Tag Archives: LMICs

World Bank Report Into Research Productivity in Sub-Saharan Africa

This report [1] shows the following:

  • Over the last decade, the research output from sub-Saharan Africa (SSA) in terms of total citations has risen rapidly, but is still less than a third of a percent of the world output, while the continent houses 12% of the global population.
  • The increase in world share is higher in two Asian countries chosen for comparison—Malaysia and Vietnam – than in African countries.
  • With the notable exception of South Africa, citation rates are lower than average per paper in SSA than in the rest of the world.
  • The most highly cited papers tend to include an author from another continent or South Africa.
  • Health research dominates except in South Africa.
  • Harvard University, the University of Oxford, the University of Liverpool (incorporating LSTM at the time of study), London School of Hygiene and Tropical Medicine, the University of Copenhagen, Institut Pasteur, Institut de Recherche pour le Développement (IRD), France Agricultural Research for Development (CIRAD), and Johns Hopkins University are the top collaborating institutions from high-income countries. But watch this space!
  • Returnees to Africa have much higher citation counts than those who never left. Visiting faculty contribute even more.

The CLAHRC WM Director is proud to be a collaborator in the CARTA (Consortium for Advanced Research Training in Africa) programme. This is an Africa-based, Africa-led initiative to rebuild and strengthen the capacity of African universities to locally produce well-trained and skilled researchers and scholars. The programme has been extremely effective in attracting high calibre applicants who go on to great things. CARTA is well networked across Africa and between Africa and Europe / North America.

— Richard Lilford, CLAHRC WM Director


  1. The World Bank & Elsevier. A Decade of Development in Sub-Saharan African Science, Technology, Engineering and Mathematics Research. Working Paper No. 91016. Washington, D.C.: World Bank Group. 2014.

Pre-Payment Systems for Access to Healthcare

In a previous news blog I explicated a theory for improved access to services in countries of moderate income.[1] I argued that services would always be limited in very low-income countries. On the other hand, in high-income countries the tax base is sufficient to support comprehensive public services, including health services. However, I explained that in countries of intermediate wealth, the tax base was often immature and small, relative to the total economy. In such a scenario it is necessary to rely on community contributions in order to improve access to services. I refer to this as the IKEA model.

I found a very nice example of the IKEA model recently. This is a pre-payment service implemented by Safaricom and other companies in Kenya called M-TIBA.[2] These organisations provide an electronic wallet that families can contribute to, which provides ready cash at the point when services are required. Such a service can ensure that money is available for out-of-pocket payments. Electronic pre-payment thus acts as a kind of community insurance or risk-sharing system.

I see great potential in these services, but feel that they should be evaluated. Like microfinance, people may make exaggerated claims of how beneficial they can be.[3] I expect that these services will be most useful when they are all linked to other services. Thus, I imagine that a pre-payment system will be much more effective in securing transport to hospital when it has grown up in parallel with an inexpensive (perhaps partially subsidised) local ambulance service. As part of my work as lead for the Access work package in the NIHR Global Health Research Unit on Global Surgery, I shall be investigating this type of system in improving access to acute surgical and medical care.

— Richard Lilford, CLAHRC WM Director


    1. Lilford RJ. Towards a Unifying Theory for the Development of Health and Social Services as the Economy Develops in Countries. NIHR CLAHRC West Midlands News Blog. 13 October 2017.
    2. PharmAccess. “M-TIBA is truly leapfrogging healthcare in Kenya”. 15 December 2015.
    3. Banerjee A, Karlan D, Zinman J. Six Randomized Evaluations of Microcredit: Introduction and Further Steps. Am Econ J Appl Econ. 2015; 7(1): 1-21.


