagnostics of how to do it, and then the institutions to offer the finance are not fully in place. This remains one of the great challenges of sustainable development.

[1] http://en.wikipedia.org/wiki/The_End_of_Poverty

[2] http://www.transparency.org/cpi2013/results/

 

The MDGs and the End of Extreme Poverty IV

A Closer Look at Official Development Assistance

We’ve seen through differential diagnosis how targeted investments in agriculture and health, in education, in infrastructure can help a very poor country, or region to spring itself free from extreme poverty. And once it’s free from that trap of extreme poverty, then by virtue of a higher income and the saving that can go along with that higher income, it can begin to make investments on a self sustaining basis.

A big part of the poverty trap however, is that when a country is impoverished, it can’t afford the very investments, for instance, in electrification, or in health and in education, that are the key to raising productivity to put that country onto a self-sustaining growth path. That, of course, is the poverty trap. How to break free of the poverty trap? Well, the, the best is if a incredible technology comes along, that’s even affordable by the poorest of the poor. Mobile telephony is such an example. Mobile phones have spread massively from a few tens of millions a little over 20 years ago, to more than 6 billion subscribers today reaching the poorest parts of the world, on a purely market basis. But alas, most technologies they are not so effective, that markets alone are, enough. We know that helping the poorest people get healthcare even to buy the bed nets to protect them from malaria or the medicines that they need to stay alive after an effective malaria bite by a mosquito, that they don’t often have the money for that low cost life saving measure that’s needed.

541And therein lies the reality of the poverty trap. Certain investments remain out of reach. And therefore, we need to find effective ways to help those countries stuck in extreme poverty get out of the trap. There are two basic ways. One is for poor countries to borrow the funds they need, thereby raising the income. And using a part of that higher income to pay off the debts. Unfortunately, this is a somewhat unreliable process. Maybe the government borrows, but it’s not able to collect the added tax revenues that it needs to service the debts. Of course, creditors understand that. And they don’t lend to some of the world’s poorest countries in the first place. Even international agencies like the International Monetary Fund have said the very poor countries don’t borrow so much, you could get into a debt crisis. The poor country governments say, yes, but what are we to do if we can’t borrow but we still need electricity, we still need clinics, we still need schools and we can’t afford them out of our own incomes. That is where the idea of temporary official development assistance, ODA in the jargon, should come in. The idea’s been around now for more than 40 years on an officially agreed basis. It’s been around in human experience for more than 60 years, really starting with the Marshall Plan funds of the United States to help rebuild Europe after World War II, that a temporary injection of funds, not as a loan but as a grant, to very poor places or maybe places destroyed by war, can jump start a process of self-sustaining growth. It’s important to understand that nobody advocates or should advocate the use of aid or ODA, Official Development Assistance for the long term as a way of life. Advocates of aid and I am very much one of them, believe that it is a temporary easure to give the help to a poor country so that it can make the crucial investments needed so that it can stand on its own and develop on its own. Indeed we use a term aid graduation to say that aid isn’t a permanent way of life. But the countries that receive aid, by virtue of the economic growth that it promotes, reach a level of income, such that that country graduates from the need for aid and graduates from being in the category of an aid recipient.

Roughly speaking, graduation occurs when a country passes from the low income category to the middle income category. Somewhere around $1,000 or $1,200 per person, per year. Now ODA as a concept, was adopted by the world community around 1970. There was a famous commission headed by then, prime minister of, Canada Lester Pearson, a Nobel Peace Prize laureate. Called partners in development. And it recommended a kind of partnership to enable the poor countries to get out of the poverty trap. Mitt said that rich countries should devote around 1% of their income to help poor countries in meeting basic needs and basic investments. And of that 1% of national income, 7 10ths of that or 0.7 of 1% of national income, should come through official channels, mainly government to government, or at least government to poor countries. And the other 0.3 of 1% should come mainly through private contributions. Corporate contributions or individual contributions or charitable organizations. So back in 1970 and 1971, the United Nations adopted a standard that the high income countries, which became known as donor countries, should give through official channels 0.7 of 1% of their national income in the form of official development assistance. Consider the United States for example. A $15 trillion economy each year. 0.7 of 1% of that is 0.7 of 150 billion, or $105 billion dollars of official development assistance each year.

