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Adam Wagstaff's blog

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.

Reconciling the two “sciences of delivery”

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Last week on Let’s Talk Development, I asked what the term “science of delivery” (SOD) means. I suggested that SOD is about moving from thinking about “what to deliver” to “how to deliver”.  We know, for example, the interventions that cut child mortality (bednets, vaccinations, breastfeeding, etc.) but these interventions reach too few children, and the trick is to get them delivered to more. Much of the Bank’s analytic work, policy dialogue and lending work has focused precisely on how to reform policies and programs to ensure the interventions that are needed to improve development outcomes actually reach people. Much of this work merits the term “science” – it makes use of an explicit “theory of change” in the form of a results framework that reflects the latest social science, and builds on rigorous empirical evidence that compares actual outcomes with an explicit and plausible counterfactual.

So what exactly is the “science of delivery”?

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The World Bank’s president, Jim Kim, has now made two major speeches outlining his vision for the institution – one at the Annual Meetings the other at Georgetown University on April 2 ahead of the upcoming Spring Meetings.

Several themes are emerging. Two are easy to grasp and likely to resonate strongly with Bank staff and stakeholders: “ending poverty” and “boosting shared prosperity”. For years the Bank has seen fighting poverty as its mission. It has made major contributions in the areas of measuring and monitoring poverty – Bank staff have authored many of the world’s most-cited publications with poverty in the title. The Bank’s work at the country level has always had a strong anti-poverty focus. “Ending” poverty – rather than merely “fighting” it – is a natural next step. The idea of “boosting shared prosperity” also resonates. While economic growth is still seen as the principal driver of poverty-reduction, the goal has always been pro-poor growth – a concept that links naturally to the idea of “shared prosperity”.

Should inequality be reflected in the new international development goals?

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The last few months have been a busy time for inequality. And over the last few days the poor thing got busier still. Inequality is now dancing on two stages. It must be really quite dizzy.

We need an inequality goal. No we don’t. Yes we do

One of the two stages is the post-2015 development goals. At some point, someone seems to have decided that reducing inequality needs to be an explicit commitment in the post-2105 goals. The UN System Task Team on the Post-2015 UN Development Agenda wrote a report on inequality and argued that “addressing inequalities is in everyone’s best interest.” Another report by Claire Melamed of Britain’s Overseas Development Institute argued that “equity, or inequality, needs to be somehow integrated into any new framework.” Last week a group of 90 academics wrote an open letter to the High Level Panel on the Post 2015 Development Agenda demanding that inequality be put at the heart of any new framework.

Using an iPad to increase your productivity: a roundup

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It's a while since I blogged about the iPad. I thought it might be useful to pull all my tips on this handy little gadget (including some new ones) together in one post. I'm going to focus for the most part on using it to improve productivity, but there will be some thoughts at the end on using the iPad to have a little fun.  

Get yourself a keyboard and stylus

There's a lot you can do without these add-ons, but they'll dramatically increase your productivity.

There are lots of keyboards on the market — here's a nice review. I waited until the Brydge came out. The Brydge team had functionality in mind, but what sold me was the design — it makes your iPad looks (almost) as cool as the MacBook Air but gives you the advantages of the iPad. 

Universal Health Coverage and the post-2015 development goal agenda. And Mrs Gauri

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In a recent blogpost I asked whether Universal Health Coverage (UHC) is old wine in a new bottle, and if so whether that’s so bad.

I argued that UHC is ultimately about making sure that “everyone – whether rich or poor – gets the care they need without suffering undue financial hardship as a result.” I suggested UHC embraces three important concepts:

• equity: linking care to need, not to ability pay;
• financial protection: making sure that people's use of needed care doesn't leave their family in poverty; and
• quality of care: making sure providers make the right diagnosis, and prescribe a treatment that's appropriate and affordable.

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