Private Providers are Consulted More Often than Public Providers in Slums

This finding comes from a number of studies across many parts of the world, including:

  1. India [1] – where private providers were both preferred over public providers and consulted more often. Private providers were more accessible in terms of distance from residence.
  2. Kenyan maternity care [2] – women preferred private over public providers, even though the private providers were rated as ‘inappropriate’ by government.
  3. Dhaka slums [3] – this is an important study because it divides health facilities according to Ahmed’s classification.[4] Most commonly consulted were pharmacies (43%), followed by government hospitals (14%), then private hospitals (4%), independent medical practitioners (3%), informal providers (3%), and traditional healers (1%). Dissatisfaction was highest with government hospitals (25%) and lowest with informal providers and pharmacists.
  4. Accra’s Sodom and Gomorrah slum [5] – the facilities accessed were similar to those in Dhaka; 61% pharmacies and 33% hospitals. In this study lack of insurance was a major factor limiting access, while distance from facilities was not.
  5. Mumbai slums [6] ­– this study did not look at pharmacies specifically, but overall local private providers were the most widely used facilities. The use of public providers rose in proportion to the seriousness of the disorder, from 15% at low categories to 42% for serious illness, and 60% for maternal health.

One important conclusion from the above literature is that facilities should be classified to capture those inside a slum and external to it, and that pharmacies / drug stores should have their own stratum and not be elided with informal or private providers. Private allopathic providers should be classified as medical, other registered health professional (nurse / medical officer), community health worker (with formal links to the public service), and informal non-qualified provider. In studies that cross slum boundaries, multi-level modelling should be used to allow for correlations within clusters and avoid an ecological fallacy / Simpson’s paradox.[7]

The above studies are all based on population/household-based questionnaires. Another Dhaka based study takes a different approach [8] – instead of asking people who live in slums where they go for their health care, Adams and colleagues mapped health facilities across six urban slums. They found that 80% of the 1041 facilities identified in their spatial survey were privately operated. Unlike NGO- and government-funded clinics, private health care delivery clinics operate in the evenings. Only a third of staff in these private clinics have a medical qualification. Overall, the ‘density’ of health delivery points across the six slums was 1.5 per 10,000 of population. The average distance to a major government hospital offering outpatient services was 3km.

In our NIHR Global Health Research Unit on Improving Health in Slums we will be combining supply-side surveys of facilities with demand-side household surveys of use and satisfaction. We plan to go further by examining the socio-political structures that have determined patterns of provision and that may facilitate or impede the future development of a more accessible and high-quality service. We will then model the costs and benefits of alternative logistically and politically viable options using an iterative approach. In developing these models we will work closely with residents of slums and with those who control the purse strings.

— Richard Lilford, CLAHRC WM Director


  1. Banerjee A, Bhawalkar JS, Jadhav SL, Rathod H, Khedkar DT. Access to Health Services Among Slum Dwellers in an Industrial Township and Surrounding Rural Areas: A Rapid Epidemiological Assessment. J Family Med Prim Care. 2012; 1(1): 20-6.
  2. Fotso JC & Mukiira C. Perceived quality of and access to care among poor urban women in Kenya and their utilization of delivery care: harnessing the potential of private clinics. Health Policy Plan. 2012; 27: 505-15.
  3. Khan MMH, Grübner O, Krämer A. Frequently used healthcare services in urban slums of Dhaka and adjacent rural areas and their determinants. J Public Health. 2012; 34(2): 261-71.
  4. Ahmed SM, Tomson G, Petzold M, Kabir ZN. Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh. Bull World Health Organ. 2005; 83: 109-17.
  5. Owusu-Ansah F, Tagbor H, Afi Togbe M. Access to health in city slum dwellers: The case of Sodom and Gomorrah in Accra, Ghana. Afr J Prim Health Care Fam Med. 2016; 8(1): a822.
  6. Naydenova E, Raghu A, Ernst J, Sahariah SA, Gandhi M, Murphy G. Healthcare choices in Mumbai slums: A cross-sectional study. Wellcome Open Research 2017; 2: 115.
  7. Lilford RJ. Simpson’s Paradox and Discrimination. NIHR CLAHRC West Midlands News Blog. 28 November 2014.
  8. Adams AM, Islam R, Ahmed T. Who serves the urban poor? A geospatial and descriptive analysis of health services in slum settlements in Dhaka, Bangladesh. Health Policy Plan. 2015; 30: i32-45.

