Brett Keller, MPA
Back in September the New York Times reported on an unexpected finding from a clinical trial: “A promising but expensive device to prop open blocked arteries in the brain in the hope of preventing disabling or fatal strokes failed in a rigorous study.” Many promising medical innovations fall short when they finally reach clinical trials, but this story was unusual because the stents had already been approved by the FDA under a so-called humanitarian exemption. The FDA approved the stents to reduce the risk of stroke, but those who received it had twice as many strokes.
How did this happen? The Times chronicled experts’ puzzlement: “Researchers said the device seemed as if it should work.” And Joseph Broderick, a prominent neurologist, is quoted as saying “Quite frankly, the results were a surprise.” Researchers are delving into this case to discover why the stent failed, but policymakers from all fields should take it as a valuable lesson. This is one more argument for testing policies whenever possible: not only does expert opinion sometimes get things wrong, but without good data there is often no way to really know when they are right.
Similar lessons can be gleaned from the history of surgical response to breast cancer. In The Emperor of All Maladies (2010), a new history of cancer, oncologist Siddhartha Mukherjee chronicles the history of such failed interventions as the radical mastectomy. Over a period of decades this brutal procedure – removing the breasts, lymph nodes, and much of the chest muscles – became the tool of choice for surgeons treating breast cancer. In the 1970s rigorous trials comparing radical mastectomy to more limited procedures showed that this terribly disfiguring procedure did not in fact help patients live longer at all. Some surgeons refused to believe the evidence – to believe it would have required them to acknowledge the harm they had done. But eventually the radical mastectomy fell from favor; today it is quite rare. Many similar stories are included in a free e-book titled Testing Treatments (2011).
As a society we’ve come to accept that medical devices should be tested by the most rigorous and neutral means possible, because the stakes are life and death for all of us. Thousands of people faced with deadly illnesses volunteer for clinical trials every year. Some of them survive while others do not, but as a society we are better off when we know what actually works. For every downside, like the delay of a promising treatment until evidence is gathered properly, there is an upside – something we otherwise would have thought is a good idea is revealed not to be helpful at all.
Under normal circumstances most new drugs are weeded out as they face a gauntlet of tests for safety and efficacy required before FDA licensure. The stories of the humanitarian-exemption stent and the radical mastectomy are different because these procedures became more widely used before there was rigorous evidence that they helped, though in both cases there were plenty of anecdotes, case studies, and small or non-controlled studies that made it look like they did. This haphazard, post-hoc testing is analogous to how policy in many other fields, from welfare and education, is developed. Many public policy decisions have considerable impacts on our livelihoods, education, and health. Why are we note similarly outraged by poor standards of evidence that leads to poor outcomes in other fields?
A recent example from New York City helps illustrate how helpful good evidence can be in shaping policy. A few years ago Mayor Michael Bloomberg rolled out a massive program that seemed to make a lot of sense: pay teachers bonuses based on their students’ performance. The common sense proposal was hailed as “transcendent” and gained the support of the teachers’ union. It cost $75 million, and it didn’t work. How do we know? The program was designed from the beginning as a pilot where schools were randomly assigned to the program or to a control group, and the research showing that the program had no effect on outcomes was subsequently published. What would have happened if this policy had been put in place without an effective evaluation plan? In all likelihood New York officials would now be touting its success at conferences and urging other cites to implement similar programs. Instead it was quietly shelved. That this particular program did not have the intended effect is disappointing, but it is much better than if we believed it worked and continued on unaware.
The pros and cons of randomized trials have been discussed here on 14 Points before – see recent posts by Jake Velker and Shawn Powers. The cases I presented here are ones where the results were not “no-brainers” at all, and without systematic evaluation bad policies would have been or tragically were put in place. While good evidence does not have to come from randomized trials, there are still many areas where they are underused. In areas where they are feasible (i.e. not macroeconomics) such evidence should be the norm, and those who implement policies with great optimism but without planning for thoughtful evaluation should be panned. Even without random assignment of the treatment, the best policy evaluations should involve a serious attempt to estimate the counterfactual: what would have happened in the absence of the intervention. Moving beyond arguments over specific programs and whether they work, policymakers can move us towards better outcomes by creating a culture where strong evidence is valued. After all, the clinical trial as we know it in medicine is a 20th century innovation; it hasn’t always been this way.
Showing posts with label health. Show all posts
Showing posts with label health. Show all posts
Friday, December 16, 2011
Friday, November 25, 2011
Saving Congress From Itself: Can the Independent Payment Advisory Board make Congress’s Medicare cost control problems go away?
David Mitchell, MPA
With the Joint Select Committee on Deficit Reduction – a.k.a., the Super Committee – missing a major deadline this week, the prospects for a debt deal before the next election seem bleaker than ever.
Eventually, Congress will have to act. The long-term deficit situation is truly unsustainable and the sequestration trigger agreed upon in August will begin sharply cutting Defense Department programs and Medicare provider payments in January 2013 (assuming Congress and the President allow it to stay in effect).
But for those hoping that responsible decision-making on the country’s entitlement and tax programs will materialize after next year’s election, prepare to be disappointed. In particular, Medicare – the public health insurance program for the aged and disabled, and by far the largest contributor to our long-term fiscal mess – has been subject to congressional mismanagement now for years.
As Wes Joines pointed out in a post earlier this month, the Medicare physician payment system is broken and has been so for more than a decade. Private insurance carriers that participate in the Medicare Advantage program have been overpaid since 2003, when the Republican-controlled Congress set artificially high payment rates as part of the same bill that expanded subsidized prescription drugs at the government's expense. And members of both parties have proven themselves unable to withstand the temptation of using the Medicare program to steer benefits to special interests. Whether it’s boosting payments to rural hospitals, delaying competitive bidding for durable medical equipment, or shielding beneficiaries from scheduled benefit cuts, there are many recent examples of costly Congressional micromanaging on both sides of the aisle.
Underlying this mismanagement is a simple political calculus: members of Congress believe that they must avoid being linked to any policy that will hurt the country’s 47 million Medicare beneficiaries (not to mention the tens of millions more about to join the program) or risk defeat at the polls. Cutting benefits is one obvious no-no, but cutting provider payments is also politically dangerous, since doctors and hospitals may then stop treating Medicare patients or otherwise incite seniors’ anger.
So what can be done? One hope is that legislators themselves may be looking for a way out of this Medicare cost-control political vortex, especially given the hard decisions that most political elites know will have to be made as part of an eventual debt reduction deal.
One sign of this thinking is Congress’s recent decision to establish an Independent Payment Advisory Board (IPAB) as part of last year’s health reform legislation.[1] The IPAB is designed to take Medicare payment policymaking out of the hands of Congress and put it into the hands of expert technocrats. Though the IPAB was not a major focus of the yearlong debate on health care legislation (Americans were otherwise obsessed with abortion, the public option, and death panels[2]), it may prove to be one of the most consequential provisions included in the ACA. In the words of former budget director Peter Orszag, IPAB represents “the largest yielding of sovereignty from the Congress since the creation of the Federal Reserve.”
Here’s how it works: A 15-member board appointed by the president and confirmed by the Senate will propose sharp cuts to Medicare payments if cost growth in the program continues on its current trajectory. What makes this Board different from past Medicare commissions – or even the current Super Committee – is that the recommended cuts will go into effect unless Congress finds equal savings elsewhere in the program or supermajorities in Congress vote to waive the new rules (and even then only if the president signs the resulting bill). There is concern that future Congresses will not allow themselves to be constrained by these parliamentary hurdles and will try to prevent the cuts by simply not confirming IPAB appointees or passing a new law revoking some or all of IPAB’s powers. But the IPAB provision includes rules to check these congressional urges, so there is reason to believe that IPAB will have teeth.
Beyond the technical details, one’s optimism about the Board depends in large part on what one believes is ailing the US health care system. If high prices are the culprit (as many on the left believe), IPAB could prove effective at withstanding political pressure from doctors, hospitals, and other providers and keeping prices low. If over-utilization is the main cost driver (as many on the right believe), IPAB’s usefulness will be limited. This is partly by design: currently, the Board can only recommend changes to provider payment rates, not benefits.
But many outside experts – including some who sat on the US Fiscal Commission last year – recommend expanding IPAB’s powers. And the president has urged Congress to lower IPAB’s cost growth rate target, making it more likely that recommendations will be triggered. Some have even speculated that IPAB could be the vehicle by which a new all-payer rate setting scheme could be implemented.
It’s unlikely that Congress will go along with any of the above proposals any time soon. Indeed, many in Congress have called for IPAB’s repeal. And it’s true that further empowering a board of unelected technocrats is not an easy sell to the American people (especially since the biggest problems facing Medicare – and the federal budget as a whole – require moral, not mathematical, answers). But as the extent of our long-term structural deficit becomes more apparent – and the situation grows more urgent – members of Congress may be tempted to delegate more and more tough decisions to IPAB. Some might view this as an undemocratic and irresponsible abdication of authority – in other words, the coward’s way out. But as Edgar Allan Poe once wrote: “That man is not truly brave who is afraid either to seem or to be, when it suits him, a coward.”
With the Joint Select Committee on Deficit Reduction – a.k.a., the Super Committee – missing a major deadline this week, the prospects for a debt deal before the next election seem bleaker than ever.
Eventually, Congress will have to act. The long-term deficit situation is truly unsustainable and the sequestration trigger agreed upon in August will begin sharply cutting Defense Department programs and Medicare provider payments in January 2013 (assuming Congress and the President allow it to stay in effect).
But for those hoping that responsible decision-making on the country’s entitlement and tax programs will materialize after next year’s election, prepare to be disappointed. In particular, Medicare – the public health insurance program for the aged and disabled, and by far the largest contributor to our long-term fiscal mess – has been subject to congressional mismanagement now for years.
As Wes Joines pointed out in a post earlier this month, the Medicare physician payment system is broken and has been so for more than a decade. Private insurance carriers that participate in the Medicare Advantage program have been overpaid since 2003, when the Republican-controlled Congress set artificially high payment rates as part of the same bill that expanded subsidized prescription drugs at the government's expense. And members of both parties have proven themselves unable to withstand the temptation of using the Medicare program to steer benefits to special interests. Whether it’s boosting payments to rural hospitals, delaying competitive bidding for durable medical equipment, or shielding beneficiaries from scheduled benefit cuts, there are many recent examples of costly Congressional micromanaging on both sides of the aisle.
