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Adam Wagstaff's blog

Health and the SDGs: Out of the doldrums, heading for the rapids

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Until quite recently, things were looking good for health in the SDG process. It wasn’t always so. Two and a half years ago, at the time of the high-level panel report on the SDGs, the health SDG discussion was actually stuck in the doldrums. Health was the only area to get less column inches than in the MDGs.

Saturday, December 12 was UHC Day. What have we learned in the last 12 months about Universal Health Coverage?

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It turns out lots of interesting things happened on December 12. Beethoven had his first lesson in music composition with Franz Joseph Haydn (1792), Washington, D.C. became the capital of the US (1800), Guglielmo Marconi sent the first transatlantic radio signal (1901), Kenya declared independence from the UK (1963), The Beatles played their last UK concert (1965), and  Ed Sheeran announced he was “taking a break” from social media (2015). Oh yes, and the UN endorsed a resolution calling for countries to “provide affordable, quality health care to every person, everywhere” (2012).

Financial incentives in health: the magic bullet we were hoping for?

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After years of bad news from developing countries about high rates of health worker absenteeism, and low rates of delivery of key health interventions, along came what seemed like a magic bullet: financial incentives. Rather than paying providers whether or not they show up to work, and whether or not they deliver key interventions, doesn’t it make sense to pay them—at least in part—according to what they do? And if, after doing their cost-benefit calculations, women decide not to have their baby delivered in a health facility, not to get antenatal care, and not take their child to be immunized, then doesn’t it make sense to try to change the benefit-cost ratio by paying them to do so?

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.

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