Vaccine in Pill Form

Storage of vaccines is an issue faced in a number of low- and middle-income countries due to the need for constant refrigeration. Some sites may have intermittent power or outages, they may simply not have the storage space for the necessary number of vaccines, or there may be difficulty in maintaining a cold temperature during transportation. A recent proof-of-concept study by Miles, et al.[1] may offer hope in the future though. The team based at Cardiff University produced a prototype oral polypeptide vaccine that was able to provide protection against the ‘flu in a mouse model. Previous polypeptide vaccines had poor stability, which hindered transport and thus therapeutic potential. For this vaccine the researchers created highly stable antigenic ‘mimics’ that did not exist in nature. It was stable in both human serum and gastric acid, was able to stimulate and prime an immune response specific to human ‘flu that was as effective as the standard biological equivalent, and remained immunogenic after being administered orally. Although there is still quite a way to go, it is worth keeping an eye on development of these encouraging findings.

— Peter Chilton, Research Fellow


  1. Miles JM, Tan MP, Dolton G, et al. Peptide mimic for influenza vaccination using nonnatural combinatorial chemistry. J Clin Invest. 2018.

Do Poor or Rich People Consult Health Services Most Often in Low- and Middle-Income Countries?

In a previous news blog [1] we argued that many poor people in cities within low- and middle-income countries (LMICs) bypass local facilities in slums and proceed directly to outpatient departments at local hospitals. They are clearly prepared to trade convenience and time to obtain what they perceive as a superior service. Now it turns out that poor people are, at least in some places, heavier users of health services than rich people. This is because they are less healthy than richer people, do I hear you say? Well, it would appear not. In their outstanding study in New Delhi, Das and Sánchez-Páramo [2] found that poor people consult more frequently for time-limited single episode diseases than richer people. And they do so despite out-of-pocket payments. What is going on here? Their behaviour is contrary to economic theory, whereby the marginal utility of a service should be less attractive to people with smaller disposable incomes, and this should be particularly the case when utility gain is small. This counter-intuitive finding reminds me of the observation that very poor people will pay for radios or television even while they are still hungry, in direct contradiction of Maslow’s hierarchy of needs.

The authors speculate the reasons for high consulting rates for short duration conditions. They consider the possibility that many short duration conditions are really manifestations of chronic diseases causing short-term complications; boils and thrush in patients with diabetes, etc. This seems unlikely because the gradient in consultation rates between rich and poor people is the same among young and old people, despite the steep gradient in prevalence of chronic disease by age. The authors think the most likely explanation lies in information asymmetry – the poor are less likely to buy their own medicines and this could reflect lower knowledge levels. I have another explanation – that low income and high consultation rates reflect the same latent variable. Some people, according to this theory, have generally less resilient personalities, find it harder to obtain and retain jobs, and are more likely to seek solace in consultation. This is a hard hypothesis to test in cross-sectional studies, but it could be studied in longitudinal studies or possibly using Mendelian randomisation. No-one should interpret any confirmatory findings as victim-bashing – rather the reverse; it provides society an opportunity to demonstrate its caring attitude.

— Richard Lilford, CLAHRC WM Director


  1. Lilford RJ. A Heretical Suggestion. NIHR CLAHRC West Midlands News Blog. 9 February 2018.
  2. Das J & Sánchez-Páramo C. Short but not Sweet: New Evidence on Short Duration Morbidities from India. Policy Research Working Paper 2971. Washington, D.C.; World Bank Development Research Group. 2003.

A Heretical Suggestion!