Underlying this mismanagement is a simple political calculus: members of Congress believe that they must avoid being linked to any policy that will hurt the country’s 47 million Medicare beneficiaries (not to mention the tens of millions more about to join the program) or risk defeat at the polls. Cutting benefits is one obvious no-no, but cutting provider payments is also politically dangerous, since doctors and hospitals may then stop treating Medicare patients or otherwise incite seniors’ anger.
So what can be done? One hope is that legislators themselves may be looking for a way out of this Medicare cost-control political vortex, especially given the hard decisions that most political elites know will have to be made as part of an eventual debt reduction deal.
One sign of this thinking is Congress’s recent decision to establish an Independent Payment Advisory Board (IPAB) as part of last year’s health reform legislation.[1] The IPAB is designed to take Medicare payment policymaking out of the hands of Congress and put it into the hands of expert technocrats. Though the IPAB was not a major focus of the yearlong debate on health care legislation (Americans were otherwise obsessed with abortion, the public option, and death panels[2]), it may prove to be one of the most consequential provisions included in the ACA. In the words of former budget director Peter Orszag, IPAB represents “the largest yielding of sovereignty from the Congress since the creation of the Federal Reserve.”
Here’s how it works: A 15-member board appointed by the president and confirmed by the Senate will propose sharp cuts to Medicare payments if cost growth in the program continues on its current trajectory. What makes this Board different from past Medicare commissions – or even the current Super Committee – is that the recommended cuts will go into effect unless Congress finds equal savings elsewhere in the program or supermajorities in Congress vote to waive the new rules (and even then only if the president signs the resulting bill). There is concern that future Congresses will not allow themselves to be constrained by these parliamentary hurdles and will try to prevent the cuts by simply not confirming IPAB appointees or passing a new law revoking some or all of IPAB’s powers. But the IPAB provision includes rules to check these congressional urges, so there is reason to believe that IPAB will have teeth.
Beyond the technical details, one’s optimism about the Board depends in large part on what one believes is ailing the US health care system. If high prices are the culprit (as many on the left believe), IPAB could prove effective at withstanding political pressure from doctors, hospitals, and other providers and keeping prices low. If over-utilization is the main cost driver (as many on the right believe), IPAB’s usefulness will be limited. This is partly by design: currently, the Board can only recommend changes to provider payment rates, not benefits.
But many outside experts – including some who sat on the US Fiscal Commission last year – recommend expanding IPAB’s powers. And the president has urged Congress to lower IPAB’s cost growth rate target, making it more likely that recommendations will be triggered. Some have even speculated that IPAB could be the vehicle by which a new all-payer rate setting scheme could be implemented.
It’s unlikely that Congress will go along with any of the above proposals any time soon. Indeed, many in Congress have called for IPAB’s repeal. And it’s true that further empowering a board of unelected technocrats is not an easy sell to the American people (especially since the biggest problems facing Medicare – and the federal budget as a whole – require moral, not mathematical, answers). But as the extent of our long-term structural deficit becomes more apparent – and the situation grows more urgent – members of Congress may be tempted to delegate more and more tough decisions to IPAB. Some might view this as an undemocratic and irresponsible abdication of authority – in other words, the coward’s way out. But as Edgar Allan Poe once wrote: “That man is not truly brave who is afraid either to seem or to be, when it suits him, a coward.”
----------------------
Notes
[1] The Affordable Care Act also created the Center for Medicare and Medicaid Innovation (CMI), which has broad powers to experiment with new payment systems like accountable care organizations and bundling, and then apply the most successful models nationwide – all without further congressional action. This is a promising idea, but the Congressional Budget Office and others are skeptical of its cost-saving potential and so it will not figure as prominently as IPAB in debt reduction negotiations.
[2] Since the bill’s passage, some have used the “death panel” moniker to describe IPAB, but during the debate that phrase was used in reference to a provision that attempted to expand the use of living wills.
Friday, November 18, 2011
Non-Communicable Diseases: The Sword of the Damocles for developing countries
Siddharth Chatterjee, MPP ’11
Dr. Ayham Alomari
Thanks to the excellent work done by the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), the Global Alliance for Vaccines and Immunization (GAVI), the International Federation of Red Cross and Red Crescent Societies (IFRC), the Bill and Melinda Gates Foundation, governments, and other institutions to ramp up immunization for vaccine-preventable diseases, it is having the desired effect in reducing infant and child mortality. This important initiative has to be kept up and would contribute greatly to achieving the UN’s Millennium Development Goals by 2015.
But there is another threat that looms like the Sword of the Damocles: non-communicable diseases (NCDs) such as cardiovascular, cancer, diabetes, and lung diseases. To some extent, of course, the increasing prevalence of NCDs is an arithmetic consequence of reducing morbidity and mortality from communicable diseases. If people do not suffer and die from communicable diseases, they typically will die from an NCD. The tragedy, however, is that humans around the world suffer and die from NCDs prematurely, long before the natural limit to which modern medicine and non-medical interventions, including community-based efforts, can push the onset of suffering and the occurrence of death. In addition, the high burden of NCDs makes them a laden threat to health and development. NCDs are barriers to poverty reduction, health equity, economic stability, and human security.
A recent issue of the Economist states: “Indeed, of the 36m people killed by NCDs [annually], some 80% live in low- and middle-income countries. These diseases are associated with increased prosperity and longevity, and the results are costly. The World Economic Forum estimates that NCDs will cost low- and middle-income countries $7 trillion over the next 15 years.”
The most striking feature of NCDs is that, contrary to what most people think, it’s not just the rich that are feeling the damaging effects of physical inactivity, obesity, and poor diets. Far from it, the poor and middle class within the developing world are facing NCDs-related deaths exponentially. According to the statistics above, each day there are 100,000 deaths from NCDs, with 80% occurring in the world’s poorest countries. And unless we act collectively and with conviction the future looks ominous. According to WHO, NCD deaths are projected to increase by 15% globally between 2010 and 2020.
With the lives of 36 million people annually at stake, we all know what it takes to prevent NCDs – healthy lifestyles. NCDs could be preventable by eliminating shared risk factors such as tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Those risk factors are the main contributors to the magnitude and scale of NCDs worldwide. But many hurdles stand in our way, most stemming from a lack of urgency as well as political will to deal with this growing scourge.
To find ways to engage broader community involvement in NCDs, prevention through dialogue and concrete action were the topic of an event co-hosted by the IFRC and the International Federation of Pharmaceutical Manufacturers Association (IFPMA) at this year’s UN General Assembly in September. The panelists – who represented leaders among Red Cross Red Crescent National Societies, WHO, the private sector, and academia (including the active participation of two prominent members of Princeton University) – reinforced the call for integrated multi-sector and multi-partner NCD prevention initiatives.
Greg Vickery, President of the Australian Red Cross, shared his experience in working with Indigenous Australians, who are among the most vulnerable to NCDs. “Our response is threefold – through the ‘Save-a-Mate’ resuscitation and education program tackling the alcohol problem they face; breakfast clubs that teach school children healthy eating habits; and the ‘Food Cents Programme’ that shows families how to eat healthily on a tight budget, i.e. simple strategies to support healthy eating habits.” Professor Uwe Reinhardt, James Madison Professor of Political Economy at the Woodrow Wilson School, reminded the audience that part of this community-based effort must be to make the individual be both able and willing to play an active role in the management of his or her own health.
So basically, the message we want to stress is simple. Says IFRC’s Secretary General, Mr. Bekele Geleta, “Humanitarian organizations such as the Red Cross Red Crescent, whose staff and close to 13 million active volunteers world-wide work closely with local communities, play an enormous role in bringing about changes in behavior and attitudes towards health and lifestyle.” We at the IFRC strongly believe that including NCDs in our health programs is consistent with our Red Cross Red Crescent Strategy 2020 to enable healthy and safe living. Our Framework for NCDs focuses on prevention, innovation & research, monitoring & evaluation, partnership, and advocacy.
But we cannot do it in silos or on our own. To make a real difference for those who are not on a health services radar screen, it is critical that we forge robust partnerships not only with governments, the UN, and NGOs but also with important thought leaders and opinion leaders like Princeton University. This has to be a collective and well-orchestrated endeavour to prevent what the UN has called “a public health emergency in slow motion” from spreading. Simple lifestyle change is the key. Resources – intellectual and financial, as well as partners from the public and private sectors alike – need to come together.
The IFRC is keen to move forward on this important initiative. In the words of Professor Reinhardt, “One thinks of the Red Cross Red Crescent more in connection with earthquakes, tsunamis, and other spectacular and sudden natural disasters. I was surprised and encouraged to learn how much the organization is doing in response to another, albeit slowly developing, natural disaster, the growing burden of premature deaths due to NCDs, much of that burden the result of people’s inability or unwillingness, or both, to manage their own health better.”
The actions, then, appear to be simple, and the outcomes desirable. But it will take a significant investment of time and money to strengthen the ties that bind the Sword above us.
Siddharth Chatterjee is the Chief Diplomatic Officer and Head of International Relations at the IFRC. Dr. Ayham Alomari is a Senior Health Officer, Community Based Health and First Aid, NCDs at the IFRC.
Dr. Ayham Alomari
Thanks to the excellent work done by the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), the Global Alliance for Vaccines and Immunization (GAVI), the International Federation of Red Cross and Red Crescent Societies (IFRC), the Bill and Melinda Gates Foundation, governments, and other institutions to ramp up immunization for vaccine-preventable diseases, it is having the desired effect in reducing infant and child mortality. This important initiative has to be kept up and would contribute greatly to achieving the UN’s Millennium Development Goals by 2015.