542That’s the international standard. Alas, the United States isn’t doing anything close to that, because the official development assistance given by the United States is around $30 billion per year, not $105 billion. So rather than being 0.7 of 1% of the national income, it’s closer to 0.2 of 1% of the national income, less than one-third of the international standard. Have a look at how countries are doing in their official development assistance. You can see on this graph that is ordered from the top being the smallest share of national income, to the countries with the biggest bars at the bottom that five countries among the donors reach at least the targeted threshold of 0.7. Some are up to 1% of their national income, purely through official channels. Those five countries are Sweden, Norway, Denmark, Luxembourg and Netherlands. And those five countries, all for many, many years have honored the 0.7% of national income threshold. At the other end of the spectrum, are countries that give quite low amounts. The United States is one of those, because rather than 0.7 as I mentioned, it’s closer to 0.2. And in many years, it’s dropped even below 2 10ths of 1% of national income. Now, the United States still gives a lot of money in an absolute level. You can see on the graph showing the total amount, not as a share of income, but the total aid. The United States is the world’s largest donor country, with $30 billion a year currently of development assistance. But as a share of the world’s largest economy, that’s a pretty modest amount, even though in absolute dollars, it’s a large amount, and it makes a big difference. What kind of spending does this money support? Official development assistance has to have the following categories. First, the money is going to poor countries. Once in a while, a rich country gives to another rich country, maybe for foreign policy or military reasons. That’s not part of Official Development Assistance. So first, the recipient country has to be eligible. Second, the money has to be provided by an official agency of the donor country, or by money that goes from an official agency to an international organization, like the World Bank, which then gives the money to an eligible recipient country. Third, the money has to be used for economic development. It can’t be used, for example, for military sales. It can’t be used to support troops. It can’t be used to support soccer games or cultural events as nice as those are. Those aren’t counted as official development assistance, because the idea is that the ODA should be for D, that is for development. There is another important distinction to make because aid comes in many shapes, and sizes, and forms. If the aid is given as a, an emergency relief, for instance food in the middle of a famine, it saves lives, it’s humanitarian relief. Similarly, if it’s emergency help after a massive flood, or an earth quake. That’s also counted as aid. But it won’t do more typically than the crucial job of keeping people alive. It’s only compensating for a terrible disaster. The kind of development aid that can help a country make a break through out of poverty is something else. That’s official development assistance that ends up as paved roads or an extended power grid, or clinics, or schools, or support for community health workers. Or antiretroviral medicines to fight AIDS, or insecticide treated bed nets for malaria. So, looking at these two pictures. One kind of aid is for emergency relief. Very valuable, but only compensating for disaster. And the other is aid as a real investment. In this case, in supporting a farmer’s cooperative, a beekeeper’s cooperative to promote economic development. There’s a lot of confusion about whether aid works or not, because not all aid is the same. If a donor agency in a rather cynical way says, we’re going to give, shoe boxes of cash, to warlords because that’ll be good for our war effort or our foreign policy. Or we’re going to give money to such and such government. We know it’s corrupt, but we, for whatever reason, want to support that dictator. Well that can get counted as aid. But it’s not going to do anything for economic development. The kind of development assistance that works, is development assistance that is truly professionally transferred to real investments in critical areas. Such as disease control.  Such as schools, and teachers, and school materials. Such as infrastructure like roads or rail systems. Such as safe drinking water and, sanitation. When that kind of aid is given, the evidence is very strong. Development assistance works. It promotes long term economic development. Make no mistake about it, aid can be wasted, but aid can be crucial to meet human needs, to help countries achieve the millennium development goals. And beyond that, to help countries escape from the poverty trap and get onto a trajectory to end extreme poverty. During the MDG period, my favorite kind of aid has been aid directed at public health needs. And as this graph shows, which measures the total development aid over the period 1990 to 2010 there was a major increase of development assistance, especially after the year 2000. And that increased assistance has played a huge roll in helping to control AIDS, malaria, tuberculosis. In helping to insure that mothers are safe in child birth. That newborns are kept alive and have a chance to thrive. That children can get nutritional benefits, and can be protected against scourges that otherwise would claim their lives or claim their potential. And we have seen the big breakthroughs that have come. The decreases in mortality rates from killer diseases. The declines of the infant and child mortality rates, especially after 2000, when those reduced mortality rates really showed the huge benefits of these kind of targeted investments. Official development assistance, in other words, can make a huge difference, when it’s operated for development and on a professional basis. It can be the difference of success or failure in breaking free of the poverty trap. It comes at very low cost by definition, under 1% of the gross domestic product. The world, the rich world should make that effort, should make that investment so that we can be the generation that ends extreme poverty.

The MDGs and the End of Extreme Poverty III

South Asia: The Continuing Challenge of the Food Supply

We’ve noted that there are two main regions in the world where there is still extensive, extreme poverty. Sub-Saharan Africa, with investments in agriculture and infrastructure, and a rapid reduction of fertility rates can break free of extreme poverty. So to can the second region, South Asia. Indeed, South Asia’s been making notable progress, but there are still around 400 million poor people in South Asia. And still major challenges of poverty in both the rural and the urban areas.