The locus of health care is moving increasingly towards the community. In high-income countries (HIC) the greatest burden of health falls to frail elderly people with multiple chronic diseases. Hospital is often bad news for such people, both from a psychological and physical point of view.[1] There are good arguments for avoidance of admissions, and for increasing care provision in the community in HICs. In low- and middle-income countries (LMICs) there are also good arguments for community care. The WHO estimates that over three-quarters of all care could be most appropriately delivered in the community. The Declaration of Alma Ata and the Bamako Initiative from the United Nations both support the development of community care for LMICs. In this News Blog I wish to probe this subject more deeply. I will argue that community care is entirely appropriate for preventive outreach care. However, I will argue that we should re-examine the case for promoting community over hospital settings for demand-led care, especially in deprived urban environment.

My re-examination of this subject came about as a result of recent tours of eight slums within Nigeria, Kenya, Pakistan and Bangladesh. While all of these areas have a strong need for supply-side preventive care in the community, I have come to question the wisdom of trying to develop demand-led care within slum localities. My misgivings are based on a number of personal observations and from a reading of the relevant literature.

On site observations suggest that local residents prefer to use hospital facilities, even when this is less convenient than a more accessible community clinic. Some, but not all, slums are reasonably well supplied by local clinics. These clinics are usually staffed by medical officers or nurses rather than doctors. In many cases they have been provided by NGOs. I have observed that these clinics do not have many clients. When I draw attention to this, I am often told that this is because I have come at a quiet period. However, when I probe more deeply, I learn that the outpatients departments of nearby hospitals receive the bulk of the patients. Certainly that is my impression on visits to hospitals in LMICs where outpatient departments ‘heave’ with patients. This finding triangulates with work that colleagues and I have carried out in India under MRC sponsorship.

Not only do local residents seem to prefer hospital-based outpatient’s care, but my reading of the literature suggests that they are right to do so. Working with colleagues, I am carrying out a review of the quality of care provided in local settings in LMICs. The literature shows that such care is almost universally of a low standard, irrespective of whether the provider is private or public. Care given by doctors is generally better than that given by non-medical personnel, but even so is of a poor standard when delivered in the community. The quality of care across both settings is a topic of enquiry in the NIHR Unit on Health Service Provision in Slums that I direct. However, I suspect that the hospital will come out on top.

The corollary of the above, rather preliminary findings, is that we should be cautious about wholesale, and perhaps ideologically-driven, policies to deliver demand-based healthcare coverage in community settings  in low-income urban environments. Pending further research I hypothesise that it may be better to improve access and quality in hospital settings, at least in the first instance. Before taking fixed positions on these important issues we need to understand more about access to healthcare at the demand-side, the quality of such healthcare, and the most-cost effective approaches to driving up the quality of health care.

Please note that all of the above remarks apply to healthcare at the demand-side. That is to say, where a person has sought care for a perceived health problem. We fully support outreach primary preventive services to ensure vaccination, detect malnutrition, and ensure that people stick to their HIV and other treatment regimes.

Box A. Section VI of the Declaration of Alma-Ata

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community [emphasis added] through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”

— Richard Lilford, CLAHRC WM Director


  1. Lilford RJ. Intensive Care Harmful in Elderly Patients. NIHR CLAHRC West Midlands News Blog. 7 December 2017.

Is Fertility Control a Demand or Supply-Side Issue?

In China, population control has been achieved by coercive means. But in other countries it must be controlled by increasing access to contraceptives or by stimulating demand by non-coercive means. Where does the main barrier lie in low- and middle-income countries? Miller and Babiarz (2016) tackle this old chest – not by means of a systematic review. They include only experimental and instrumental variable-based studies.[1]

They find few RCTs. The most famous of these experiments is the Matlab study in Bangladesh,[2] where 141 areas were randomised in a cluster trial. The intervention group received visits every two weeks by community reproductive health workers who provided information and access to contraception. This intense, and arguably unscalable, intervention yielded a drop in fertility of about 20% over a lifetime. A slightly smaller effect was found in a further trial, this time of 37 clusters in Ghana. However, the two remaining RCTs consisted of family services that were grafted onto an existing program (HIV services in Kenya and micro-credit in Ethiopia), and both yielded null results.

