Globally, tremendous progress has been made in reducing extreme poverty in the last 25 years. However, the number of poor remains unacceptably high, at just over 1 billion in 2011 compared with 1.2 billion in 2008, creating a widening gap between the living standards of those in the bottom 40 percent and the top 60 percent of the population. According to the recently released Global Monitoring Report, the well-being of low income households still remains below that of households in the top 60 percent directly impacting young children who are 2-3 times more likely to be malnourished than those in the highest wealth quintiles.
Last week, Mali announced a national strategic plan to scale up Community Health Workers in every region of the country. This initiative has the potential to save tens of thousands of lives, including significantly reducing the risk of an Ebola epidemic.
How was this achieved? Roll back a few years and meet Djeneba, a young girl living in Yirimadjo. Today she goes to school but her life was once threatened. Djeneba started getting high fevers but her parents did not have enough money to pay for care. They tried to break the fever by bathing her in herbal remedies and buying unregulated pharmaceuticals but the fevers persisted and became increasingly severe.
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.
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.
Following is an abstract from World Bank Policy research working paper no 6779 by Norbert Schady (Inter-American Development Bank), Jere Behrman (University of Pennsylvania), Maria Caridad Araujo (Inter-American Development Bank), Rodrigo Azuero (University of Pennsylvania), Raquel Bernal (Universidad de Los Andes), David Bravo (Universidad de Chile), Florencia Lopez-Boo (Inter-American Development Bank), Karen Macours (Paris School of Economics & World Bank), Daniela Marshall (University of Pennsylvania), Christina Paxson (Brown University), and Renos Vakis (World Bank).
Research from the United States shows that gaps in early cognitive and noncognitive abilities appear early in the life cycle. Little is known about this important question for developing countries. A recent World Bank owrking paper, Wealth gradients in early childhood cognitive development in five Latin American countries, provides new evidence of sharp differences in cognitive development by socioeconomic status in early childhood for five Latin American countries. To help with comparability, the paper uses the same measure of receptive language ability for all five countries. It finds important differences in development in early childhood across countries, and steep socioeconomic gradients within every country. For the three countries where panel data to follow children over time exists, there are few substantive changes in scores once children enter school. These results are robust to different ways of defining socioeconomic status, to different ways of standardizing outcomes, and to selective non-response on the measure of cognitive development.
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?
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.
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.
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.”