But there is another threat that looms like the Sword of the Damocles: non-communicable diseases (NCDs) such as cardiovascular, cancer, diabetes, and lung diseases. To some extent, of course, the increasing prevalence of NCDs is an arithmetic consequence of reducing morbidity and mortality from communicable diseases. If people do not suffer and die from communicable diseases, they typically will die from an NCD. The tragedy, however, is that humans around the world suffer and die from NCDs prematurely, long before the natural limit to which modern medicine and non-medical interventions, including community-based efforts, can push the onset of suffering and the occurrence of death. In addition, the high burden of NCDs makes them a laden threat to health and development. NCDs are barriers to poverty reduction, health equity, economic stability, and human security.
A recent issue of the Economist states: “Indeed, of the 36m people killed by NCDs [annually], some 80% live in low- and middle-income countries. These diseases are associated with increased prosperity and longevity, and the results are costly. The World Economic Forum estimates that NCDs will cost low- and middle-income countries $7 trillion over the next 15 years.”
The most striking feature of NCDs is that, contrary to what most people think, it’s not just the rich that are feeling the damaging effects of physical inactivity, obesity, and poor diets. Far from it, the poor and middle class within the developing world are facing NCDs-related deaths exponentially. According to the statistics above, each day there are 100,000 deaths from NCDs, with 80% occurring in the world’s poorest countries. And unless we act collectively and with conviction the future looks ominous. According to WHO, NCD deaths are projected to increase by 15% globally between 2010 and 2020.
With the lives of 36 million people annually at stake, we all know what it takes to prevent NCDs – healthy lifestyles. NCDs could be preventable by eliminating shared risk factors such as tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Those risk factors are the main contributors to the magnitude and scale of NCDs worldwide. But many hurdles stand in our way, most stemming from a lack of urgency as well as political will to deal with this growing scourge.
To find ways to engage broader community involvement in NCDs, prevention through dialogue and concrete action were the topic of an event co-hosted by the IFRC and the International Federation of Pharmaceutical Manufacturers Association (IFPMA) at this year’s UN General Assembly in September. The panelists – who represented leaders among Red Cross Red Crescent National Societies, WHO, the private sector, and academia (including the active participation of two prominent members of Princeton University) – reinforced the call for integrated multi-sector and multi-partner NCD prevention initiatives.
Greg Vickery, President of the Australian Red Cross, shared his experience in working with Indigenous Australians, who are among the most vulnerable to NCDs. “Our response is threefold – through the ‘Save-a-Mate’ resuscitation and education program tackling the alcohol problem they face; breakfast clubs that teach school children healthy eating habits; and the ‘Food Cents Programme’ that shows families how to eat healthily on a tight budget, i.e. simple strategies to support healthy eating habits.” Professor Uwe Reinhardt, James Madison Professor of Political Economy at the Woodrow Wilson School, reminded the audience that part of this community-based effort must be to make the individual be both able and willing to play an active role in the management of his or her own health.
So basically, the message we want to stress is simple. Says IFRC’s Secretary General, Mr. Bekele Geleta, “Humanitarian organizations such as the Red Cross Red Crescent, whose staff and close to 13 million active volunteers world-wide work closely with local communities, play an enormous role in bringing about changes in behavior and attitudes towards health and lifestyle.” We at the IFRC strongly believe that including NCDs in our health programs is consistent with our Red Cross Red Crescent Strategy 2020 to enable healthy and safe living. Our Framework for NCDs focuses on prevention, innovation & research, monitoring & evaluation, partnership, and advocacy.
But we cannot do it in silos or on our own. To make a real difference for those who are not on a health services radar screen, it is critical that we forge robust partnerships not only with governments, the UN, and NGOs but also with important thought leaders and opinion leaders like Princeton University. This has to be a collective and well-orchestrated endeavour to prevent what the UN has called “a public health emergency in slow motion” from spreading. Simple lifestyle change is the key. Resources – intellectual and financial, as well as partners from the public and private sectors alike – need to come together.
The IFRC is keen to move forward on this important initiative. In the words of Professor Reinhardt, “One thinks of the Red Cross Red Crescent more in connection with earthquakes, tsunamis, and other spectacular and sudden natural disasters. I was surprised and encouraged to learn how much the organization is doing in response to another, albeit slowly developing, natural disaster, the growing burden of premature deaths due to NCDs, much of that burden the result of people’s inability or unwillingness, or both, to manage their own health better.”
The actions, then, appear to be simple, and the outcomes desirable. But it will take a significant investment of time and money to strengthen the ties that bind the Sword above us.
Siddharth Chatterjee is the Chief Diplomatic Officer and Head of International Relations at the IFRC. Dr. Ayham Alomari is a Senior Health Officer, Community Based Health and First Aid, NCDs at the IFRC.
Friday, November 11, 2011
New Year's Irresolution: Medicare’s sustainable growth rate and physician reimbursement
Wes Joines, MPA
Unless Congress acts between now and the end of 2011, at least one group will not be experiencing a happy New Year: physicians who provide services to Medicare patients. Under current law, starting in 2012, reimbursement for Medicare-provided services will be reduced by an estimated 30%. Why is this happening? It is all related to policies enacted nearly 15 years ago in an earlier iteration of debt reduction efforts.
The Balanced Budget Act of 1997 was signed into law on August 5, 1997 and was designed to balance the federal budget by 2002. Of its $160 billion in spending cuts during that time period, $112 billion was applicable to the Medicare program, which is the primary health coverage program for older and some disabled Americans. A key component of the cuts to Medicare included, for the first time, a budgetary restraint on Medicare’s total expenditures to maintain budget neutrality. Known as the sustainable growth rate (SGR), it is a major component of the current formula for determining annual updates to physician reimbursement. While Medicare payment rate increases since 1992 had been tied to trends in physician utilization (i.e. efficient use of medical tests and facilities by a doctor), in 1997, for the first time, the implementation of the SGR meant that Medicare reimbursement changes would be linked to four factors: 1) changes in input costs, 2) changes in Medicare fee-for-service enrollment, 3) changes in the volume of physician services relative to growth in the national economy, and 4) changes in expenditures due to changes in law and/or regulation.
The SGR resulted in annual increases to the Medicare fee schedule until 2002, when a 4.8% reduction took place. Since that time, rate reductions called for by the formula have been deferred, although Congress has not changed the underlying SGR formula or the cumulative spending targets. Because of vast increases in the volume and complexity of health care services for the Medicare population in recent years, especially when compared to the SGR designers’ projections, the formula specifies cuts in physician payments that become more severe with each passing year. In fact, at a cost of $19 billion, a last-minute December 2010 vote delayed a scheduled 25% reduction in the SGR that was to take place in January 2011.
So, here we are again, this time in late 2011, deciding whether or not reimbursement for Medicare providers will be cut. Even before the current debt reduction debate and increasing prevalence of political gridlock in Congress, policy movement regarding the SGR involved numerous short-term fixes. For example, from 2003 through 2010, Congress included provisions in 13 separate pieces of legislation to forestall reimbursement cuts. As a long-term fix for the SGR – e.g. replacing it with a current fee freeze – would be extremely costly to the taxpayer (some estimates currently peg it around $300 billion over 10 years), short-term fixes have generally proved to be an easier bargain (as much as they have irritated physicians and their respective trade associations).
At this point, anyone’s guess is as good as another’s regarding the level of reimbursement for Medicare services on January 1, 2012. Although the current political climate is not one that generally supports massive spending to doctors that would be required for a long-term fix, many believe that cuts of the magnitude prescribed by the SGR would not be conducive to ensuring beneficiary access to services. Therefore, another short-term fix might be in the works as a stop-gap measure. However, there is also a chance that the currently-convened deficit reduction “Super Committee” might address the SGR as part of its proceedings.
If compromise is within reach, within or outside of the Joint Select Committee on Deficit Reduction, it may be similar to a plan recently recommend by the Medicare Payment Advisory Commission (MedPAC), which ironically enough, was also established by the Balanced Budget Act of 1997 and serves as an independent advisor to Congress. MedPAC’s plan, which would cost $200 billion over 10 years (instead of the $300 billion of the fee freeze), would protect both primary care and specialty physicians from the deep cuts called for by SGR. Primary care physicians would see physician fees associated with Medicare services frozen for 10 years, while specialists would see smaller cuts (of 5.9% per year) over the first three years that would then remain frozen for the remaining seven years in the budget window.
Granted, MedPAC’s suggestion is not a panacea, but it is a good start. At the very least, it should focus us on attempting to resolve this looming crisis.
Unless Congress acts between now and the end of 2011, at least one group will not be experiencing a happy New Year: physicians who provide services to Medicare patients. Under current law, starting in 2012, reimbursement for Medicare-provided services will be reduced by an estimated 30%. Why is this happening? It is all related to policies enacted nearly 15 years ago in an earlier iteration of debt reduction efforts.
The Balanced Budget Act of 1997 was signed into law on August 5, 1997 and was designed to balance the federal budget by 2002. Of its $160 billion in spending cuts during that time period, $112 billion was applicable to the Medicare program, which is the primary health coverage program for older and some disabled Americans. A key component of the cuts to Medicare included, for the first time, a budgetary restraint on Medicare’s total expenditures to maintain budget neutrality. Known as the sustainable growth rate (SGR), it is a major component of the current formula for determining annual updates to physician reimbursement. While Medicare payment rate increases since 1992 had been tied to trends in physician utilization (i.e. efficient use of medical tests and facilities by a doctor), in 1997, for the first time, the implementation of the SGR meant that Medicare reimbursement changes would be linked to four factors: 1) changes in input costs, 2) changes in Medicare fee-for-service enrollment, 3) changes in the volume of physician services relative to growth in the national economy, and 4) changes in expenditures due to changes in law and/or regulation.
The SGR resulted in annual increases to the Medicare fee schedule until 2002, when a 4.8% reduction took place. Since that time, rate reductions called for by the formula have been deferred, although Congress has not changed the underlying SGR formula or the cumulative spending targets. Because of vast increases in the volume and complexity of health care services for the Medicare population in recent years, especially when compared to the SGR designers’ projections, the formula specifies cuts in physician payments that become more severe with each passing year. In fact, at a cost of $19 billion, a last-minute December 2010 vote delayed a scheduled 25% reduction in the SGR that was to take place in January 2011.