Instrumental variable studies depend on a sudden increase or decrease in supply that does not seem to be attributable to a change in demand. Mostly these take the form of a stepwise roll-out of services (Iran after 1989; Colombia in 1965) and find reductions of around 20% infertility. Likewise fertility increased and then decreased in Romania when a ban on abortion, the main method of contraception in that country, was imposed and then lifted.[3] I guess the best one can say is that, absent China style enforcement, contraceptive provision is a necessary, but not sufficient condition for fertility control.

— Richard Lilford, CLAHRC WM Director


  1. Miller G & Babiarz KS. Family Planning Program Effects: Evidence from Microdata. Popul Dev Rev. 2016; 42(1): 7-26.
  2. Schultz TP. Population policies, fertility, women’s human capital and child quality. In: Handbook of Development Economics Volume 4. 2007, pp. 3249–303.
  3. Pop-Eleches C. The Impact of an Abortion Ban on Socioeconomic Outcomes of Children: Evidence from Romania. J Polit Econ. 2006; 114(4): 744-73.

Traditional Healers and Mental Health

The case for traditional healers in mental health

There are two arguments for traditional healer involvement in mental health provision; one pragmatic and one theoretical. The pragmatic argument turns on the huge shortfall in human resources to deal with mental health problems in low- and middle-income countries (LMICs).[1] Traditional healers could make up for this shortage in human resources in the formal sector. A theoretical argument for the role of traditional healers turns on cultural factors. The argument here is that traditional healers are ideally placed to intervene in conditions with social origins, or when symptoms are coloured by cultural assumptions. Traditional healers, one might suppose, can tap into the beliefs and expectation of local people to reach parts of the mind that are simply inaccessible under a ‘medical model’. According to this argument modern medicine is the appropriate vehicle for the diagnosis and management for the conditions that are mainly of the body. It would be unwise, for example, to rely on traditional healers for the treatment of an acutely febrile child, or for provision of contraceptive advice. However, the traditional healer might be the appropriate first port of call for people with conditions of the mind.

The case against traditional healers in mental health

An argument against the above position is that the most serious types of mental health condition, psychotic illnesses, require modern pharmacotherapy, at least to stabilise patients. While all psychiatric conditions are of both brain and mind, psychotic conditions can be closer in form to those of standard medical diseases and the effects of properly targeted chemotherapy can be dramatic. There are many well documented cases where access to appropriate pharmacological therapy was denied or cruelly delayed while patients were treated unsuccessfully by traditional healers. From this perspective one should no more consult a traditional healer for a mental illness than for suspected malaria.

Reconciling the case for and against: a topic for investigation and research

On the one hand, traditional healers can offer culturally sensitive treatment for non-psychotic conditions, while on the other hand, severe mental illness requires medical services. It could be argued that traditional and modern medical services should be integrated so that traditional healers could treat the majority of patients, i.e. those with non-psychotic diseases, while allopathic clinicians treat the more severe cases. Moreover, different people have different preferences, and individuals may wish to receive care from both types of providers, even for the same illness. These would seem to be further arguments to integrate traditional and allopathic services within the same system and, indeed, in an integrated reimbursement system. Before implementing such a system it would surely be sensible to evaluate the effectiveness of traditional healers in the treatment of various psychiatric conditions and to ensure that, with the appropriate education, they would be able to refer cases that need medical treatment.

Philosophical problems in collaboration between traditional healing and modern medicine

