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The weekly HIV clinic is teeming with patients of all ages, from babies to grand-parents.

A health care worker is questioning one of them about their social and economic background.

He writes down an increasingly grim litany.

Education - none, job - none, children - many, rooms in mud hut - too few.

It is clear that these are people in need.

In Malawi, one in eight adults are infected with HIV.

But drugs alone may not be the answer to this deadly scourge.

Care in the community

In Neno, a remote area in southern Malawi, poverty and HIV are both rampant.

People here are obviously very poor. It is the recipe for a major health crisis, one that is far beyond the resources of the government to cope with.There are clutches of straw roofed huts, neglected villages and abandoned crops.

But in the last three years, they have joined forces with Partners In Health (PIH), a social enterprise dedicated to providing quality health care to the world's poorest people.

PIH believes that social factors are as important as medical ones.

They do not just offer medical care, but practical help as well. They argue that the poor need food, homes, work and education in order to stay healthy, not just tablets and surgery.

This means that a lot of their work does not take place in hospitals, but out in the community...

Food enterprise

PIH also helps patients get jobs.

But with little formal employment, they have to do this by giving them grants to set up their own businesses. 

In a nearby town, a group of 15 women recently set up their own restaurant with the support of PIH.

They are former prostitutes, and all are HIV positive.

The women, all on anti-retroviral medication, wanted a business, not only to provide money to live on, but to give them a sense of pride in themselves.

Good food is essential for HIV positive patients, but the local diet is generally poor.

The staple food is "sima", a maize flour mixed with water.

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Local handmade paper and products marketer and sales agent Phumani Paper is actively involved in assisting community-based enterprises to diversify their income base by introducing innovative products. One of these products is the ecofuel briquette.

University of Johannesburg (UJ) associate professor in the Faculty of Art Design and Architecture Kim Berman explains that the fuel briquette is a round disc made of slightly decomposed and compressed plant matter, with a hole in the centre to allow the flame to breathe and burn.

"The technology of recycling agricultural waste in Phumani Paper craft enterprises around the country provides a synergy in that the waste materials from the handmade papermaking process, including the use of waste plant and paper fibre, used water and rotting or leftover paper pulp, can all be recycled to manufacture fuel briquettes. "These briquettes can be used as an alter- native energy source (for cooking and heating) and contribute to environmental conservation," she says.

She explains that, as an alternative source of energy, the ecofuel briquette has several additional benefits in the South African context: it is a cheap and efficient source of energy and can assist in job creation; it can preserve indigenous biodiversity through the use of invasive plant species (as raw material); it can boost the local economy; and it is lightweight and can, therefore, be carried over long distances.

The research process of the ecofuel brick project consists of a network of collaborators from different disciplines, based at UJ. The aim is to develop an economically viable and marketable new product to introduce into some of the Phumani Paper enterprises, she adds.

Phumani Paper was originally set up in 2000 as a government-funded poverty alleviation project of the former Technikon Witwatersrand (now UJ) to establish a new cultural industry in handmade paper production in South Africa. It is registered as an independent Section 21 nonprofit company and has developed small business enterprises in handmade papermaking and craft production across the country.

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Three days a month, Annalita is too embarrassed to go to school.

The Rwandan teen, like millions of her peers worldwide, is menstruating. Her family can't afford sanitary pads, so Annalita makes do with what few materials she can find including rags, bark and mud.

But these makeshift pads are usually ineffective. Rather than focusing on her studies, Annalita spends her day anxious about a potential accident in front of her classmates.

She also worries about embarrassment in her community. Menstruation carries a stigma of uncleanliness. Considering she can't openly wash and dry her rags, walking home in soiled clothing would bring her further shame.

"If you have pads when you are travelling it would be easy," said Annalita at a meeting run by community health workers. There in the crowded, dirt-floored room it had taken some time for her to start talking. Soon though, everyone became eager to discuss the dilemma. "That would help you to continue with your daily programs and let you go where you wanted to go and do what you wanted to do."

