Transportation infrastructure
January 24th, 2009 § 1 Comment
Walking a bicycle taxi up the newly paved road
I’ve been trying diligently to imagine Nyamata as it must have been in the peri-genocidal period, and it’s an interesting thought. I keep coming back to Hatzfeld‘s research, and one of the genocidaires’ statement that the looting that was so common during the genocide allowed the impoverished farmers to go into shops in Nyamata “where farmers had never been before.” I also keep thinking of the night when the 6 mzungus apparently bought all of the beer in Mbyo. If the economic situation along the Kigali-Bugesera-Burundi road has picked up since it was paved last year, its baseline must have been awfully low, which offers further commentary on the poverty of the farmer-genocidaires.
Improved transportation infrastructure is obviously going to be more beneficial to people who already have the wherewithall to use it – the wealthier shopkeepers in Nyamata, I’m guessing. The picture of pre-genocide Bugesera that Hatzfeld develops seems predicated on local production to a much greater degree than it is today, where you can find Primus & packaged foods way the hell off the main road, like in Ngeruka. (I’m pretty sure Ngeruka is still waiting for the water pipeline to come its way.) So transport of heavy & imported items, like bottled beer and maize flour, would be privileged. It extends the reach of existing markets.
I suppose what I’m wondering about is its effect on the incomes of people inside and outside of Nyamata, then. It seems reasonable that their incomes must have gone up to some degree in order to be able to afford such things; was this because of trade with Kigali, or because new markets developed with truckers and construction workers passing through town? I’d also love to know how this affected the market access of rural Bugesera residents. The weekly market at Nyamata strikes me as decently large; did a paved road make it easier for outlying farmers to come to town? Or does pavement only really make a difference for people who can afford wheeled transport? The rain here rarely makes roads totally unwalkable after it’s finished, so perhaps pavement would only be a marginal improvement for people who were just walking anyway. Institutional memory in Rwanda seems remarkably short sometimes, in large part because of the enormous upheaval and movement in the several years following the genocide; I’m not sure that anyone in Nyamata, literally, has been there long enough to know.
Healthcare access & equity
January 21st, 2009 § Leave a Comment
When I was researching microinsurance and maternal mortality last year, I was struck by some of the observations that other researchers felt it necessary to include in their results. One of them was the finding that distance to a health center affects people’s access to care. In other news, water quenches thirst! I had to wonder if this was a relic of the general lack of forethought that must be put into procuring transport in the global North, where it’s more or less equally simple to reach a doctor one kilometer from one’s home as thirty kilometers. I otherwise fail to see how it’s notable that people who live farther from a clinic may use it less often.
This does highlight the fact that there are fundamental issues of healthcare access that aren’t purely microeconomic in nature. Distance is one, but the challenge of retaining skilled doctors in a low-wage environment is a second, and difficulties in obtaining and maintaining quality equipment and medication stocks (non-counterfeit medications!) are a third. The attitudes of healthcare workers also appeared extremely important to low-income patients, who seemed understandably sensitive about their social status, and hesitant to use centers where they would be treated disrespectfully because of their poverty.
The other thing I’ve been thinking of, however, was a little-discussed (at least in the papers that I read) corollary to the observations that microinsurance increases healthcare access, and health centers are favorably inclined towards patients who can actually pay for their care. My immediate concern upon reading these statements was, if access to microinsurance is still uneven, isn’t there a real possibility that patients who are even slightly better off will crowd out those who are too poor to afford $2-a-year insurance at all? If the resource base of health centers is fixed (and it may not be – I don’t have info on that), dramatic increases in patients covered by microinsurance could very well make the poorest of the poor even more vulnerable. I wonder how you’d best be able to test that. I imagine you’d have to look at the effects of a growing resource base (if the increased payments are used at the local level) or the improved quality of care referenced in the last post, and sort out what effects those have on the healthcare uptake rates of the poorest. Perhaps the question actually is, does extending microinsurance to some harm the uninsured by crowding them out, or does it improve their situation by letting them get a bit of a free ride on some improvements brought about by the insurance payments? Interesting.