531What distinguishes South Asia from other regions? Of course, many aspects of wondrous culture traditions and physical environment. But the one that I would want to underscore is the extraordinary population density of South Asia. Consider India, with its 1.2 billion people out of 7.2 billion people total in the planet. That’s roughly 15% of the world’s population, yet India has just 2.5% of the world’s land area. And many parts of that land mass of India are very dry, or even desert. Have a look at the map of population density where countries are shaded according to their population density. And you see that India and its next door neighbor, Bangladesh are indeed shaded as two of the most densely populated parts of the world. The numbers indeed are quite staggering. Bangladesh has on average 1,200 people per square kilometer, India about 410 people per square kilometer. The  nited States by contrast has about 32 people per square kilometer. And so, the population density in India is more than 10 times higher than in the United States. And the implications of this throughout India’s history have been adverse. Indian farms are very, very small. Indian farmers traditionally have been able to grow only a small amount of food. And have eked out an existence of poverty in the thousands of Indian villages from time immemorial.

The cities, too are extraordinarily dense and crowded as India’s and South Asia’s cities more generally have increased. Many people thought the situation was hopeless for South Asia looking in the 1950s and 1960s. They said population is already so large and it continues to rise. India and its neighbors don’t have a chance to feed itself. People forecast that there would be mass dying from mass starvation. Bangladesh, when it gained independence in the early 1970s as notoriously called a basket case, absolutely hopeless. 532Now thank goodness this has not proven to be the case. And indeed India has been one of the best economic performers in recent years. And it has taken a pride of place as one of the leaders of the information technology revolution with wonderful engineering wonderful innovation in using information technology for economic development. And through IT it has become integrated into the whole world economy. Often in cutting-edge industries using information technology with great programming and systems developed by India’s engineers, some of the world’s finest. How did this happen? How did India avoid the fate that was so widely predicted for it? Well there we have to start naturally with agriculture, because once again India was overwhelmingly a small holder, peasant society living in villages and living in poverty.

It was a great breakthrough in technology that enabled India to begin this lift off into sustained rapid economic growth. And that breakthrough in technology has been given a famous name that is the green revolution. The revolution in crop yields that really started in Mexico and India in the 1950s, and then has spread to most of the developing countries, still to be enjoyed by Sub-Saharan Africa. What is the Green Revolution?

533Well the Green Revolution starts with the individual pictured here a great hero of mine, Norman Borlaug. A Nobel Peace Prize winner who, as a highly skilled agronomist, a seed breeder, using his great ingenuity developed high-yield seed varieties for wheat, working in Mexico in the 1940s and the 1950s. Norman Borlaug was invited to India in the early 1960s. His counterpart was another absolutely wondrous a, agronomist pictured here, another hero of mine, M S Swaminathan. The two of them took seeds that Norman Borlaug had developed for Mexican conditions and planted them in Indian soils and Indian conditions. First year didn’t work out that well. They looked again. They decided on a different approach The second year proved that lo and behold, Mexico’s varieties developed by Borlaug for Mexican conditions worked beautifully in the Indian conditions. And they decided from that point on, that a green revolution for India could be within technological reach. To make it happen they had to add a third to this great triumvirate, and he’s shown here.

The minister of agriculture of the mid-1960s, Minister Subramaniam. The idea was to multiply the Sonora, Mexico seeds that Norman Borlaug had developed and that M S Swaminathan had helped to prove would work in India. To combine them with fertilizer and irrigation and transport facilitation, so that India could begin to experience a major takeoff of crop yields. Now, the picture you’re looking at here shows the green revolution for the whole developing world. You see that yields up until the mid 1960s were still under 1,000 kilograms per hectare of arable land. That is one ton per hectare. But then, look what happens after that.

534The march up the yield curve to the point where in recent years, yields on average in the developing world have been between 2.5 and three tons per hectare. With many parts of the developing world achieving more than three tons per hectare. Well fortunately, India is one part of that overall green revolution. It hasn’t had the most stupendous of the results but it has had important beneficial results, as shown in this picture. First you see Mexico’s take off. That’s where Norman Borlaug first developed the high yield seeds. India and Pakistan lagged far behind Mexico already by the early 1960s. Mexico had jumped to two tons per hectare, whereas India and Pakistan were averaging still under one ton per hectare of land. Then came India’s green revolution, also undertaken in Pakistan. And the average yields start to rise of all of the feed grains: wheat, rice, maize, and of other grains where improved variety seeds were also developed and combined with fertilizer and good water management. Well, India and Pakistan did not catch up with Mexico, which went on to more than four tons per hectare planted. India and Pakistan have reached more than two tons per hectare. Well over doubling the average yields of the pre-green revolution crops. This has been the key to India feeding itself. To defeating those pessimistic forecasts of mass hunger. And of helping to set off a process of more rapid economic growth. But, there’s a problem.