Menstruation is rarely viewed as a pressing issue in developing nations. But, as community health workers encourage girls like Annalita to talk, they uncover a staggering problem. Every year, women and girls miss on average 50 days of work or school because they can't afford effective sanitary pads.

For Annalita, this could amount to 5 years of lost potential as she hides due to shame.

But, Elizabeth Scharpf wants Annalita to be free of embarrassment every day of the month.

"I think you have to understand what resonates with each group of people," says the founder of Sustainable Health Enterprises, a social enterprise focusing on market-based approaches to development. "For example, when we talk to the Rwandan Minister of Finance, we talk about the economic consequences of girls not going to school. We talk about the future of the country."

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A Swedish entrepreneur is trying to market and sell a biodegradable plastic bag that acts as a single-use toilet for urban slums in the developing world.

Once used, the bag can be knotted and buried, and a layer of urea crystals breaks down the waste into fertilizer, killing off disease-producing pathogens found in feces.

The bag, called the Peepoo, is the brainchild of Anders Wilhelmson, an architect and professor in Stockholm.

"Not only is it sanitary," said Mr. Wilhelmson, who has patented the bag, "they can reuse this to grow crops."

In his research, he found that urban slums in Kenya, despite being densely populated, had open spaces where waste could be buried.

He also found that slum dwellers there collected their excrement in a plastic bag and disposed of it by flinging it, calling it a "flyaway toilet" or a "helicopter toilet."

This inspired Mr. Wilhelmson to design the Peepoo, an environmentally friendly alternative that he is confident will turn a profit.

"People will say, 'It's valuable to me, but well priced,' " he said.

He plans to sell it for about 2 or 3 cents - comparable to the cost of an ordinary plastic bag.

In the developing world, an estimated 2.6 billion people, or about 40 percent of the earth's population, do not have access to a toilet, according to United Nations figures.

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Many technologists and entrepreneurs have argued that mobile phones can empower people in the developing world by providing civic and commercial resources where traditional infrastructure is lacking. But what actually happens when people start using such technologies? An MIT economist's detailed new study from Kenya sheds light on the impact of a mobile phone-based money system in a developing economy.  

Kenya's new mobile-money system, called M-PESA, really is changing the way Kenyans manage their money, by letting them borrow, save and pay for services more easily, according to Tavneet Suri, an assistant professor at the MIT Sloan School of Management, who along with Georgetown University economist William Jack is leading a major research project on the subject. 

"I don't think anybody thought it would take off quite as fast as it did or be as popular as it's been," says Suri. "The adoption has been very quick compared to almost any other technology we've seen." 

Since its introduction in 2007, the researchers found, 38 percent of Kenyan households have at least one M-PESA user in them; by contrast, only 22 percent of adults have bank accounts. "In these sorts of economies, there's not much of a bank presence, but money transfers are still important," notes Suri. "People do them all the time."

Kenya's rapid adoption of mobile money is occurring with a larger global trend of increased cellphone use. There are now over 4 billion mobile phone subscriptions worldwide, compared to 1 billion in 2002, according to a 2009 report by the International Telecommunications Union, a United Nations agency. Of those subscriptions, about two-thirds are in developing countries.

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The argument for the development of the private health sector in Africa could not have been more strongly made than at a recent international conference held in Accra under the aegis of the World Bank Group. 

Featuring diverse success stories on health care financing and insurance from Ghana, Kenya and Mali, it was perhaps the story of the exploits of the Malian Association of Rural Medical Practitioners that most caught the imagination of participants and positioned an entrepreneurial private sector as possible solutions to access to healthcare. Shortages in the numbers of health professionals have also often been aggravated by inequitable distribution. The underlying reasons were most succinctly made by Dr. Khama Rogo former President of the Kenyan Medical Association and now with the World Bank Group. 

