The garbage people: unintended consequences of change

With a capacity for 20 000 people, the cave church of St. Simon are said to be the largest Christian church in the Middle East.  The church’s limestone walls have breath-taking carvings.  Getting there requires travelling through a section of Cairo’s Manshiyat Naser neighborhood known as the garbage city. This is breath-taking in a completely different way…

Your senses alert you that this is the garbage city, the putrid smell is intense and there is garbage everywhere.  Garbage fills the narrow streets, the balconies, kids play in it and the shops are hidden between garbage. Garbage city is home to the Zabaleen (garbage people).  The Zabaleen travels from house-to-house in Cairo, collecting household waste and transporting the collected waste back to the garbage city. Each family specialize in a type of garbage that they sort, recycle and sell.

Until 2003 the Zabaleen collected garbage at almost no cost to the government and residents of Cairo.  Their main income came from recycling the garbage.  It’s estimated that in 2003 the Zabaleen recycled 80% of the garbage collected.  This was described as one of the most efficient recycling systems globally and it has earned the Zabaleen international acknowledgement.

 

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View from the car window

 

The Zabaleen are Christians in a Muslim majority country.  In the recycling business this provides them with a competitive advantage: the ability to keep pigs.  The Muslim’s religion does not permit living close to or keeping pigs. Most of the waste collected is food waste; the Zabaleen recycles this by feeding it to their pigs to fattening them up.  Once fat, the pigs are sold, providing further income.

The improvement: fake green grass on the other side of the fence

In 2003, the Mubarak government decided to ‘modernize’ the garbage collection system of Cairo by adopting the systems used in Europe.

Unintended consequences of the change

  • Adverse impact on the socio-economic stability of the Zabaleen
  • The modern mechanism of compressing garbage complicated recycling and the level of recycling dropped
  • Cairo’s streets were too narrow for the mechanized equipment, uncollected garbage was dumped by the residents
  • The new collection system introduced higher fees resulting in further illegal dumping, burning of waste and increased pollution

To compare: in 1997 the Zabaleen collected 3000- 4000 tons of garbage per day at almost no cost to the government; they recycled about 80% of the waste collected.  In 2004 the government was paying ten times more to have only 60% of the garbage collected and 20% of the collected garbage was recycled.

 

Then in 2009, the Egyptian government ordered the slaughter of some 300 000 pigs as precautionary measure to prevent swine flu (H1N1). This effectively destroyed another vital aspect of the Zabaleen’s recycling methods.  The WHO called the killing ‘scientifically unjustified’. The government’s actions against the Zabaleen was almost certainly politically motivated and grounded in religious tensions.

Moral of the story

There is a tendency to view another country, organization or functional work unit’s methods as superior.  It is problematic when these methods are adopted without considering feasibility, cultural differences and why the current system operates the way it does. There is always a reason for the faults in the current system, a few examples would include hierarchies, history or power struggles.

 

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The grass is not always greener on the other side….

 

Even in healthcare, when low-middle income countries (LMIC) undertake to improve their healthcare systems, they often model their interventions after high income countries (HIC).  However, HIC have the enabling infrastructure to support advanced health systems. In LMIC’s with poor roads, it would be more sustainable to invest in bicycle ambulances than to establish ambulance services.  Rather than develop university curriculums, train community first responders in the rural areas.  Instead of creating an urban center of excellence, provide electricity and running tap water in all the small rural clinics.

To the Egyptians, investing in the Zabaleen’s existing informal system would’ve probably been more beneficial, cost effective and sustainable.  By disregarding the functioning informal system, the policy makers destroyed a functioning system and adopted a system not suitable for their setting.  This resulted in failure so devastating that it’s even been cited as a reason for the 2011 uprising.