535The problem is that India’s population growth remained rapid as well. Have a look at India’s population growth. In 1950 India’s population was about 400 million, a huge and already densely populated country. By today, that population has tripled. So while grain production has roughly increased four-fold, population has tripled, not undoing all of the gains per person, but unfortunately undoing many of them. And measuring India’s feedgrain production per person shows what this has meant. Have a look at this graph which shows the feedgrains per capita from the beginning of the 1950s til close to today. The curve was rather significantly rising up until the mid 1970s. The spikes in the curve come from the fact that some years are good monsoon years and others are bad monsoon years. So, some years are extra good yield, and other years are crop failures and even disaster.

But on average the curve was rising up to the early 1980s. It’s really then that the population increase started to bring the whole burden, because the increase of output per person essentially stopped. And from the early 1990s onward India is now producing less feedgrain per person than it did 20 years ago. This has created a new round of troubling hunger. So, when one takes the combination of a green revolution that produced great results. But not as strong as in some other parts of the developing world. And then, a still fast growing population that continues to grow rapidly today.

536 Because the United Nations forecasts that today’s population of 1.2 billion could still reach 1.6, even 1.7 billion Indians within a few decades. We have a problem that India’s rapid development, while very real, is still burdened, held back by problems in the countryside. And we can see this by looking at one stark indicator, and that is childhood stunting. Childhood stunting is an indication of chronic undernutrition of young children. When young children don’t get the nutrients they need, they don’t achieve their potential height for age. And stunting signifies a significant reduction of height per age relative to the potential of a population. When you look at where stunting is in the world today, alas, it is in many parts of tropical Africa. And it is, alas, continuing throughout South Asia, and with India being the country with by far the largest number of children that are stunted.

What’s the conclusion? Well, one could talk about many wondrous aspects of India’s development and its rapid growth in information technology and in areas of manufacturing. Its leadership in global engineering, and India’s real potential. It’s also true to say, as M S Swaminathan has emphasized repeatedly in recent years, India needs a second green revolution. Not exactly like the first one because this time it’s going to have to be oriented not only towards more yields, but it’s going to have to be oriented even more consciously towards protecting the natural environment. India is going to need to get more crop per drop of water, more efficient water use. It’s going to need to get more output per input of fertilizer. Because the extent of pollution caused by the runoff of nitrogen and phosphorous-based fertilizers has also become very large. India is going to have to focus on higher yields on the existing farmland, because further expansion of farmland means the elimination of remaining forest areas and encroachments on very endangered ecosystems. So India needs a second green revolution. That’s going to have to be science based and dependent on very ecologically focused strategies to economize on water, on fertilizer on land use to get the maximum output per unit of input to ensure environmental sustainability. India and South Asia more generally, also face the continuing challenge represented by MDG 3, and that is gender equality. In traditional society women face massive burdens.

537Not allowed to, to be in the labor force. Very subservient, not allowed to own or inherit property. Not allowed to manage money often. And the burdens of gender inequality of course, were passed traditionally from mother to daughter. One of the great breakthroughs therefore  to note in India’s and South Asia’s recent advances is the continued empowerment of women and girls, gender equality in the South Asian context. And one of the greatest ways that this has been accomplished started in next door Bangladesh a country that was viewed as a hopeless basket case in the early 1970s, but pioneered one of the greatest grassroots directions to unlock the poverty trap. And that has been through women’s groups of empowerment and microfinance. You know the famous non-governmental organizations that arose in Bangladesh, Grameen Bank of Mohammad Yunus, the Nobel laureate, Brock and other great NGOs which pioneered women’s empowerment in the villages, and undertook a massive expansion of microfinancing through a group lending process. And it’s because of that, that microfinance spread throughout the world as a new powerful tool for grassroots empowerment, for gender equality, and for a breakthrough out of extreme poverty. One of the notable features of these women’s groups and the microfinance has been that by empowering young women in Bangladesh, it also gave these young women the sense and the incentive to reduce the fertility rate, to have fewer children. After all, the mother’s now in the labor force. She’s earning her own income. And she knows now through knowledge gained through her peers that having fewer children will enable her to invest more in each of her children so that they have a chance for a better life. And when you look at the decline of the fertility rate in Bangladesh, it is wonderful, good news. Back at the time of independence, Bangladesh’s total fertility rate was around seven, meaning that on average, a woman would have seven children. On average that would mean half of them of course, girls. For every 100 women they would be having 700 children, 350 of whom would be girls, and so in one generation 100 mothers would be raising 350 future mothers. You can imagine how rapidly the population would be growing. But because of microfinance, because of women’s empowerment, you see that the fertility rate on a voluntary basis came down extraordinarily rapidly, so that as of today the fertility rate is at the so called replacement level. Each woman on average is having two children, one of them a daughter. Each woman therefore is you could say, replacing herself with a daughter who will become a mother of the next generation. Leading over the longer term to a stabilization of the population and a much, much better chance for economic development. South Asia, like Sub-Saharan Africa therefore has the end of extreme poverty within reach. But it will require a major effort. Another green revolution, focused investments in infrastructure, empowerment of women, and especially completing the demographic transition as well so that India, like Bangladesh, reaches the replacement rate sooner rather than later. Gives itself that added opportunity to combine its wondrous capabilities in services and information technology in industry with a newly renovated ecologically friendly agriculture. And with a society that is running on the full empowerment of its women alongside its men. Go back to start of transcript.