The CLAHRC WM Director is keen to explore the relative effectiveness of traditional and allopathic treatments for non-psychotic mental illness but he is concerned that there may be irreconcilable philosophical differences in the traditional versus allopathic approach. This concern arises from different ontologies that underpin the different kinds of service. That is to say these traditions have different views on what counts as truth. Modern medical practice is very much a product of what might be called ‘enlightenment thinking’; practice built on an understanding of biological mechanisms / scientific explanations.[2] Such a world view is a far cry from the assumptions that underpin traditional healing, and which are guided by a set of traditional beliefs, often of a religious nature. So the question is whether it is possible to truly integrate systems with such different sets of underpinning assumptions? This is partly an empirical question – different systems could be examined to understand how well they can work together. The CLAHRC WM Director understands that moves are afoot to integrate allopathic medicine with traditional Chinese medicine in China, and in Ayurvedic medicine in India. It would be interesting to make independent studies of these systems. But in the meantime I would suggest a thought experiment. Let us imagine a proposed trial of rose-hip water vs. anti-depressant medication taking place in an integrated hospital. The allopathic practitioners present this as a placebo-controlled trial, while the traditional healers present this as a trail of two effective alternatives – the underlying belief systems determine how the treatments are presented. The CLAHRC WM Director suspects that it is very difficult to really integrate two systems based on very different philosophical premises. It is one thing to make irenic statements about mutual respect and so on, but another to supress tensions that seem likely to arise from fundamentally irreconcilable philosophical assumptions.

Living with contradictions

The question of integrating these different systems of thought is, perhaps, unresolvable. The systems have existed side by side for a hundred years or more. In high-income countries there is a thriving industry in complementary therapies and the list of alternative methods is almost too long to recite. Likewise traditional medicine and modern medicine have existed side by side quite happily in Africa, South Asia and China for many years. The populations in all these countries seem, on the whole, pretty savvy at working out which method is more appropriate for them in which condition. I have never heard of anyone going to a homeopath for their family planning needs. But systems co-existing in society is one thing, integrating them in common administrative and reimbursement systems is another. Every now and then there is an attempt to unite religion and science around a common purpose – the Lancet commission is currently involved in such a process.[3] [4] However, it may be the case that like religion and science; traditional and allopathic medicine can live happily side by side within the same community and within the same individual. Whether and how they can really be brought together in a structural / organisational sense, for example in the same institution or within the same reimbursement system, is a matter for analysis and exploration. One thing I am sure of is that policy should not be made as though this were a technical issue and without considering the very different world views that lie behind each type of provision. Maybe the best that can be accomplished is for the systems to become more aware of each other and cross-refer when necessary, but to continue to make their own independent contributions?

— Richard Lilford, CLAHRC WM Director


  1. Rathod S, Pinninti N, Irfan M, Gorczynski P, Rathod P, Gega L, Naeem F. Mental Health Service Provision in Low- and Middle-Income Countries. Health Serv Insights. 2017; 10:
  2. Spray EC. Health and Medicine in the Enlightenment. Jackon M (ed). The Oxford Handbook of the History of Medicine. 2011.
  3. Horton R. When The Lancet went to the Vatican. Lancet. 2017; 389: 1500.
  4. Lee N, Remuzzi G, Horton R. The Vatican-Mario Negri-Lancet Commission on the value of life. Lancet. 2017; 390: 1573.

Deforestation and Diarrhoea

Contaminated water can lead to numerous diseases, including diarrhoea, a leading cause of child mortality. In a previous News Blog we discussed the importance of water contamination, and the many methods by which it can occur.[1] One such route is contaminated surface water, which has been linked to outbreaks of diarrhoea in previous studies.[2] A major factor affecting the quality of surface water is the ‘watershed condition’ – the natural land cover provided by the ecosystem, such as forests and wetlands. This ecosystem filters pollutants and pathogens from surface water supplies, and can stabilise soil, and minimise erosion and sediment loading.

Herrera and colleagues conducted an observational database study of almost 300,000 children aged under 5 from 35 countries, looking at their health, socioeconomic factors (such as mother’s education, household wealth, access to improved sanitation and water sources), climate (temperature and precipitation) and watershed condition.[3] Watershed condition was measured by estimating the percentage of water that was affected by people and livestock or tree cover upstream from the household.

They found that high tree cover upstream of the child’s household was associated with a lower probability of diarrhoea (odds ratio less than 1, but not specified). This was significant only for rural households, however, not urban. In rural communities it is estimated that only 33% of households obtain their water from piped sources (compared to 79% in urban areas), and 93% of people who use surface water as their main water source live in rural areas.