Although acute shortages in health personnel have been observed, it is becoming increasingly indisputable that many African governments are unable or will be unable to adequately fund the huge wage bill that is anticipated should all these qualifying health professionals be employed in the public sector. The phenomenon was cited in Kenya for example where although the State could certainly do with more doctors, securing employment for all qualified doctors was increasingly becoming challenging due to budgetary limitations. As a result, some newly qualified doctors or housemen realizing the housemanship as a part of training have begun offering their services for free in order to be signed off for full certification. Similar scenarios have been reported in Nigeria. 

In Ghana, Ministry of Health estimates put the number of doctors in 2007 at 2, 026 and yet if the West African state were to achieve prevailing doctor: patient ratios of 1: 1000 in some middle income countries by 2025 by which time its population is expected to hit 32 million, it would require not less than 32, 000 doctors. Twice this number of nurses would be required also if the estimates contained in the 2006 UN World Population Prospects are anything to go by. Assuming that governments were able to fund the training of all these doctors, is it safe to also assume the state's ability to employ all these doctors? The clarion call for governments, doctors and other major stakeholders to embrace a new era of entrepreneurial driven health agenda could not therefore have been made more loudly. While this should not be seen purely as a commercialization of the health needs of the people, it should be positioned within a framework that ensures the availability of such health services to the less privileged and underserved areas and this the Malians seem to have done brilliantly.

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While billions of pounds have been spent on food aid for developing countries, only a small portion has made any long-term difference to the future economic prospects of subsistence farmers in the world's poorest communities.

"Sometimes in Africa you could feel as though you were just pouring money into a bucket with a big hole in the bottom," says Simon Maddrell, who founded the charity Excellent Development in 2002 with Kenyan farmer and engineer Joshua Mukusya.

Schemes such as sand dams, which provide a year-round source of filtered water, and terracing soil to reduce erosion, repay the community's investment of "free" labour by giving a more reliable harvest of valuable food and dramatically reducing the number of hours individuals spend walking miles to collect clean water.He was determined to ensure the new charity would take a longer-term view by only developing projects at the request of the local community, and that these should be built using voluntary local labour.

"Nothing comes for free," says Mr Maddrell, 44. "It is generally true that people don't value what they are given for free as much as what they have worked for. We want communities to engage with and own the process of the project."

As a result of securing community involvement, benefits can be provided at lower cost; typically, every £1 donated by a member of the public achieves £1.44 worth of improvements, fostering "independence and self-reliance", as Mr Maddrell puts it.

"It is challenging the idea that farmers in Africa are idiots who need to be told how to grow food," he says.

The charity is currently helping 67 community groups in Kenya. By way of example, it says a typical one-year project might see a group mobilised to build a sand dam, dig 4,000 metres of terracing and plant 3,800 trees to counteract deforestation caused by population growth.

The community contribution would amount to more than 2,500 days of labour - digging, building and collecting stones, sand and water. Groups must also provide the food eaten by the workers during the one day each week they are expected to contribute.

Based on the minimum wage for an agricultural worker of about £1 per day, and adding the cost of food, the local input would be worth £6,771.

The cost to the charity of providing technical expertise and imported materials such as cement would come to about £15,255, so almost one third of the total £22,026 cost is met by the recipients.

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Players in the microfinance industry are looking forward to the establishment of branchless banking so that they can reach more people countrywide without the cost of erecting brick and mortar outlets.

The planned changes to the legislation governing the setting up of financial institution branches ,which will allow for the establishment of branchless banking or agency banking, is expected to provide microfinance institutions with a leverage to extend their reach at minimal cost.

"The establishment of branchless banking will allow us to reach more people, especially in the rural areas where the majority are unbanked ," said Lydiah Koros, the chairperson of the Association of Microfinance Institutions (AMFI).

Ms Koros said agency banking will transform the industry by offering financial services through easy -and simple- to -use devices such as point of sale (POS) terminals and at the customers doorsteps .

Current rules on the establishment of branches for commercial banks and MFIs require brick and mortar, steel and glass structures before services can be rendered.