The MDGs and the end of extreme poverty II

A Strategy to End Extreme Poverty in Africa

The end of extreme poverty is within reach. Where is that extreme poverty that remains on the planet? There are roughly 1.2 billion people living below the World Bank’s poverty line of $1.25 per person per day. That number, thankfully, is down sharply from about 1.9 billion in 1990 and as a share of the population of the still growing developing countries, the poverty rate has fallen by more than half to 20% or so in the year 2010. So where are those remaining areas of extreme poverty?

521The most poverty stricken region of world is tropical Sub-Sahara in Africa. Around 40% of the population of tropical Sub-Saharan Africa remains below the poverty line, though fortunately, that rate is declining now and has been declining since the start of the new millennium. The other place with remaining extreme poverty is South Asia. And there, the poverty rate is estimated to be perhaps around 30% of the population. If you take the total numbers there are, are around 400 million people living in extreme poverty in tropical Sub-Saharan Africa, there are around 400 million people living in extreme poverty in South Asia, that’s about 30% of the total in each case. Around 20% of the total population, around 250 million people are still in extreme poverty in East Asia. Though East Asia seen the fastest decline of extreme poverty, because of the rapid growth of China and neighboring countries. Around 10% of the total population of extreme poor, that is around a hundred million people are in North Africa and the Middle East. And the rest, which is around another hundred million are scattered in the remaining regions of the developing world, for instance, in Latin America and the Caribbean.

522So we know, as we’ve noticed on many occasions that the two big areas for breakthrough are Sub-Saharan Africa and South Asia. Let’s take a look at the differential diagnosis for Sub-Saharan Africa and what can be done to help those parts of Sub-Saharan Africa still stuck in extreme poverty to accelerate the progress out of extreme poverty. Have a look at the year to year growth rates of the whole world economy and of Sub-Saharan Africa. This is the change of gross domestic product taken for the whole Sub-Saharan African region and the gross world product looking at a comparison. And what we can see is some very good news, and that is that the average growth rate in Sub-Saharan Africa of the overall economy picked up significantly after the year 2000. And indeed, Sub-Saharan African has been achieving economic growth faster than the average of the world economy. Sub-Saharan Africa has been growing at around 5% per year, now remember the rule of 70 if Sub-Saharan Africa’s growing at 5% per year, divide 70 by 5 that’s 14. That says that the period it takes for the African economy to double in size would be about 14 years. So, something’s going right and it’s possible even to get faster progress. If we make a differential diagnosis of Africa’s problems, of course we see that in those seven big categories where we want to investigate, there are challenges and issues in nearly all of them. In the physical geography, we’ve seen the problems of disease, and the number of land-locked countries, and the distance of population to the coast, which cry out for improved transport infrastructure, which cry out for improved public health, for example, to combat malaria, a geographically determined disease.

524We’ve seen problems cultural attitudes of very high fertility rates in very poor places. Meaning that very poor households that have six or seven or eight children are not able to provide the investments in health care, nutrition and education that their children need to get out of poverty. Of course there have been many political failures and geo-political failures as well. A lot of violence, many wars, though fortunately many of those wars have come to an end. So there are places that have been stuck in conflict that have a chance for development, now that peace, if fragile is present and providing a new foundation for economic development. I think its fair to say that we would want to look at four categories of investment in Africa for that breakthrough. The first is in rural development. Especially to spur agricultural development.

The second is in the urban areas. Africa throughout its history has been predominantly rural, but it’s fast urbanizing and therefore, productive dynamic cities that can meet the needs of their populations is crucial. The third category, broadly I would say is the national infrastructure. The road network. The rail network. The power grids. The management at large scale of water resources. Because Africa, historically, has been bereft of the vital infrastructure that it needs for national or regional development. And the fourth big category that I would bid us to look at is demography and that is the challenge of Africa’s still very, very fast population growth. So let’s take a look at some of that. Turn first to the challenge of agriculture, as you can see in this map, which shows according to color the productivity of agriculture, measured as the amount of grain produced on each hectare of farmland, we see that Africa is among the low yield parts of the world. On average, small holder farmers in Sub-Saharan Africa have gotten a yield that is a grain output per hectare of farmland generally of between half a ton and one ton of grain per hectare. Now, this is not good in international comparative terms. Many countries have three or four or five tons of grain per hectare of farm land. And in the most productive grain-belts of the world, those yields can rise even to ten times Africa’s yield. Some farms getting ten tons of rice, or maize, or wheat per hectare of land. What’s the cause of this? Well, African farming faces many obstacles.