So, here we are again, this time in late 2011, deciding whether or not reimbursement for Medicare providers will be cut. Even before the current debt reduction debate and increasing prevalence of political gridlock in Congress, policy movement regarding the SGR involved numerous short-term fixes. For example, from 2003 through 2010, Congress included provisions in 13 separate pieces of legislation to forestall reimbursement cuts. As a long-term fix for the SGR – e.g. replacing it with a current fee freeze – would be extremely costly to the taxpayer (some estimates currently peg it around $300 billion over 10 years), short-term fixes have generally proved to be an easier bargain (as much as they have irritated physicians and their respective trade associations).
At this point, anyone’s guess is as good as another’s regarding the level of reimbursement for Medicare services on January 1, 2012. Although the current political climate is not one that generally supports massive spending to doctors that would be required for a long-term fix, many believe that cuts of the magnitude prescribed by the SGR would not be conducive to ensuring beneficiary access to services. Therefore, another short-term fix might be in the works as a stop-gap measure. However, there is also a chance that the currently-convened deficit reduction “Super Committee” might address the SGR as part of its proceedings.
If compromise is within reach, within or outside of the Joint Select Committee on Deficit Reduction, it may be similar to a plan recently recommend by the Medicare Payment Advisory Commission (MedPAC), which ironically enough, was also established by the Balanced Budget Act of 1997 and serves as an independent advisor to Congress. MedPAC’s plan, which would cost $200 billion over 10 years (instead of the $300 billion of the fee freeze), would protect both primary care and specialty physicians from the deep cuts called for by SGR. Primary care physicians would see physician fees associated with Medicare services frozen for 10 years, while specialists would see smaller cuts (of 5.9% per year) over the first three years that would then remain frozen for the remaining seven years in the budget window.
Granted, MedPAC’s suggestion is not a panacea, but it is a good start. At the very least, it should focus us on attempting to resolve this looming crisis.
Skip Over Low-Hanging Fruit to Reach the Millennium Development Goals
Leslie Lai, MPA
In 2000, the UN established the Millennium Development Goals (MDGs) to improve the social and economic conditions of the world’s poorest countries by 2015. Of the eight MDGs, two specifically target the reduction of child mortality and the improvement of maternal health. Despite increased aid in the past decade from foundations, bilateral donors, and multilateral organizations, several countries in Sub-Saharan Africa will fail to reach these two goals in the next four years.
The main reason for this is the lack of an equity focus in the planning processes of national health ministries. For economic and political reasons, governments have focused on targeting “low hanging fruit,” or populations that are most easily reached, through the expansion of traditional delivery service mechanisms such as hospitals. While there has been significant progress in health outcomes due to increased international aid, improvements in national averages conceal widening disparities in poverty and worsening health outcomes for the most marginalized populations. Furthermore, the perceived difficulty and economic inefficiency in reaching the poorest hinders donors from targeting technical assistance to those who need the most help.
A practical solution to this challenge is to show evidence that integrating an equity focus into health planning can actually be cost-effective. Organizations such as the United Nations Children’s Fund (UNICEF) has proven this with a bottleneck analysis budgeting software created with the World Bank to assess the marginal costs of scaling up coverage of proven high-impact interventions. The tool incorporates over 186,000 input variables including the building of new facilities, vaccine transport costs, training of community health workers, etc. It also measures the potential number of lives saved per US $1 million invested depending on the mix of health services delivered and to whom.
Using health data from 68 developing countries, UNICEF used the software to show that each of these countries could not only provide essential health services to the most deprived in an economical fashion, but could also potentially achieve the health-related MDGs by 2015. Surprisingly, UNICEF’s analysis also showed that countries ignoring the hardest-to-reach would miss the MDG targets. So just what exactly does a country need to do to reach the MDGs and expand coverage to its hardest-to-reach beneficiaries?
Ethiopia is a successful example of a country that has successfully incorporated the bottleneck analysis tool into its national health plan to expand coverage to its underserved. Ethiopia’s key intervention is the training and deployment of Health Extension Workers (HEWs), young women who provide immunizations and maternal health services to children and women in rural areas. Based on marginal budgeting calculations, Ethiopia could potentially save 68.1 children’s lives per US $1 million spent with the HEW program compared to only 52.9 lives saved without. To achieve this, donors and technical assistance would need to enhance the HEW program or implement similar types of interventions.
Since Ethiopia has historically experienced serious health problems among women and children, it is an ideal model for Sub-Saharan African countries with similar issues. Unfortunately, political matters may obstruct successful implementation in other countries. And in the meantime, the clock is running out…
In 2000, the UN established the Millennium Development Goals (MDGs) to improve the social and economic conditions of the world’s poorest countries by 2015. Of the eight MDGs, two specifically target the reduction of child mortality and the improvement of maternal health. Despite increased aid in the past decade from foundations, bilateral donors, and multilateral organizations, several countries in Sub-Saharan Africa will fail to reach these two goals in the next four years.
The main reason for this is the lack of an equity focus in the planning processes of national health ministries. For economic and political reasons, governments have focused on targeting “low hanging fruit,” or populations that are most easily reached, through the expansion of traditional delivery service mechanisms such as hospitals. While there has been significant progress in health outcomes due to increased international aid, improvements in national averages conceal widening disparities in poverty and worsening health outcomes for the most marginalized populations. Furthermore, the perceived difficulty and economic inefficiency in reaching the poorest hinders donors from targeting technical assistance to those who need the most help.
A practical solution to this challenge is to show evidence that integrating an equity focus into health planning can actually be cost-effective. Organizations such as the United Nations Children’s Fund (UNICEF) has proven this with a bottleneck analysis budgeting software created with the World Bank to assess the marginal costs of scaling up coverage of proven high-impact interventions. The tool incorporates over 186,000 input variables including the building of new facilities, vaccine transport costs, training of community health workers, etc. It also measures the potential number of lives saved per US $1 million invested depending on the mix of health services delivered and to whom.
Using health data from 68 developing countries, UNICEF used the software to show that each of these countries could not only provide essential health services to the most deprived in an economical fashion, but could also potentially achieve the health-related MDGs by 2015. Surprisingly, UNICEF’s analysis also showed that countries ignoring the hardest-to-reach would miss the MDG targets. So just what exactly does a country need to do to reach the MDGs and expand coverage to its hardest-to-reach beneficiaries?
Ethiopia is a successful example of a country that has successfully incorporated the bottleneck analysis tool into its national health plan to expand coverage to its underserved. Ethiopia’s key intervention is the training and deployment of Health Extension Workers (HEWs), young women who provide immunizations and maternal health services to children and women in rural areas. Based on marginal budgeting calculations, Ethiopia could potentially save 68.1 children’s lives per US $1 million spent with the HEW program compared to only 52.9 lives saved without. To achieve this, donors and technical assistance would need to enhance the HEW program or implement similar types of interventions.
Since Ethiopia has historically experienced serious health problems among women and children, it is an ideal model for Sub-Saharan African countries with similar issues. Unfortunately, political matters may obstruct successful implementation in other countries. And in the meantime, the clock is running out…
Sunday, October 23, 2011
Immigration: The costs of a broken system
Sebastian Chaskel, MPA
On October 14th and 15th Princeton’s campus hosted Voz Latina 2011, the third annual symposium organized by the university’s Office of Academic Affairs and Diversity and the Latino Graduate Student Association in honor of Latino Heritage Month. This year’s topic: "Immigration in the 21st Century—the Costs of a Broken System."
The conference organizers could not have chosen a more opportune moment for a conversation on immigration. While the percentage of foreign-born residents in the United States has skyrocketed from 5% in the 1960s to 13% today, some state governments are implementing the strongest anti-immigrant policies the country has ever seen, reflecting a strong xenophobia in certain regions. The United States’ 11.2 million undocumented immigrants—half of them Mexican—now represent 5% of the US labor force. Yet they continue to work in the shadows, lacking the rights and protections that the rest of the population enjoys. As Princeton Professor Douglas Massey commented in his presentation, the structural conditions are being created for a semi-permanent underclass in the United States.
The symposium’s guests highlighted the elevated costs of a broken system. Enrique Morones, the founder of Border Angels, mentioned that about 10,000 people have died on the US-Mexico border attempting to cross it. His organization places water, blankets, and food on the border in an attempt to prevent further deaths, and records the stories of those that have perished in order to give a human face to the statistics. Professor Jorge Bustamante from Notre Dame University commented on his findings as UN Special Rapporteur on the Human Rights of Migrants from 2005 to 2011. During this time, he witnessed constitutional violations executed by U.S. Immigration and Customs Enforcement Agency (ICE) agents who entered homes without warrants and seized occupants without legal bases. At the time the US government questioned Bustamante’s accusation, but a 2009 report by the Immigration Justice Clinic at Yeshiva University's Cardozo Law School, Constitution on Ice, seconded Bustamante’s findings, “reveal[ing] an established pattern of misconduct by ICE agents” in the region covered by the study.
Princeton Professor Patricia Fernandez-Kelly argued that undocumented immigrants are more likely than others to suffer from the country’s broken health system. Her research shows that those that choose to immigrate to the United States are healthier than the average person in their countries of origin, but health problems emerge once they enter the United States. As immigrants assimilate, they and their descendents pick up unhealthy smoking, drinking, and eating habits, along with the diseases that accompany them, such as diabetes and cardiovascular disease. Their health is further impaired by limited access to health services due to state and local policies nationwide which limit immigrant access to basic medical care. New Jersey and Miami-Dade County stand out for the services they offer immigrant populations, while San Diego is notorious for its barriers to health access.
Professor Marta Tienda focused on Latino education trends, lamenting that although 16% of the American population is Hispanic, only 6% of college degree holders identify as such. She implored the Latino students present to do their part by encouraging and assisting other Hispanics in their college application processes. “Bring along two others, one in each hand,” Professor Tienda urged.
