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Adam Wagstaff's blog

We just learned a whole lot more about achieving Universal Health Coverage

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Subsidized health insurance is unlikely to lead to Universal Health Coverage (UHC); insurance coverage doesn’t always improve financial protection and when it does, doesn’t necessarily eliminate financial protection concerns; and tackling provider incentives may be just as – if not more – important in the UHC agenda as demand-side initiatives. These are the three big and somewhat counterintuitive conclusions of the Health Equity and Financial Protection in Asia (HEFPA) research project that I jointly coordinated with Eddy van Doorslaer and Owen O’Donnell.

As we all now know, UHC is all about ensuring that everyone – irrespective of their ability to pay – can access the health services they need without suffering undue financial hardship in the process. The HEFPA project set out to explore the effectiveness of a number of UHC strategies in a region of the world that has seen a lot of UHC initiatives: East Asia. The project pooled the skills of researchers from six Asian countries (Cambodia, China, Indonesia, the Philippines, Thailand and Vietnam), several European universities and the World Bank.

Inequality of opportunity: the new motherhood and apple pie?

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On the face of it, questioning the usefulness of “inequality of opportunity” seems about as wrongheaded as questioning the merits of family vacations, Thanksgiving or dessert trolleys. What’s not to like about it? Well, as we argue in a recent World Bank working paper, the idea is not quite as useful as it might at first glance appear, and is in fact rather dangerous. But turned upside down, it might yet be useful.

A simple idea – let’s see some numbers

The idea behind inequality of opportunity is simple yet powerful. Not all inequality is bad. The bad bit of inequality (‘inequality of opportunity’) is the part that emerges because of factors over which we have no control (our 'circumstances'). By contrast inequality that emerges because of our different choices and efforts (holding constant our circumstances) is fine, and to be encouraged.

Were the poor left behind by the health MDGs?

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Thanks to Thomas Piketty, we’ve heard a lot this year about rising inequality. And with just over a year to go before the MDG ‘window’ closes, we’ve also heard a lot about the ‘post-2015 agenda’. In a paper with Leander Buisman that just came out in the World Bank Research Observer, we bring these two themes together and ask: “Were the poor left behind by the health MDGs?” Influenced perhaps by all the talk of rising income inequality, there are certainly plenty of pessimistic folks out there who think that health inequalities, too, are on the rise; that the better off are likely to have seen much faster improvements in MDG indicators than the poor.

A guide to the top World Bank blogs and blogposts of 2013

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In both 2011 and 2012, I did a roundup of the most read 200 World Bank blogposts of the year, and compared the performance of the various World Bank blogs in terms of readership. What did blogging at the World Bank in 2013 look like?

Table 1 compares the Bank’s blogs in terms of how many of the 200 most-read posts they produced. As before, I excluded pages that didn’t look like posts – blog home pages, blogger profiles, thematic pages, and so on. I got the data on views from Omniture. This apparently gives more precise – and typically lower – page view figures than the Bank’s blogger platform whose counts are vulnerable to spammers. Readers who manage to read an entire blogpost without clicking on the URL of the post (e.g. through Feedly or the now defunct Google Reader) won't show up in my numbers are readers

How and why do countries vary so much in their use of health services?

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I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

What exactly is the public-private mix in health care?

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I’ve been in quite a few meetings recently and read quite a lot of documents where people have made claims about the relative sizes of the public and private sectors in health care delivery. A recent report from the World Bank Group on the private sector in Africa claims that “the private health sector now provides half of all health services in the region.” A document I reviewed recently claimed that “much” of medical care is provided by the private sector – an assertion I hear quite often.

As far as I can make out, the data underlying such claims reflect a very partial picture. The Africa data are from the Demographic Health Survey which captures only treatment for (outpatient) maternal and child health services (MCH); it also covers only the developing world, and only the poorer part of it. Some claims reflect data for just one country. I’ve heard a lot about India, but these data (obviously) cover just India, and only outpatient visits.

The Academic Sting Operation

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Nobody likes to be stung. Doctors regard it as unethical. Publishers say it betrays the trust of their profession. But the fact is, as three recent studies have demonstrated, sting operations can be extremely effective at exposing questionable professional practices, and answering questions that other methods can't credibly answer.

Sting #1: Are open-access journals any good? 

Much of the world has gotten fed up with the old academic publishing business. Companies like the Anglo-Dutch giant Elsevier and the German giant Springer earn high profit margins from their academic journals (Elsevier earns 36% profit, according to The Economist), through a mix of ‘free’ inputs from academics (the article itself and the peer-review process) and high (and rapidly rising) subscription charges that impede access by academics working in universities whose libraries can’t afford the subscriptions. Of course, many of these universities paid for the authors’ time in the first place, and/or that of the peer-reviewers; tax-payers also contributed, by direct subsidizing universities and/or by the research grants that supported the research assistants, labs, etc. Unsurprisingly, libraries, universities, academics and tax-payers aren’t happy.

Health and the post-2015 development agenda: Stuck in the doldrums?

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I think it’s fair to say most of us don’t typically take UN reports with us on our summer vacation. But you might want make an exception in the case of the high-level panel (HLP) report on the post-2015 development agenda. It offers a nice opportunity to reflect how – over the last 15 years or so – we have seen some serious global shifts in values, expectations and motivations. 

The HLP feels the MDGs were worthwhile: “the MDGs set out an inspirational rallying cry for the whole world”. As my colleague Varun Gauri argues, goals inspire if they are underpinned by a moral case, and the panel pushes hard on issues of rights and responsibilities, social justice, and fairness: “new goals and targets need to be grounded in respect for universal human rights”; “these are issues of basic social justice. Many people living in poverty have not had a fair chance.” 

Were Gordon Brown and I right? Were poor children actually left behind by the Millennium Development Goals for education?

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It’s quite fun being picked up by a prime minister. Not literally of course. Unless you happen to be a baby seized from your mother’s arms during an election campaign, in which case it must be rather exciting, and quite possibly the highlight of the day. No, I mean being picked up in print. 

In a recent Washington Post op-ed, former UK Prime Minister Gordon Brown, and current United Nations’ Special Envoy for Global Education, cited a Let’s Talk Development blog post of mine asking whether inequality should be reflected in the new international development goals. Toward the end of the post I presented some rather shocking numbers showing how – in a large number of developing countries – the poorest 40% have made slower progress toward key MDG health targets than the richest 60%. Although I didn’t actually offer any evidence on education, I argued: “If inequalities in education and health outcomes across the income distribution matter, and if we want to see “prosperity” in its broadest sense shared, it looks like we really do need an explicit goal that captures inequality.

Cost-effectiveness vs. universal health coverage. Is the future random?

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I've been blogging a bit about Universal Health Coverage (UHC) recently. In my "old wine in a new bottle" post, I argued that UHC is ultimately about ensuring that rich and poor alike get the care they need, and that nobody suffers undue financial hardship from getting the care they need. In my "Mrs Gauri" post, I used my colleague Varun Gauri's mother as a guinea pig to see whether the general public feels that UHC is a morally powerful concept and whether it could be expressed in a way that the general public would find accessible.

My sense from Ms Gauri's comment on the post, is that the answer to both questions could well be Yes. So far so good.

Some bad news—resources are finite

But before we place orders for colorful placards and huge banners with my suggested slogans "Everyone should get the care they need!" and "End impoverishment due to health spending!", we should break some bad news to Ms Gauri and the rest of the general public: resources are finite, and especially in poor countries the available resources won't allow us to get to UHC anytime soon.

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