One is that the farmers traditionally have been too poor to be able to keep the soils filled with the nutrients needed. Especially with the nitrogen, potassium, and phosphorus needed to have high yields of crops. If you don’t feed your crops with a decent nutrients, you don’t get growth. And in Africa, the soils have been relatively bereft of the key nutrients that are needed for farmers to get a high yield. The next map shows us why. In all other parts of the world, farmers used extensive fertilizers, both organic and chemical to replenish the key nutrients, especially the so called macro nutrients of nitrogen, phosphorous and potassium that are taken out with each crop. When a crop is harvested, out go the nutrients. Somehow those nutrients have to be put back in, whether in green manures so called of organic farms or whether through chemical fertilizer, which puts nitrogen back into the soil. But Africa’s peasant farmers have been so poor that they have been farming without the advantage of those added nutrients. And that has kept them in a poverty trap. Because of their poverty, they can’t buy the fertilizers that they need, whether organic or chemical. Their soils therefore continue to be depleted of key nutrients. The yields remain low. And year after year, the farmers get a very, very meager income and farm families face tremendous bouts of hunger. It’s not only the fertilizer input that’s key, other inputs necessary for high yields include water management through irrigation. And that requires wells and pumps, typically. And good seed varieties where seeds are bred through a variety of means to give high yields. And African farmers traditionally have lacked the means to invest in irrigation and to invest in high yield seeds in just the same way that they’ve lacked the means to replenish the soil nutrients. It all adds up to an agricultural poverty trap. It all tells us that a high priority for Africa to breakout of extreme poverty is to invest in its small holder farmers with government programs that enable even the poorest farmers to get the inputs that they need whether on credit or as a grant so that they can have higher yields, higher income and thereby start investing in these crucial inputs and then peasant farmers stuck in poverty,can become commercial farmers earning a good income and then using a part of that improved income to keep making the investments in soil nutrients, in water management, and in improve seed varieties. Now to bring this about requires investment in infrastructure.

525 We’ve already looked at the difference in the railroad map of Africa and India, but let’s look again. Remember that in India, the rail network was a complete grid created by British imperial rule. Whereas in Africa, you just have small, rail lines not even connected with each other, typically running from a single diamond mine or gold mine, or maybe from a plantation area to a port. Well that’s a big problem, even for agriculture. Because farmers need to be able to buy fertilizer at low cost. They need to be able to market their grain output and other output at low transport cost. And if the transport network doesn’t exist to bring the inputs to the farm and to bring the produce from the farm to the market, eats up a tremendous amount of the potential income, so investing in the basic transport infrastructure, whether it’s the road network, or whether it’s the rail network, is also absolutely crucial. Other aspects of infrastructure are also especially important in the 21st century. I would say it should be taken as a given that there can be no economic development on a sustained basis without electrification. But have a look at this well known world picture taken by satellite by NASA of the Earth at night which basically tells us where there are lights on due to an electricity grid. And you can see the bright lights of the United States. The bright lights of Europe, the lights of China and Japan, the lights of the Arabian Peninsula and of India. But look at sub-Saharan Africa. Its lights out at night. A large part of rural Africa, and that’s the predominant part of the African population, still lacks access to electricity. And that means not only not having lights at night for children to study and for being able to go about one’s activities at home. But it means the lack of reliable power for pumping water, for irrigation, for refrigeration for preservation of agricultural outputs for processing of food for textiles and apparel and every other kind of manufacturing activity. The absence of electrification has been a huge barrier and another aspect of Africa’s poverty trap. Without electricity, productivity is very low. Poverty means the inability to invest in the electricity that could help lift the region out of poverty. That’s the poverty trap once again. The vicious circle. It has to be broken either by Africa taking loans to invest in infrastructure, such as electrification. Or by receiving grants and development assistance that would enable Africa, through the help of richer countries and international organizations to be able to undertake those investments, even if they can’t be afforded out of Africa’s income itself. Now in the 21st century, another aspect of infrastructure worth mentioning is information technology. And here there’s good news. Because these technologies are so powerful and the costs of bringing them in have come down so much that Africa now has massive access to mobile telephony, reaching even the most remote villages. It has several submarine cables of fiber optics surrounding the continent and bringing increasingly the Internet and broadband connectivity to Africa. Like the rest of the world, Africa is now poised for a breakthrough. By targeted investments in agricultural productivity, targeted investments in the core infrastructure of Africa’s fast-growing cities, targeted investments in the national scale infrastructure such as the road and rail network, or the fiber network, Africa can make a breakthrough that has eluded it throughout its history. But there is one final point that is key, and that is that Africa, like the other parts of the developing world, also needs that rapid, voluntary reduction of fertility rates, so that economic growth can keep ahead of a rapidly growing population. Back in 1950, Africa’s population was only 180 million people in the Sub-Saharan region. By now, that population has increased roughly five times to a population of around 900 million. On the current fertility estimates, Africa’s population would continue to soar. So that by the end of the 21st century, Africa’s population would be an astounding 3.8 billion people. This is too much for Africa’s physical environment, for the water and for the crop yields, especially in an era of climate change. It’s too much for very poor families needing to invest in the health and the nutrition and the education of their children. So, in addition to the investments in agriculture, in health and education, in roads, in rail, in fiber optics, in electrification, Africa too needs to invest in the rapid voluntary reduction of fertility rates of today’s poor households making sure that family planning and modern contraception are available, making sure that young girls aren’t forced to drop out of school, because they lack the income to go on, but have the opportunity to go on to a full secondary education, and a university education, so that girls don’t end up illiterate, married young, and starting on another cycle of poverty with six or seven or eight children. When Africa puts together that fore fold strategy of rural, urban infrastructure and demographic transformation, all within reach, Africa, like the rest of the world, will break free of the poverty trap, and by 2030 indeed can end extreme poverty.521