The national immigration correspondent for the New York Times, Julia Preston, explained that the harsh state anti-immigration laws being implemented across the country, such as Alabama’s HB56, and Arizona’s SB 1070, reflect the disagreements between states and the federal government over immigration reform. Professor Massey argued that these and other restrictive developments, such as greater border control, have not decreased illegal immigration, but have encouraged illegal immigrants to “hunker down” in the US, as the costs of traveling home and returning have increased. “Coyotes,” or smugglers, now charges $5,000-$7,000 per person brought to the country, compared to $1,000 or $2,000 just five years ago. Illegal migration has dropped in recent years, but this is due to decreased job openings in the United States, greater legal migration opportunities, and reduced fertility in Mexico. As a result, there is a net inflow of zero illegal immigrants to the U.S. now—fewer people are coming, but fewer people are also going back.
In terms of what should be done, both Professor Bustamante and Instituto Tecnológico Autónomo de México (ITAM) Professor Denise Dresser argued that the ideal policy response would be a bilateral agreement between Mexico and the United States on immigration. Legislative reform by nature is unilateral, Bustamante explained, and will therefore not be able to solve a bilateral problem. Such an agreement was on the table when Vicente Fox and George W. Bush led Mexico and the US, respectively, but the notion of a bilateral agreement disappeared on September 11, 2001. Immigration is now seen through a prism of security and thus such an agreement is no longer a viable option.
Professor Massey argued that the US is closer to passing comprehensive immigration reform than most think. The border is now secure and a system by which Mexicans and others can apply to work in the United States is already in place. The one outstanding issue is dealing with the 11.2 million unauthorized immigrants in the country, and Massey sees the only feasible and humane policy choice as 1) granting automatic legal status to everyone who was brought illegally to the US as a child, and 2) creating a system by which those that came as adults can gain citizenship.
Julia Preston predicted that policymakers will not touch immigration reform until after the 2012 presidential election due to the sensitivity of the subject to constituents. Professor Massey explained that the uneasiness many middle-age Americans feels about the increasing level of foreign-born residents in the US can be partly explained in that they came to age in the 1950s-60s, a time in which the foreign-born percentage of US residents was at an exceptional low of about 5%. The current 14% is closer to the country’s historical record, but it is nevertheless s a new reality for that generation. Professor Dresser emphasized that it is in both the United States’ and Mexico’s interest to find a sustainable solution and encouraged those interested in seeing reform, including the Mexican government, to pressure American legislators at a local level in order to create the incentives for reform.
A population of 11 million residing in the US without access to basic rights clashes with the values American society purports to uphold. While there was variance among the participants as to the best policy choice and the most efficient strategy to achieve reform, there was unanimous agreement in recognizing that the current situation is inhumane, dangerous, and unsustainable. Lest the United States become a country with permanent first- and second-class citizens, with different sets of rights and protections, immigration reform should be an urgent priority for the country’s decision makers.
On October 14th and 15th Princeton’s campus hosted Voz Latina 2011, the third annual symposium organized by the university’s Office of Academic Affairs and Diversity and the Latino Graduate Student Association in honor of Latino Heritage Month. This year’s topic: "Immigration in the 21st Century—the Costs of a Broken System."
The conference organizers could not have chosen a more opportune moment for a conversation on immigration. While the percentage of foreign-born residents in the United States has skyrocketed from 5% in the 1960s to 13% today, some state governments are implementing the strongest anti-immigrant policies the country has ever seen, reflecting a strong xenophobia in certain regions. The United States’ 11.2 million undocumented immigrants—half of them Mexican—now represent 5% of the US labor force. Yet they continue to work in the shadows, lacking the rights and protections that the rest of the population enjoys. As Princeton Professor Douglas Massey commented in his presentation, the structural conditions are being created for a semi-permanent underclass in the United States.
The symposium’s guests highlighted the elevated costs of a broken system. Enrique Morones, the founder of Border Angels, mentioned that about 10,000 people have died on the US-Mexico border attempting to cross it. His organization places water, blankets, and food on the border in an attempt to prevent further deaths, and records the stories of those that have perished in order to give a human face to the statistics. Professor Jorge Bustamante from Notre Dame University commented on his findings as UN Special Rapporteur on the Human Rights of Migrants from 2005 to 2011. During this time, he witnessed constitutional violations executed by U.S. Immigration and Customs Enforcement Agency (ICE) agents who entered homes without warrants and seized occupants without legal bases. At the time the US government questioned Bustamante’s accusation, but a 2009 report by the Immigration Justice Clinic at Yeshiva University's Cardozo Law School, Constitution on Ice, seconded Bustamante’s findings, “reveal[ing] an established pattern of misconduct by ICE agents” in the region covered by the study.
Princeton Professor Patricia Fernandez-Kelly argued that undocumented immigrants are more likely than others to suffer from the country’s broken health system. Her research shows that those that choose to immigrate to the United States are healthier than the average person in their countries of origin, but health problems emerge once they enter the United States. As immigrants assimilate, they and their descendents pick up unhealthy smoking, drinking, and eating habits, along with the diseases that accompany them, such as diabetes and cardiovascular disease. Their health is further impaired by limited access to health services due to state and local policies nationwide which limit immigrant access to basic medical care. New Jersey and Miami-Dade County stand out for the services they offer immigrant populations, while San Diego is notorious for its barriers to health access.
Professor Marta Tienda focused on Latino education trends, lamenting that although 16% of the American population is Hispanic, only 6% of college degree holders identify as such. She implored the Latino students present to do their part by encouraging and assisting other Hispanics in their college application processes. “Bring along two others, one in each hand,” Professor Tienda urged.
The national immigration correspondent for the New York Times, Julia Preston, explained that the harsh state anti-immigration laws being implemented across the country, such as Alabama’s HB56, and Arizona’s SB 1070, reflect the disagreements between states and the federal government over immigration reform. Professor Massey argued that these and other restrictive developments, such as greater border control, have not decreased illegal immigration, but have encouraged illegal immigrants to “hunker down” in the US, as the costs of traveling home and returning have increased. “Coyotes,” or smugglers, now charges $5,000-$7,000 per person brought to the country, compared to $1,000 or $2,000 just five years ago. Illegal migration has dropped in recent years, but this is due to decreased job openings in the United States, greater legal migration opportunities, and reduced fertility in Mexico. As a result, there is a net inflow of zero illegal immigrants to the U.S. now—fewer people are coming, but fewer people are also going back.
In terms of what should be done, both Professor Bustamante and Instituto Tecnológico Autónomo de México (ITAM) Professor Denise Dresser argued that the ideal policy response would be a bilateral agreement between Mexico and the United States on immigration. Legislative reform by nature is unilateral, Bustamante explained, and will therefore not be able to solve a bilateral problem. Such an agreement was on the table when Vicente Fox and George W. Bush led Mexico and the US, respectively, but the notion of a bilateral agreement disappeared on September 11, 2001. Immigration is now seen through a prism of security and thus such an agreement is no longer a viable option.
Professor Massey argued that the US is closer to passing comprehensive immigration reform than most think. The border is now secure and a system by which Mexicans and others can apply to work in the United States is already in place. The one outstanding issue is dealing with the 11.2 million unauthorized immigrants in the country, and Massey sees the only feasible and humane policy choice as 1) granting automatic legal status to everyone who was brought illegally to the US as a child, and 2) creating a system by which those that came as adults can gain citizenship.
Julia Preston predicted that policymakers will not touch immigration reform until after the 2012 presidential election due to the sensitivity of the subject to constituents. Professor Massey explained that the uneasiness many middle-age Americans feels about the increasing level of foreign-born residents in the US can be partly explained in that they came to age in the 1950s-60s, a time in which the foreign-born percentage of US residents was at an exceptional low of about 5%. The current 14% is closer to the country’s historical record, but it is nevertheless s a new reality for that generation. Professor Dresser emphasized that it is in both the United States’ and Mexico’s interest to find a sustainable solution and encouraged those interested in seeing reform, including the Mexican government, to pressure American legislators at a local level in order to create the incentives for reform.
A population of 11 million residing in the US without access to basic rights clashes with the values American society purports to uphold. While there was variance among the participants as to the best policy choice and the most efficient strategy to achieve reform, there was unanimous agreement in recognizing that the current situation is inhumane, dangerous, and unsustainable. Lest the United States become a country with permanent first- and second-class citizens, with different sets of rights and protections, immigration reform should be an urgent priority for the country’s decision makers.
Sunday, October 9, 2011
Seeing Beyond Tomorrow: The scourge of extreme poverty and finally ending it
Ayokunle Abogan, MPA
Can we end extreme poverty within the next three decades?
This question was posed in an article I read while in Nigeria, my home country. In trying to answer it, I cannot help but view the problem from a personal angle. Herein I share Modupe’s story.
Modupe is a woman I met during a volunteer project created to eradicate poverty in Nigeria. She is a Nigerian woman, likely in her mid-thirties, although she can only guess. AIDS (contracted from her now-dead husband), poverty, and hunger have taken a devastating toll on her—she looks more like 60. Does Modupe worry whether her six children also have AIDS? No. She doesn’t have time to worry. She’s focused solely on daily survival. Her mother, who lives with her, needn’t worry about AIDS—she’s already dying of tuberculosis.
Modupe scavenges for scrap paper at the rubbish dump to sell to market vendors. If Modupe is lucky, she can make as much as 60 cents a day. When luckier, she finds discarded dregs of produce, meat and dairy. Most days Modupe is not lucky. She averages three to four meals in a week. Land surrounds her leaf-and-mud hut but the adjacent factory’s chemical wastes have rendered the land toxic, infertile. It doesn’t matter. Dying of AIDS, Modupe can barely scavenge, never mind farm, competing alongside scores of others scrabbling for scraps. They suffer, too.
I know Modupe. I know many like her. Too many.
Nearly 1.2 billion people worldwide—one-sixth of the world’s population—suffer from extreme poverty. No clean water, sanitation, or electricity. The numbers are staggering. Illiteracy ensures that they continue to suffer. Some regions with entrenched cycles of poverty, death, and inequity, helplessly pass them from one generation to another. In my continent, Africa, more than half of us live in extreme poverty. Come 2040, nearly 30 years from now, the world’s population is forecast to increase to 8.8 billion, with more than 70% living in so-called developing countries. If we can’t manage poverty now, how will we manage it then on such a greater scale?