There are a few lessons that we can take from this:

  • Don’t discard local ownership
  • Thoroughly observe and analyze the current situation prior to suggesting change
  • The above implies spending time to explore the current situation
  • The first consideration should always be to augment the local/informal system or to formalize the informal system
  • If the solution is adopted, make it context specific, in other words innovate on what worked somewhere else
  • When formal systems are developed it should be done considering the integration of formal and informal systems from the beginning

Disregarding the above will result in change programs that are not sustainable.  Not integrating formal and informal systems result in parallel systems where the systems compete to the detriment of both.

Conclusion

A year after implementing the ‘modern’ system the Egyptian policy makers had to acknowledge failure. A decade later they are taking steps to integrate the Zabaleen into the formal system.  They are also investing in the Zabaleen that now have uniforms and vehicles.

In short, don’t solve problems that don’t require solving, observe, investigate and find the real and right problems.  Solutions should be feasible, involve the locals and the informal systems and don’t ever blindly adopt, rather innovate and make change context-specific.

To watch a short documentary about the garbage people

https://www.youtube.com/watch?v=D0s7WsoC528

Read more

Wael Salah Fahmi. Keith Sutton.  (2006)  Cairo’s Zabaleen garbage recyclers: multi-nationals take over and state relocation plans.  Habitat International 30 (2006) 809-837

http://www.yourmiddleeast.com/culture/turning-waste-into-wealth-with-cairos-garbage-people-photos_31874

https://www.theguardian.com/global-development/poverty-matters/2014/mar/27/waste-egypt-refuse-collectors-zabaleen-cairo

http://weekly.ahram.org.eg/News/14892/32/Egypt%E2%80%99s%20garbage%20problem.aspx

https://en.wikipedia.org/wiki/Zabbaleen

http://www.samaanchurch.com/en/about_us.php

http://news.nationalgeographic.com/news/2009/04/090430-egypt-swine-flu-video-ap.html

 

Addressing South Africa’s health system dilemmas, one entrepreneur at a time

A successful economy is dependent on a population that is healthy enough to work.  The health system in South Africa is responsible for supporting and promoting health, whilst treating and preventing illness, but it is unable to meet the growing burden of disease.

In the Western Cape the public health system provides chronic medication to 200 000 patients each month.  Queues to collect medication start at five in the morning and people are frequently known to queue for eight or more hours.  The people queuing for medication may be elderly, disabled, sick, or they may have to bring their children with them because they do not have childcare.  Patients are forced to take time off work. This means they sacrifice their wages, spend money on transport and lose out on productive time due to long waiting times.

The failure to meet health outcomes is apparent in informal settlements such as Khayelitsha where the population that is reliant on the public health sector is large, dense and they are mainly from low-income households.

Khayelitsha is reputed to be the largest and fastest growing township in South Africa.  It is one of the poorest areas in Cape Town with a median family income of R20 000 per year.  The most common forms of employment for residents include domestic work, service work, skilled and unskilled manual labour.  With high levels of unemployment, it is estimated that 89% of Khayelitsha households are either moderately or severely food insecure.  Khayelitsha has the highest rate of murder, aggravated robbery, assault with intent to do grievous bodily harm and sexual offences in South Africa.  And surprisingly, it has the lowest police to population ratio in the Western Cape.

Enter Sizwe Nzima

After matriculating in 2009, Sizwe Nzima completed a course as a legal secretary, only to join the large number of South Africa’s unemployed youth.   ’Youth’ (aged 14 – 35 years, as categorised by the National Youth Policy) represent 55% of South Africa’s population, and 60% of them are unemployed.

Sizwe Nzima was not prepared to give up his dreams of having a job and being successful. In 2012 he was accepted as a student at the Raymond Ackerman Academy of Entrepreneurial Development, based at the Graduate School of Business.  Scavenging newspapers for ideas at the Academy, he read about the difficulty that patients face collecting their medication from public health facilities and the difficulty the health facilities have in meeting the needs of their patients.  He was reminded of his own experience collecting medication for his grandparents, with whom he grew up, and so a business idea was born.