The MDGs and the end of extreme poverty I

The reasons to believe that extreme poverty can be ended

We’ve studied the process of modern economic growth and we’ve seen how economic progress has diffused throughout the world[1]. We’ve adopted the method of differential diagnosis so that we can help regions that are still stuck in low growth or even in a poverty trap to overcome that trap through a careful, evidence based diagnosis of the problems. Therefore, we’ve arrived at a very exciting moment.

511The world is poised, for the first time in human history, to end the scourge of extreme poverty. It may seem fanciful to many people and may seem Utopian, but it’s real. The rate of extreme poverty has been falling. The evidence is clear, it can continue to fall, can decline sufficiently rapidly that this generation could be the generation that sees the end of extreme poverty. Now, what the differential diagnosis tells us is that it won’t happen by itself. It’s not automatic, but the end of poverty is within reach. Just take a look at the numbers. Back in 1980, the World Bank estimates that a little bit more than half of the world’s population in developing countries, perhaps 55 to 60%, were in extreme poverty using the World Bank’s criterion of living at less than $1.25 per person per day, measured in purchasing power adjusted prices. By 1990 that poverty rate had come down to around 44 or 45%.

But since 1990, the progress has been specatcular. From 1990 to 2010, the poverty rate in the developing world fell by more than half. From around 44% to around 20% in the year 2010. And it continues to decline now. This is the reason why finance ministers and development leaders gathered at the World Bank in the year 2013, voted to make the World Bank’s target and mission, to be supportive of the end of extreme poverty by the year 2030. In other words, our generation could be the one to see end of extreme poverty. It’s our job, of course, to understand how this could happen and then to act to make it happen. Before we get to the strategy up to 2030, let me turn back the clock to 1930. It was the depths of the Great Depression, there was a lot of poverty in today’s high income world as well as in the poor countries, the developing world. John Maynard Keynes, that great political economist of the 20th century, wrote a wonderful essay, Economic Possibilities for our Grandchildren. That’s the one where Keynes noted that from the time of the Roman Empire, up until the 18th century, the rate of technological progress had been extraordinarily low, so low in fact, that a peasant from the Roman Empire would have felt at home in rural England in the early years of the 1700s. But Keynes went on in that essay to note the explosion of technology of the Industrial Revolution, and he drew, in 1930, in the depths of the Great Depression, a startling lesson from that technological progress. Because you could imagine in the Great Depression, with mass unemployment, and with the pessimism around, that one could have been overwhelmed feeling that economic progress was at an end. But Keynes said no, let’s look more deeply. Technological change means that even though we have a serious short-run crisis, the long-run is promising. Let me quote what John Maynard Keynes wrote in 1930. And I quote. I would predict that the standard of life in progressive countries 100 years hence will be between four and eight times as high as it is today. There would be nothing surprising in this, even in the light of our present knowledge. It would not be foolish to contemplate the possibility of a far greater progress still. I draw the conclusion, says Keynes, that assuming no important wars and no important increase of population, the economic problem, by that, he means the problem of poverty, may be solved, or be at least within sight of solution, within a 100 years.

This means that the economic problem is not, if we look into the future, the permanent problem of the human race. It’s interesting, 1930, John Maynard Keynes says the economic problem meaning the persistence of poverty, could be a thing of the past within one century and it’s exactly at that century mark that the World Bank now contemplates the realistic end of extreme poverty. A pretty good call. Now, John Maynard Keynes said that he could foresee this if there was no significant increase of population. Of course there has been, because when he wrote in 1930, the world population was 2 billion. Now it’s 7.2 billion, more than three times as large, and by the middle of this century it will be more than 9 billion, most likely. He also said that barring world war. But of course, there was another major war, the Second World War. And despite both of those facts, the massive increase of world population and the continuing tragedies and destruction of war. Keynes’ basic insight, that technological progress can bring about the end of poverty, remains true, and it remains prescient, because we are at the cusp of that final push to end extreme poverty, if we decide to make it happen.