To cite statistics here, however, is to intellectualize a crisis that one must feel viscerally. Ironically, society today is now inured to others’ pain while being simultaneously, due to technological advances, close enough to observe it. We witness yet remain detached, isolated. But if you experience directly what I have experienced, the more critical question becomes: “Can we really afford to wait 30 years?”
International organizations including the World Bank and the UN emphasize improving income levels. That doesn’t work. It benefits only a small percentage, the educated, who better grasp how to improve living standards. The illiterate do not.
Basic needs must be met first. How can people educate themselves if they don’t even have food or water? If disease is everywhere around them? Surviving today isn’t just a means to an end; it becomes the end itself. Resolving basic needs will then naturally segue into health services, education and improved housing.
These are the core necessities we must provide our starving brothers and sisters:
Modupe doesn’t have 30 years. Neither do we.
Can we end extreme poverty within the next three decades?
This question was posed in an article I read while in Nigeria, my home country. In trying to answer it, I cannot help but view the problem from a personal angle. Herein I share Modupe’s story.
Modupe is a woman I met during a volunteer project created to eradicate poverty in Nigeria. She is a Nigerian woman, likely in her mid-thirties, although she can only guess. AIDS (contracted from her now-dead husband), poverty, and hunger have taken a devastating toll on her—she looks more like 60. Does Modupe worry whether her six children also have AIDS? No. She doesn’t have time to worry. She’s focused solely on daily survival. Her mother, who lives with her, needn’t worry about AIDS—she’s already dying of tuberculosis.
Modupe scavenges for scrap paper at the rubbish dump to sell to market vendors. If Modupe is lucky, she can make as much as 60 cents a day. When luckier, she finds discarded dregs of produce, meat and dairy. Most days Modupe is not lucky. She averages three to four meals in a week. Land surrounds her leaf-and-mud hut but the adjacent factory’s chemical wastes have rendered the land toxic, infertile. It doesn’t matter. Dying of AIDS, Modupe can barely scavenge, never mind farm, competing alongside scores of others scrabbling for scraps. They suffer, too.
I know Modupe. I know many like her. Too many.
Nearly 1.2 billion people worldwide—one-sixth of the world’s population—suffer from extreme poverty. No clean water, sanitation, or electricity. The numbers are staggering. Illiteracy ensures that they continue to suffer. Some regions with entrenched cycles of poverty, death, and inequity, helplessly pass them from one generation to another. In my continent, Africa, more than half of us live in extreme poverty. Come 2040, nearly 30 years from now, the world’s population is forecast to increase to 8.8 billion, with more than 70% living in so-called developing countries. If we can’t manage poverty now, how will we manage it then on such a greater scale?
To cite statistics here, however, is to intellectualize a crisis that one must feel viscerally. Ironically, society today is now inured to others’ pain while being simultaneously, due to technological advances, close enough to observe it. We witness yet remain detached, isolated. But if you experience directly what I have experienced, the more critical question becomes: “Can we really afford to wait 30 years?”
International organizations including the World Bank and the UN emphasize improving income levels. That doesn’t work. It benefits only a small percentage, the educated, who better grasp how to improve living standards. The illiterate do not.
Basic needs must be met first. How can people educate themselves if they don’t even have food or water? If disease is everywhere around them? Surviving today isn’t just a means to an end; it becomes the end itself. Resolving basic needs will then naturally segue into health services, education and improved housing.
These are the core necessities we must provide our starving brothers and sisters:
- Enhanced food production. Food is fuel; we don’t run without it. Farmers comprise 60+ percent of the world’s extremely poor. Why not teach subsistence farming techniques for that 60 percent? A simple application of the “give a man a fish and he eats for a day; teach him to fish and he eats for a lifetime” philosophy. Governments must invest in responsible farming techniques, tools, storage, and irrigation, and also develop suitable transit of farm products to outlying marketplaces.
- Basic Infrastructure and Amenities. Clean water supply, electricity, and basic sanitation are taken for granted yet are all but unknown to the impoverished. The technology exists! Waste recycling, management, education and facilities will cut disease. Healthcare facilities decrease malaria and HIV/AIDS and preventable death. Rainwater harvesting, water wells, and hand pumps when appropriate, can provide additional water—substantial hours are spent daily traveling to obtain water; local water quality inspections limits typhoid and other water-related problems. Constructing micro-hydroelectric plants to boost electricity supply can funnel power to those outside centralized grid sources. Basic sanitation systems eradicate health risks, lessen water source pollution, and enhance human dignity.
- Education. In addition to lifestyle education, developing human capital leads to better jobs, wages, and living conditions. The educated make informed decisions concerning healthcare, reproduction, employment, and economic equality. Attendance at school until a legally-employable age, for men and women, and vocational training/skills improvement for adults lacking education are a must.
- Debt Relief. Developed countries not only consume most of the world’s resources but also have technology to improve their economies. With debt relief, struggling countries can focus their resources to address national poverty. Fluctuating food prices and high energy proces make it more difficult for poor people to afford enough food to eat. Food and energy represent 60 percent of impoverished household expenditure. Even the US, an affluent nation, has seen much of its middle and lower classes forced into poverty by rising food and energy costs while battling unemployment and foreclosure in an economic crisis. The Middle East continually faces riots due to spiraling food costs. Mitigating the devastating price swings and economic slowdowns in developing countries is critical.
Modupe doesn’t have 30 years. Neither do we.
Friday, May 20, 2011
Disaster risk reduction: Africa’s development challenge
Carolyn Edelstein, MPA
Natural disasters happen. When, where, and how disasters strike is hard to forecast, but they occur often, and increasingly so. Usually, we try to mitigate disasters by shoring up our defenses, mostly through large-scale engineering feats. We apply similar strategies everywhere in the world, regardless of local conditions.
Problematically, this concept of disaster management leaves little room for human agency, and tends to over-rely on skills and resources unavailable in many parts of the developing world. But there is a new conception of disaster management, and the change highlights the need for professionals in developing countries—Africa especially—to generate their own solutions.
The last two decades have witnessed an emerging paradigm of “disaster risk reduction.” It contends that disasters are not just events to which we should respond, but rather the result of human vulnerabilities to environmental hazards in local contexts. The roots of vulnerability may be a matter of an individual’s characteristics, like old age or a disability, or may have structural causes: a lack of affordable housing, poor government service provision, and high crime rates; at a macro level, the legacies of colonialism, the global economic system, and so on. The explanations for vulnerability—and people’s strategies for overcoming vulnerability—quickly grow complex.
As such, disaster risk reduction demands a highly contextualized response. Researchers partner with residents of localities to identify hazards, vulnerabilities, and sources of resilience. Data-gathering and fine-resolution mapping inform local risk management practices. Disaster risk reduction heavily emphasizes preparation and adaptation, not just post-disaster relief. Such efforts are most successful when they incorporate an understanding of existing practices and perceptions. Who better to conduct the work than resident scholars and practitioners?
There is a blanket need for more research, especially in Africa. Existing work has focused on Asia and Latin America, though the need to understand the African context is clear. In spite of rising disaster incidence, deaths from natural disasters have been decreasing everywhere but in Africa. Elsewhere, sudden-onset crises prevail. Africa, by contrast, experiences “creeping emergencies,” when slow-onset hazards like droughts become unmanageable, or when underlying challenges like HIV/AIDS and malnutrition turn a relatively small event catastrophic. In this context, the typical emergency relief-based response to disasters proves less effective than preventative disaster risk reduction approaches.
Not only are relief efforts less helpful, but development suffers when plans ignore local risks. Mozambique offers an illustrative example of this inefficiency. There, the World Bank financed the construction of 487 schools over twenty years, but just one disaster, the floods of 2000, damaged or destroyed roughly 500 primary schools alone. The World Bank, Red Cross, and others have shown that every dollar invested in preventative risk reduction measures saves between $2 and $10 in disaster losses.
To encourage uptake of disaster reduction in development, the UN declared the 1990s the “International Decade for Natural Disaster Reduction.” In 2005, 164 member nations signed the Hyogo Framework for Disaster Risk Reduction, pledging to build a risk reduction approach into disaster management and development.
And yet, myopia persists amongst development agencies. The World Bank’s Independent Evaluation Group found that disasters are “still sometimes treated as an interruption in development rather than as a risk to development.” Forty-four percent of current World Bank-supported country assistance strategies make no mention of disasters. More broadly, 96% of disaster-related assistance from the industrialized world still comes solely as emergency relief.
Better information may improve vulnerability reduction efforts, with added developmental benefits if Africans drive the effort themselves. Despite potential advantages of an African-led research initiative, the continent’s scholars produced only two of the African disaster risk-related research papers published in 2008. There were also few African programs for educating and training disaster management practitioners.
Early signs exist of a growing Africa-based field of study. A network of ten universities across the continent has started graduate-level programs in disaster risk science. Called Peri-Peri U, they model themselves after a research center based at the University of Cape Town, which primarily uses community-level risk assessments and spatial data mapping to analyze the vulnerability. The unit has the ear of government officials, community organizers, and a growing number of Southern African graduate students.
In 2011, the Peri-Peri network will seek renewed funding from the US Agency for International Development. Program reviews have consistently demonstrated positive yields of the new research centers for disaster management, and certainly for the emergence of a new generation of African-trained researchers, planners, and practitioners. With increased support, the local scholarship program can be scaled up and better tackle the urgent need to increase African preparedness to disaster risks.
Natural disasters happen. When, where, and how disasters strike is hard to forecast, but they occur often, and increasingly so. Usually, we try to mitigate disasters by shoring up our defenses, mostly through large-scale engineering feats. We apply similar strategies everywhere in the world, regardless of local conditions.
Problematically, this concept of disaster management leaves little room for human agency, and tends to over-rely on skills and resources unavailable in many parts of the developing world. But there is a new conception of disaster management, and the change highlights the need for professionals in developing countries—Africa especially—to generate their own solutions.
The last two decades have witnessed an emerging paradigm of “disaster risk reduction.” It contends that disasters are not just events to which we should respond, but rather the result of human vulnerabilities to environmental hazards in local contexts. The roots of vulnerability may be a matter of an individual’s characteristics, like old age or a disability, or may have structural causes: a lack of affordable housing, poor government service provision, and high crime rates; at a macro level, the legacies of colonialism, the global economic system, and so on. The explanations for vulnerability—and people’s strategies for overcoming vulnerability—quickly grow complex.