Iyeza Express, a bicycle courier service collects medication from the day hospitals in Khayelitsha Site B and Harare delivering it to the patients’ doors.  No more waiting in long queues for the day. Initially Sizwe Nzima worked by word-of-mouth referrals, charging R10 a delivery.  R10 is a lot of money for some residents and the profit margin for Iyeza Express is tiny. Fortunately Sizwe Nzima has managed to secure financial sponsorships.

Mr Nzima is currently in negotiations with Western Cape Department of Health to assist his work through funding from the budget for the Chronic Dispensing Unit (CDU).  The CDU’s goal is to alleviate the crowding of approximately 47 000 patients per month by delivering medication to patient homes.  And Iyeza Express has an advantage over the CDU in Khayelitsha: Local knowledge. Informal settlements have limited street name signs, house numbers, and maps of the area are incomplete, certain areas are difficult to access and local knowledge of potential dangers is important.  The large geographic area that CDU needs to service creates new challenges of timeous deliveries, fuel costs and distances covered over many areas within the Western Cape.

Improved ways to serve resource-poor communities are receiving attention globally. One solution is to involve community members.  Local examples includes the emergency first aid response (EFAR) system first implemented in Manenberg, where community members are trained as first aid responders, or the City of Cape Town’s treatment support system for Tuberculosis (TB) management.  These initiatives, and Iyeza Express, demonstrate that task shifting in healthcare creates new leverage, and it challenges the tradition of exclusive reliance on trained professionals for healthcare delivery.

Iyeza Express addresses one of the biggest frustrations to both patients and healthcare workers: waiting time.  Iyeza Express has increased patients’ accessibility to healthcare and arguably affordability (by taking out their transport costs, and removing the need to lose wages through hours spent waiting in queues).

Why it matters on a macro-economic level

Brain drain, staff shortages, burn out, low attrition rates after studying are common factors hindering the public health sector’s ability to serve community health needs.  Doctors and nurses are expensive to train and it takes several years before they are competently trained. Waiting for enough qualified health professionals to save the day is simply not a viable option. Thus, investing in training more health workers is only part of the solution.   Supporting and using innovative local community members must be another part of the solution.

There is an association between a country’s stage of economic development and its level of entrepreneurial activity.  According to the Global Entrepreneurship Monitor (GEM) high levels of entrepreneurial activity are predicted for South Africa.  However the rate of entrepreneurship has been steadily decreasing and is far below the average for efficiency-driven economies such as South Africa.  The link between entrepreneurs and economic prosperity is particularly true and important in developing countries.

In May 2014 a new ministry for Small Business Development was established and in November 2014 its Minister, Lindiwe Zulu, unveiled a target for raising the GDP contribution of small, medium and micro enterprises (SMME’s) to between 60 – 80% over the next 15 years.  Current contribution to GDP is 35% and the global average is 45%. She has also set goals to reduce some limiting factors in this sector such as reducing red tape and regulations.  This makes it easier for people such as Mr Nzima to develop ideas and grow enterprises within the economy.

The government does not have the capacity to resolve unemployment on their own.  South Africa needs innovators in the informal settlements that can create hope and set an example to the youth.  Sizwe Nzima is such a person: an inspiration and mentor. He has employed people to assist him in his social enterprise, thus directly impacting on unemployment.

Final thoughts

I’m inspired by Sizwe Nzima’s story and it shows us that where there is a will there is a way. I think that he is courageous and I’ve enjoyed learning and reading about him.  I’ve included a link to an interview with him by ‘Kaelo Stories of Hope’.  I would recommend watching it for a good dose of inspiration.  https://www.youtube.com/watch?v=Z-_1qXbZ4x8

Healthcare is a dominant economic and political issue.  In South Africa healthcare is a constitutional right, however inequity remains rife.  This inequity creates opportunities that only emerge when a current system is failing.  We need more grassroots entrepreneurs such as Sizwe to help our health sector become more efficient and effective in rendering care.

Read more about Sizwe Nzima and Iyeza Express at www.iyezaexpress.co.za