512Now in the year 2000, a remarkable thing did happen. 160 plus leaders of the world gathered together in September 2000, at the United Nations, to usher in the new millennium. And when they did so, they wanted to convey the hope of the new millennium. So the Secretary General of the United Nations, at that time, Kofi Annan, put forward to the world leaders, a millennium declaration. That called for the new millennium to realize the great hopes for human rights, for peace and security, and for economic development and the reduction of extreme poverty that humanity yearns for. The world leaders adopted the Millennium Declaration and within it adopted specific development goals, which have become known as the Millennium Development Goals.  Eight ambitious goals to fight extreme poverty adopted in September 2000 and to carry us to the end of 2015. And you are looking now at the schematic of these eight Millennium Development Goals, drawn as a cartoon for each goal, but that by itself is a telling point because these goals are not for high theorists they’re not for the textbooks, they’re for all of us.

They’re for humanity to grasp. To promote, to urge our governments to take seriously, and for us to take seriously in our individual actions, in our roles in business, or academia, or in our places of worship, or workplaces so that we can each contribute to the end of extreme poverty. Have a look at the eight goals. Goal number 1 calls for eradicating extreme poverty and hunger. Goal number 2 is to achieve universal primary education. Goal number 3 is to promote gender equality. So that women, like men, have rights and, and access for economic progress. So that girls as well as boys go to school and get a decent education. Goal number 4 is to reduce sharply child mortality. Goal number 5 is to reduce sharply maternal mortality and ensure safe and healthy pregnancy for mothers and for their children. Goal number 6 was to fight the raging pandemic diseases of AIDS, TB, Malaria and other mass killers. Goal number 7 is to promote environmental sustainability. And goal number 8 is to promote a global partnership, where by the rich countries help the poor countries to achieve the first seven goals.

513Now in fact, beneath this general description, are some specific quantitative targets and many dozen indicators. For the eight Millennium Development Goals, there are 21 targets, specific and quantified, and there are around 60 detailed indicators to measure the progress. It’s been my honor and pleasure to serve as Special Adviser, first to U.N. Secretary General Kofi Annan, and now to U.N. Secretary General Ban Ki-moon on the Millennium Development Goals. And to help analyze and to help coordinate the UN’s efforts to enable and support poor countries to achieve all of these Millennium Development Goals. It’s been a wondrous process to see how this kind of goal setting can energize civil society.

Can help to reorient governments that may have been neglecting crucial issues of disease control or the safety of childbirth or ensuring that all children go to school. And to reorient priorities, political awareness, budgets to achieve these goals. But progress has been notable, and breakthroughs have occurred for some of the world’s poorest countries. Have a look at the overall trend of extreme poverty, as measured by the World Bank at the $1.25 per person per day threshold. And what you see here is that sharp decline, which I mentioned just previously. That from a poverty rate of around 44% in 1990, the poverty rate has come down to around 20% in 2010 and it continues downward today. The millennium development goals by themselves certainly did not accomplish all of that reduction of poverty.

514There was a powerful trend underway. China’s remarkable economic growth is a big part of the story. But we’ve seen parts of the world and notably tropical sub Saharan Africa achieve a real breakthrough in faster economic growth and therefore in the reduction of poverty after the year 2000 spurred on by the millennium Development Goals. Here you’re looking at the rapid increase of the number of people kept alive by antiretroviral medicines when they are infected with the HIV virus. Now the HIV virus, if not stopped in its tracks by antiretroviral medicines, causes AIDS. And causes a near certain death. But because of the Millennium Development Goals and programs that it has helped to spur, millions and millions of people now receive life-saving antiretroviral medicines. The reduction of malaria burden that has been achieved by the scaling up of focus and attention and budgets to fight malaria through the range of modern technologies. Long lasting insecticide treated bed nets, a new generation of anti malaria medicines and many other advances that have been enabled through better technologies during the last decade. And this is causing a remarkable decline of malaria deaths and malaria disease, especially in Sub-Saharan Africa since the peak was reached in the early 2000s. Well, we can see that the combination of continued rapid technological change, and a good differential diagnosis that helps us to focus investments where the poorest places need it. Whether it’s in infrastructure or healthcare, or getting children in school or safe drinking water and sanitation, gives us a very powerful combination to not only witness the underlying forces of poverty reduction, but to help spur them on so that we can be the generation that brings an end to that long standing human scourge of extreme poverty. The Millennium Development Goals have given us a big push up to the year 2015 and one more major effort form 2015 to 2030 will vindicate John Maynard Keynes’s forecast. A 100 years before that. That the economic problem of extreme poverty can come to an end.

[1] http://www.who.int/research/en/