This pushes up the costs of operation as financial institutions are forced to put up structures in order to roll out services.

"The new regulation on agency banking will boost MFIs as we don't have the wherewithal resources to put up branches across the country to match our rapid customer growth base", said Ms Koros who is also the Chief Executive Officer of Faulu Microfinance. This development comes as Kenya prepares to host the Africa-Middle East Micro-credit Summit in April.

The meeting, which will be attended by over 2,000 delegates from over 40 countries from Africa and the Middle East, is expected to show case Kenya's best practice and innovation in offering of microfinance services to the poor.

Its the first to be held in Africa and has received sponsorship of Sh9 million from Craft Silicon, a local leading software solutions vendor.

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Soon, low-income families in Kenya will be able to add to their diet a pre-cooked porridge product that is rich in proteins and vitamins and supplies the nine essential amino acids required by the human body.

The porridge will not be delivered under the auspices of an aid agency or a government-funded programme.

Most families will buy it as part of a revenue-based approach to attacking malnutrition.

The market-based approach to malnutrition is something being explored by large companies such as Unilever, PepsiCo and Danone, as awareness grows of the need to address malnutrition - something that affects not only the poorest communities but also higher income populations - and the potential of doing so through for-profit products. However, some believe that there is a role for smaller entrepreneurs in coming up with hybrid models that can address what is often known as "hidden hunger".

It is for this reason that Acumen Fund - a New York-based social venture fund that provides financing to enterprises using market-based approaches to addressing poverty - has invested in Insta Products, a Kenya-based private company that supplies organisations such as the World Food Programme and Unicef with emergency relief food.

"The majority of their revenue is going to come from the big aid contracts," says Omer Imtiazuddin, health portfolio manager at Acumen Fund, which is working on these types of food products with the Geneva-based Global Alliance for Improved Nutrition, a non-profit group that promotes public-private partnerships to fight malnutrition. "But for Insta this could be a significant source of revenue."

The food product Insta is developing - known locally as uji - is particularly well suited to Kenyan tastes, as the porridge is eaten by 80 to 90 per cent of the local population across all age groups and income segments.
The fortified version is badly needed. Many women in Kenya suffer from low micronutrient intake during pregnancy, making it hard to gain the necessary weight for the development of their babies.

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NAIROBI, 19 January 2010 (IRIN) - Fridah Awour Agolla has sold vegetables in Nairobi's Mathare slum for 20 years. In better times, her stock sold out every day. But lately market forces have begun to bite even harder for the millions in Kenya who live in such squalid, neglected settlements. 

"My customers are buying less and less; now I find that goods like vegetables do not sell out, they go into the next day. People's ability to buy these goods has really dropped," Agolla, a mother of five, told IRIN. 

Agolla managed to put her children through primary school but never earned enough to pay for secondary education. 

"If I could afford to join a savings club [where members' regular contributions are distributed on a rotational basis], I'd buy a variety of food to improve my stock and I would probably be selling more, and perhaps some of my children could go back to school," she said. 
Pamela Anyango Odhiambo, 25, and a mother of five, says making ends meet gets harder and harder in Mathare. 

"I think food prices have more than doubled within a short time; for example, with 300 shillings [US$4] I could feed my family for days. Now it is not even enough for one day," said Odhiambo, nursing two-month-old twins. 

"Humanitarian crisis" 

Slum-dwellers are among the Kenyans worst hit by high food prices, yet they receive far less humanitarian attention than other demographic groups. The poorest urbanites spend up to two-thirds of their income on staple foods alone. 

"There is a humanitarian crisis in deprived informal settlements around the world, and one of the regions where this dynamic is playing out is in Kenya," said Choice Okoro, advocacy and outreach officer for the UN Office for the Coordination of Humanitarian Affairs-Kenya. 

"Urban poverty is set to be Kenya's defining crisis over the next decade if it is not urgently addressed," she added.

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