The authors used a model to estimate that increasing tree cover upstream by 30% would have a similar effect to improving sanitation (an estimated 4% reduction in probability of diarrhoea from baseline). It would, however, not have as great an impact as improving the water source (7% reduction), wealth (12% reduction) or education of the households (13% reduction). It seems that, under certain conditions, conservation strategies that ensure that tree cover is high could serve as effective investments in public health.

— Peter Chilton, Research Fellow


  1. Lilford RJ. A Secondary Sanitary Revolution? What About the First One? NIHR CLAHRC West Midlands News Blog. September 1, 2017.
  2. Bessong, P., Odiyo, J., Musekene, J. & Tessema, A. Spatial distribution of diarrhoea and microbial quality of domestic water during an outbreak of diarrhoea in the Tshikuwi community in Venda, South Africa. J Health Popul Nutr 2009; 27: 652-9.
  3. Herrera D, Ellis A, Fisher B, et al. Upstream watershed condition predicts rural children’s health across 35 developing countries. Nature Comm 2017; 8: 811.

Towards a Unifying Theory for the Development of Health and Social Services as the Economy Develops in Countries

In a previous news blog I proposed grassroots solutions to the transportation of critically ill patients to hospital.[1] Other work has demonstrated the effectiveness of community action groups in many contexts, such as maternity care.[2] More recently I have read that the Kenyan government is proposing a combination of local authority and community action (Water Sector Trust Fund) to improve water and sewage in urban settlements.[3] The idea is for the local authority to provide the basic pipe infrastructure and then for local communities to establish linkages to bring water and sewage into homes. The government does not merely lay pipes, but also stimulates local involvement, including local subsidies and micro-enterprises. This epitomises collaboration between authorities and community groups.

In an extremely poor, post-conflict country, such as South Sudan, it is hard to find activities where the authorities and local people work together to improve health and wellbeing. On the other hand, in extremely rich countries like Norway and Switzerland, the government provides almost all that is required; all the citizen has to do is walk into the bathroom and turn on the tap.

The idea that is provoked by these many observations is that different solutions suit different countries at different points in their development. So much so obvious. Elaboration of the idea would go something like this. When a country is at the bottom end of the distribution for wealth, there is very little to be done other than put the basics of governance and law and order into place and try to reduce corruption. Once the country becomes more organised and slightly better off, a mixture of bottom-up and top-down solutions should be implemented. At this point, the tax base is simply too small for totally top-down, Norwegian style, solutions. In effect the bottom-up contribution makes good the tax deficit – it is a type of local and voluntary taxation. As the economy grows and as the middle class expands, the tax base increases and the government can take a larger role in funding and procuring (or providing) comprehensive services for its citizens.

This might seem anodyne written down as above. However, it is important to bear in mind that harm can be done by making the excellent the enemy of the good. Even before a substantial middle-class evolves in society, wealth is being generated. I recently visited a number of urban settlements (slums) in Nigeria, Pakistan and Kenya. All of these places were a hive of economic activity. This activity was mostly in the informal sector, generating small surpluses. Such wealth is invisible to the tax person, but it is there, and can be used. Using it requires organisation: “grit in the oyster”. The science base on how best to provide this ‘grit’ is gradually maturing. In order for it to do so, studies must be carried out across various types of community engagement and support. I expect this to be a maturing field of inquiry to which the global expansion of the CLAHRC message can contribute. Members of our CLAHRC WM team are engaging in such work through NIHR-funded programmes on health services and global surgery, and we hope to do so with regard to water and sanitation in the future.

— Richard Lilford, CLAHRC WM Director


  1. Lilford RJ. Transport to Place of Care. NIHR CLAHRC West Midlands News Blog. 29 September 2017.
  2. Lilford RJ. Lay Community Health Workers. NIHR CLAHRC West Midlands News Blog. 10 April 2015.
  3. Water Sector Trust Fund, GIZ. Up-scaling Basic Sanitation for the Urban Poor (UBSUP) in Kenya. 2017.