As such, disaster risk reduction demands a highly contextualized response. Researchers partner with residents of localities to identify hazards, vulnerabilities, and sources of resilience. Data-gathering and fine-resolution mapping inform local risk management practices. Disaster risk reduction heavily emphasizes preparation and adaptation, not just post-disaster relief. Such efforts are most successful when they incorporate an understanding of existing practices and perceptions. Who better to conduct the work than resident scholars and practitioners?
There is a blanket need for more research, especially in Africa. Existing work has focused on Asia and Latin America, though the need to understand the African context is clear. In spite of rising disaster incidence, deaths from natural disasters have been decreasing everywhere but in Africa. Elsewhere, sudden-onset crises prevail. Africa, by contrast, experiences “creeping emergencies,” when slow-onset hazards like droughts become unmanageable, or when underlying challenges like HIV/AIDS and malnutrition turn a relatively small event catastrophic. In this context, the typical emergency relief-based response to disasters proves less effective than preventative disaster risk reduction approaches.
Not only are relief efforts less helpful, but development suffers when plans ignore local risks. Mozambique offers an illustrative example of this inefficiency. There, the World Bank financed the construction of 487 schools over twenty years, but just one disaster, the floods of 2000, damaged or destroyed roughly 500 primary schools alone. The World Bank, Red Cross, and others have shown that every dollar invested in preventative risk reduction measures saves between $2 and $10 in disaster losses.
To encourage uptake of disaster reduction in development, the UN declared the 1990s the “International Decade for Natural Disaster Reduction.” In 2005, 164 member nations signed the Hyogo Framework for Disaster Risk Reduction, pledging to build a risk reduction approach into disaster management and development.
And yet, myopia persists amongst development agencies. The World Bank’s Independent Evaluation Group found that disasters are “still sometimes treated as an interruption in development rather than as a risk to development.” Forty-four percent of current World Bank-supported country assistance strategies make no mention of disasters. More broadly, 96% of disaster-related assistance from the industrialized world still comes solely as emergency relief.
Better information may improve vulnerability reduction efforts, with added developmental benefits if Africans drive the effort themselves. Despite potential advantages of an African-led research initiative, the continent’s scholars produced only two of the African disaster risk-related research papers published in 2008. There were also few African programs for educating and training disaster management practitioners.
Early signs exist of a growing Africa-based field of study. A network of ten universities across the continent has started graduate-level programs in disaster risk science. Called Peri-Peri U, they model themselves after a research center based at the University of Cape Town, which primarily uses community-level risk assessments and spatial data mapping to analyze the vulnerability. The unit has the ear of government officials, community organizers, and a growing number of Southern African graduate students.
In 2011, the Peri-Peri network will seek renewed funding from the US Agency for International Development. Program reviews have consistently demonstrated positive yields of the new research centers for disaster management, and certainly for the emergence of a new generation of African-trained researchers, planners, and practitioners. With increased support, the local scholarship program can be scaled up and better tackle the urgent need to increase African preparedness to disaster risks.
Friday, May 13, 2011
Latin Americans: A disproportionate share of the uninsured
Veronica Guerra, MPA
Healthcare in America is designed as a multi-payer or privatized system, meaning everyone is responsible for securing his or her own health services. Excluding the young and old who are covered under federal or state social welfare programs, the majority of Americans get healthcare either through private insurance or their employer. Yet, nearly 55.6 million Americans lack access to basic health services, and even those who do find costs prohibitive: nearly half of bankruptcies in America are related to medical care payments. These statistics become paradoxical when one considers ballooning national expenditures in the health services industry.
In 2005 almost 34% of Latinos were uninsured, constituting a disproportionate share of the nation’s uninsured population. (This high rate has also led to further exacerbation of existing health inequities and to more pronounced health disparities.) The likelihood of being uninsured is far higher among non-citizen Latinos who primarily speak Spanish. There are various factors that contribute to the increasingly uninsured status of the Latino population, including employment, employee benefits, household income, language, and citizenship status.
Immigration from Latin America to the United States has steadily risen over time. Latino citizens and non-citizens are less likely to have both public and private insurance coverage. Non-citizens do not qualify for various public programs including Medicaid and the State Children’s Health Insurance Program (SCHIP), and legal immigrants often do not apply for public programs because of fear of jeopardizing their residency status or because they are ineligible during the first five years of gaining residency. When employed, they are less likely to receive employee health benefits, and low-wages prevent the purchase of private insurance. In general, minorities and immigrant families have lower average incomes than white citizen families. These income differences pose a challenge in obtaining health benefits because low incomes lead many families to make difficult decisions between health care coverage and other basic necessities due to the increasing costs of health coverage.
Language also has an implicit effect on uninsured status. Those who have limited English proficiency may have limited employment opportunities and may work in low-wage sectors that do not offer employee health benefits. Furthermore, language barriers both pose a challenge in completing insurance applications and may compromise the quality of health care when access is obtained.
One important recommendation that could decrease the number of uninsured is to restore public insurance eligibility for legal immigrants, either through federal legislation or at the state level through programs such as Medicaid and SCHIP. Resources should be concentrated in the Latino community to help reduce the number of uninsured and decrease medical expenses incurred through emergency care visits. Existing resources that provide care for the uninsured such as safety-net clinics should be improved and provided increased funding to meet the high demand for their services. Additionally, policies that improve the quality of jobs held by Latinos or that incentivize businesses to offer insurance to low-income workers could lead to increased offers in employer-based health insurance. Processes to apply for insurance—whether public or private—should be streamlined and accessible to those who require language assistance. It is important that government efforts be focused on decreasing health disparities, improving preventive efforts, and increasing access to health care coverage for adults and children. This is not simply beneficial to the Latino community, but to Americans nationwide.
Healthcare in America is designed as a multi-payer or privatized system, meaning everyone is responsible for securing his or her own health services. Excluding the young and old who are covered under federal or state social welfare programs, the majority of Americans get healthcare either through private insurance or their employer. Yet, nearly 55.6 million Americans lack access to basic health services, and even those who do find costs prohibitive: nearly half of bankruptcies in America are related to medical care payments. These statistics become paradoxical when one considers ballooning national expenditures in the health services industry.
In 2005 almost 34% of Latinos were uninsured, constituting a disproportionate share of the nation’s uninsured population. (This high rate has also led to further exacerbation of existing health inequities and to more pronounced health disparities.) The likelihood of being uninsured is far higher among non-citizen Latinos who primarily speak Spanish. There are various factors that contribute to the increasingly uninsured status of the Latino population, including employment, employee benefits, household income, language, and citizenship status.
Immigration from Latin America to the United States has steadily risen over time. Latino citizens and non-citizens are less likely to have both public and private insurance coverage. Non-citizens do not qualify for various public programs including Medicaid and the State Children’s Health Insurance Program (SCHIP), and legal immigrants often do not apply for public programs because of fear of jeopardizing their residency status or because they are ineligible during the first five years of gaining residency. When employed, they are less likely to receive employee health benefits, and low-wages prevent the purchase of private insurance. In general, minorities and immigrant families have lower average incomes than white citizen families. These income differences pose a challenge in obtaining health benefits because low incomes lead many families to make difficult decisions between health care coverage and other basic necessities due to the increasing costs of health coverage.
Language also has an implicit effect on uninsured status. Those who have limited English proficiency may have limited employment opportunities and may work in low-wage sectors that do not offer employee health benefits. Furthermore, language barriers both pose a challenge in completing insurance applications and may compromise the quality of health care when access is obtained.
One important recommendation that could decrease the number of uninsured is to restore public insurance eligibility for legal immigrants, either through federal legislation or at the state level through programs such as Medicaid and SCHIP. Resources should be concentrated in the Latino community to help reduce the number of uninsured and decrease medical expenses incurred through emergency care visits. Existing resources that provide care for the uninsured such as safety-net clinics should be improved and provided increased funding to meet the high demand for their services. Additionally, policies that improve the quality of jobs held by Latinos or that incentivize businesses to offer insurance to low-income workers could lead to increased offers in employer-based health insurance. Processes to apply for insurance—whether public or private—should be streamlined and accessible to those who require language assistance. It is important that government efforts be focused on decreasing health disparities, improving preventive efforts, and increasing access to health care coverage for adults and children. This is not simply beneficial to the Latino community, but to Americans nationwide.
Guess Who’s Coming to Breakfast? And Lunch, and Dinner?
Jenn Onofrio, MPA
Earlier this month the Food and Drug Administration issued guidelines for food manufacturers on recommended decreases in the level and frequency of sugar-sweetened cereals marketing to children. The guidelines, though voluntary, remind us again of the pervasive place of the food industry at the kitchen table.
Ask a parent who has tried to get her child to eat the boring oatmeal instead of the Cocoa Puffs before dashing out the door—the task is daunting to say the least. Food research tells us, though, that this is not entirely a matter of children’s taste buds being so normalized to sugar that they just hate oatmeal—it’s also the product of millions of dollars of targeted advertising that reminds children over and over again through television and internet commercials that Tony the Tiger is “grrrrrrreat!”
According to the Rudd Center for Food Policy and Obesity at Yale University, “food marketing to youth has been shown to increase preference for advertised foods; consumption of advertised foods; overall calorie consumption; requests to parents to purchase advertised foods (known as “pester power”); and snacking.”
The food industry has literally wedged itself between parents and children.
I studied food policy this fall as part of a working group preparing recommendations for the Robert Wood Johnson Foundation’s Childhood Obesity Group. We researched and visited programs all over the country that were tackling the issue of childhood obesity. I was fortunate to be able to meet with leadership in San Francisco about the hot topic of the time, the so-called “Happy Meal ban.” What was amazing was that it wasn’t a ban at all, but rather a requirement that fast food companies could not hand out a free toy with a meal that contained over 600 calories (with more than 35% derived from fat), and more than 640mg of sodium. It was actually an incentive for companies to increase their nutritional standards. Make it healthier, and add a serving of fruit and veggies. So long as they complied, they could reintroduce the toy.
