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Rob: Many thanks for your further comments, which give us the opportunity to clarify further. Your comments also convinced us that we need a broader piece on user-fees, which we will put out shortly, and hope that you will contribute to it with your valuable insights. First, infant mortality in Africa has indeed declined rapidly in the new millennium. The World Bank has been working on this, and the Economist article you highlight was partly provoked by, and cites, the work of our colleague, Gabriel Demombynes, who along with Michael Clemens at the Center for Global Development has been doing valuable analysis on this front. Second, as you point out, there are multiple pathways to better health. The one thing we know from all the OECD experience is that big declines in infant mortality happen when governments focused and committed to reducing population exposure to infectious diseases. Typically, this was done through the provision of "big public goods"--clean water, better sanitation, draining of swamps, more and better vaccination. Our post, and all of our responses to comments, are highly supportive of government action to solve problems of under-provision of preventive measures to reduce exposure to infectious diseases.This is also what we appear to be seeing in Africa. One example is the recent improvement in sanitation (though still short of the MDG), which helps reduce illnesses like childhood diarrhea. Another is the large-scale provision of ITN bed-nets, which help reduce the spread of malaria. In the case of malaria, the arrival of artemisinin-combination therapies (ACT) was also, no doubt, a contributor. Let us be absolutely clear about this: There is a fundamental role for the government to play in the financing of public goods that are under-provided due to contagion externalities. In fact, we believe that these goods are over-privatized: For instance, the public goods of draining swamps and improving sewage systems in urban areas may be a better alternative than providing (private) bed-nets. Third, careful evaluations of what drives health outcomes are necessary precisely to understand the specific pathways and therefore guide policies in the future. As we know from Clemens and Demombynes’ critique of the Millennium Village Project, infant mortality declines in the project villages were no larger than in comparable areas in Kenya--despite the fact that the original article published in Lancet showed huge improvements. The studies we have pointed to try to get at these issues by constructing the necessary and careful counterfactuals for each of these policies, and they should make us think very hard about how to move forward. Fourth, when it comes to curative care, we are never advocating that poor people should be paying for all of their health care. For us, that violates fundamental notions of equity and what it means to fight towards a world free of poverty. Yet, we also hold in great respect the decisions that the poor make, particularly given the oft-onerous conditions under which these decisions are forced on them. And in many countries in Sub-Saharan Africa and South Asia, the poor choose in favor of fee-paying private services (http://www.who.int/bulletin/volumes/83/4/274.pdf). Unless we also argue that the poor cannot make informed judgments (something on which there is very little evidence), this is a telling remark about the quality of services in the public sector that is available to them. The fundamental question then is: What are the set of institutional arrangements, or the process of institutional change, that can lead to better quality health care for the poor--whether from the public or private sector. Some of this may require greater accountability from communities. Some of it may require more top-down accountability measures in public clinics. Some of it may require financial incentives for providers (as in Rwanda) and, yes, some it may require separating the financing of health care from its provision--whether through instruments such as vouchers or subsidized private insurance (as in India). To what extent these subsidies should be focused on medical advice versus medicines and for what illnesses should medicines be subsidized are all hard policy choices that require a clear understanding of the conditions under which the poor can receive better care, as well as a framework of the rationales for government action. But what is absolutely critical is that we experiment and evaluate moving forward, so that we don't repeat the mistakes of the past. Such a repetition would continue to represent a tragedy, one that we can ill-afford at this time. Jishnu and Shanta