But that wasn’t the argument heard ’round the world. Frustrated parents accused the government of trying to take the happy out of the meal. Parent after parent protested, “But my kid wants the Happy Meal.”
Without greater regulation of marketing standards, we’re getting our battles confused. Kids (with the help of the food industry) rebel against adults; adults rebel against government initiatives because of what their kids want. (Conveniently, it’s also what the food industry wants.) It creates a lot a noise and not a lot of change in the fact that the childhood obesity rate has tripled since 1980. According to the Centers for Disease Control, 17% of American children are obese.
Regulation won’t cure everything. Our research found that the most effective programs implemented a mix of bans, incentives, and education. To complement this troika, it may be time to think about setting one less place at the kitchen table. Tony the Tiger, you’re out.
Editor’s Note: You can read more about this subject in “Tipping the Scales: Strategies for Changing How America’s Children Eat,” a WWS graduate policy workshop final report presented to the Robert Wood Johnson Foundation. Available here.
Earlier this month the Food and Drug Administration issued guidelines for food manufacturers on recommended decreases in the level and frequency of sugar-sweetened cereals marketing to children. The guidelines, though voluntary, remind us again of the pervasive place of the food industry at the kitchen table.
Ask a parent who has tried to get her child to eat the boring oatmeal instead of the Cocoa Puffs before dashing out the door—the task is daunting to say the least. Food research tells us, though, that this is not entirely a matter of children’s taste buds being so normalized to sugar that they just hate oatmeal—it’s also the product of millions of dollars of targeted advertising that reminds children over and over again through television and internet commercials that Tony the Tiger is “grrrrrrreat!”
According to the Rudd Center for Food Policy and Obesity at Yale University, “food marketing to youth has been shown to increase preference for advertised foods; consumption of advertised foods; overall calorie consumption; requests to parents to purchase advertised foods (known as “pester power”); and snacking.”
The food industry has literally wedged itself between parents and children.
I studied food policy this fall as part of a working group preparing recommendations for the Robert Wood Johnson Foundation’s Childhood Obesity Group. We researched and visited programs all over the country that were tackling the issue of childhood obesity. I was fortunate to be able to meet with leadership in San Francisco about the hot topic of the time, the so-called “Happy Meal ban.” What was amazing was that it wasn’t a ban at all, but rather a requirement that fast food companies could not hand out a free toy with a meal that contained over 600 calories (with more than 35% derived from fat), and more than 640mg of sodium. It was actually an incentive for companies to increase their nutritional standards. Make it healthier, and add a serving of fruit and veggies. So long as they complied, they could reintroduce the toy.
But that wasn’t the argument heard ’round the world. Frustrated parents accused the government of trying to take the happy out of the meal. Parent after parent protested, “But my kid wants the Happy Meal.”
Without greater regulation of marketing standards, we’re getting our battles confused. Kids (with the help of the food industry) rebel against adults; adults rebel against government initiatives because of what their kids want. (Conveniently, it’s also what the food industry wants.) It creates a lot a noise and not a lot of change in the fact that the childhood obesity rate has tripled since 1980. According to the Centers for Disease Control, 17% of American children are obese.
Regulation won’t cure everything. Our research found that the most effective programs implemented a mix of bans, incentives, and education. To complement this troika, it may be time to think about setting one less place at the kitchen table. Tony the Tiger, you’re out.
Editor’s Note: You can read more about this subject in “Tipping the Scales: Strategies for Changing How America’s Children Eat,” a WWS graduate policy workshop final report presented to the Robert Wood Johnson Foundation. Available here.
Wednesday, March 23, 2011
With international aid, it’s not always the high profile things where focus is needed
Kim Bonner, MPA
We sat on the dusty porch and exchanged self-congratulations as people trickled in, signed up to receive the bed nets, and returned home. This was my second national bed net distribution drive in Tanzania and I was ever vigilant to make sure it ran as smoothly as possible. All was going well on the final day of our pilot run, and after two hours watching others put the finishing touches on our successful campaign, I strolled around the back of the medical clinic dispensary, where a smattering of village residents had gathered, but not to pick up their free bed nets.
There were two rows of women stretched around the perimeter of the porch. Awkwardly trying to be friendly, I greeted the older woman nearest me and asked her why there was such a crowd on the dispensary porch. Her neighbor leaned in and told me that this woman’s daughter had lost so much blood in labor that after delivering the baby that she had collapsed. She was lying inside the dispensary, still bleeding.
“But,” I sputtered, “Why isn’t anything being done? Why don’t they just give her stitches?”
The woman leaned in again. “They don’t have anything here. No medicine. No needles. Nothing to stitch. The clinic worker called the district hospital for an ambulance almost two hours ago, and it still hasn’t arrived.”
Horrified, I thought of the NGO’s landcruiser that had been sitting out front the dispensary the entire time. We moved the car around back just as the ambulance arrived. Heavily supported by her mother and the clinic worker, the woman climbed in the car. It was the last we saw of her.
To this day, I have no idea of this woman’s fate. I hope that she survived, that she’s enjoying watching her child take his or her first few steps right about now.
What stays with me is the nagging feeling that many crucial areas in health are being overlooked. While I am happy to report that many more people have bed nets, I can’t say how many dispensaries have a full supply of medicines at any given time.
In a world where donor governments are willing to give billions to the highest profile diseases, there is no reason for logistics and procurement maintenance to be neglected. The interplay of conditional aid and decision-making in cash-strapped governments can create perverse incentives to neglect lower profile components of the health system. Foreign assistance for health has been associated with a consequent decrease in government expenditure for health, ranging from a $0.43 to a $1.14 decrease per $1.00 received. [1]
Much of this foreign assistance is earmarked for certain high-profile diseases. The Global Fund alone has granted $22 billion for HIV/AIDS, tuberculosis, and malaria since its inception in 2002. [2] Consequentially, countries that displace domestic health funding with foreign assistance encounter restrictions on how much of their budgets can be used to support the mundane, but crucial, task of running a health system.
While there has been a shifting focus towards strengthening health systems in general, a demonstrated national and global commitment towards the lower-profile health activities is yet to be shown. [3] Fortunately, increasingly donor governments are shifting to health basket funding, where unrestricted aid is contributed directly to ministries of health. While this system faces challenges in accountability and timely disbursal of funds, it enables governments to spend funding in accordance with their priorities. While these priorities don’t necessarily make for photos as lovely as our bed nets, they are just as necessary for improving the quality of healthcare in Tanzania and around the world.
----------------
References:
[1] 95% confidence interval. Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ. “Public financing of health in developing countries: a cross-national systematic analysis,” Lancet (375: 9723), 17 Apr 2010, pp. 1375-87.
[2] The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. Grant Portfolio. http://www.theglobalfund.org/en/
[3] Waddington C. “Does earmarked donor funding make it more or less likely that developing countries will allocate their resources towards programmes that yield the greatest health benefits?” Bulletin of the World Health Organization.
We sat on the dusty porch and exchanged self-congratulations as people trickled in, signed up to receive the bed nets, and returned home. This was my second national bed net distribution drive in Tanzania and I was ever vigilant to make sure it ran as smoothly as possible. All was going well on the final day of our pilot run, and after two hours watching others put the finishing touches on our successful campaign, I strolled around the back of the medical clinic dispensary, where a smattering of village residents had gathered, but not to pick up their free bed nets.
There were two rows of women stretched around the perimeter of the porch. Awkwardly trying to be friendly, I greeted the older woman nearest me and asked her why there was such a crowd on the dispensary porch. Her neighbor leaned in and told me that this woman’s daughter had lost so much blood in labor that after delivering the baby that she had collapsed. She was lying inside the dispensary, still bleeding.
“But,” I sputtered, “Why isn’t anything being done? Why don’t they just give her stitches?”
The woman leaned in again. “They don’t have anything here. No medicine. No needles. Nothing to stitch. The clinic worker called the district hospital for an ambulance almost two hours ago, and it still hasn’t arrived.”
Horrified, I thought of the NGO’s landcruiser that had been sitting out front the dispensary the entire time. We moved the car around back just as the ambulance arrived. Heavily supported by her mother and the clinic worker, the woman climbed in the car. It was the last we saw of her.
To this day, I have no idea of this woman’s fate. I hope that she survived, that she’s enjoying watching her child take his or her first few steps right about now.
What stays with me is the nagging feeling that many crucial areas in health are being overlooked. While I am happy to report that many more people have bed nets, I can’t say how many dispensaries have a full supply of medicines at any given time.
In a world where donor governments are willing to give billions to the highest profile diseases, there is no reason for logistics and procurement maintenance to be neglected. The interplay of conditional aid and decision-making in cash-strapped governments can create perverse incentives to neglect lower profile components of the health system. Foreign assistance for health has been associated with a consequent decrease in government expenditure for health, ranging from a $0.43 to a $1.14 decrease per $1.00 received. [1]
Much of this foreign assistance is earmarked for certain high-profile diseases. The Global Fund alone has granted $22 billion for HIV/AIDS, tuberculosis, and malaria since its inception in 2002. [2] Consequentially, countries that displace domestic health funding with foreign assistance encounter restrictions on how much of their budgets can be used to support the mundane, but crucial, task of running a health system.
While there has been a shifting focus towards strengthening health systems in general, a demonstrated national and global commitment towards the lower-profile health activities is yet to be shown. [3] Fortunately, increasingly donor governments are shifting to health basket funding, where unrestricted aid is contributed directly to ministries of health. While this system faces challenges in accountability and timely disbursal of funds, it enables governments to spend funding in accordance with their priorities. While these priorities don’t necessarily make for photos as lovely as our bed nets, they are just as necessary for improving the quality of healthcare in Tanzania and around the world.
----------------
References:
[1] 95% confidence interval. Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ. “Public financing of health in developing countries: a cross-national systematic analysis,” Lancet (375: 9723), 17 Apr 2010, pp. 1375-87.
[2] The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. Grant Portfolio. http://www.theglobalfund.org/en/
[3] Waddington C. “Does earmarked donor funding make it more or less likely that developing countries will allocate their resources towards programmes that yield the greatest health benefits?” Bulletin of the World Health Organization.
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