On February 1st, India’s finance minister presented the Union Budget for 2017-2018, and announced the government’s plan to eliminate tuberculosis (TB) by 2025. This is a welcome move. While ridding people of the burden of any disease is a worthy goal by itself, TB elimination provides perhaps one of the strongest cases for public intervention from an economic point of view.
All communicable diseases present what economists call externalities: infectious people can infect other people who in turn infect others and so on. In fact, economist Phillip Musgrove used TB in particular to illustrate this: “no victim of tuberculosis is likely to ignore the disease, so there is no problem of people undervaluing the private benefits of treatment. Rather, the cost of treatment--and the fact that they may feel better even though the disease has not been cured-- may lead people to abandon treatment prematurely, with bad consequences not only for themselves but for others. The rest of society therefore has an interest in treating those with tuberculosis, and assuming at least part of the cost.” Reducing TB incidence could generate benefits of $33 per dollar spent, prompting The Economist to put TB among their list of ‘no-brainers’. According to the Stop TB Partnership, ending TB globally could yield US$ 1.2 trillion overall economic return on investment.
access to affordable health care
This is the third post in a three-part series from Brian Levy on the manner in which the media, activists and politicians talk about the role of government. This post is about Obamacare. It’s hardly news anymore, I know. But my focus is less on the details of America’s ongoing efforts to reform its health sector, than on the way the discourse has played out – making the post another in my series on the dysfunctional ways in which we speak about government.
In an earlier post, I explored Great Gatsby-style carelessness. This time, I want to introduce a dance move — the ‘good governance high standards shuffle’, a display of exuberant glee (disguised as disappointment) whenever the real world intrudes, and the outcome of one or another public initiative is less than perfect.
In the same way that it can be difficult to distinguish between real tears of disappointment, and malicious glee hiding behind crocodile tears, sometimes the ‘high standards shuffle’ can be difficult to detect. Sincerity can all too easily get ‘played’ by cynicism in disguise. While some dancers of the standards shuffle are clumsily obvious, others have the moves down pat — making it hard to tell whether or not one is being played. (And some exponents might even be unaware that they’re doing the standards shuffle.)
Each year, as part of my teaching at Johns Hopkins School of Advanced International Studies, I select a ‘live’ example of the challenges of public management. A few weeks ago, as I described in another post in this series, I used the case of Washington’s Metro to explore with my students at SAIS the costs of careless in our discourse about government. In 2014, my focus was on the ongoing American debate on health care reform (also known as “Obamacare”). That debate offers a marvelous opportunity for seeing the high standards shuffle in action – an opportunity that has not diminished with the passage of time. So: come dance with me……
An exchange in the United States Congress early this past summer illustrates what the clumsy version of the standards shuffle looks like. Here (as reported by the Washington Post’s Dana Milbank) is President Obama’s Secretary of Health and Human services, Sylvia Burwell, being grilled by Sam Johnson, Republican Congressman of Texas:
There is a perfect start, there is a less than perfect start and there is an imperfect start. As a social entrepreneur, the thing I have learned is that it pays to START- even if it’s less than perfect or imperfect.
So, there I was, I had left my job, had no savings, but kept people like Bonti in my mind. But, I had no idea how, or even where to start.
Eye Research Center (ERC) Eye Care was officially founded in the summer of 2011. With the generous help of my mother, we were just one clinic – in her kitchen – in the heart of the city. Although we had a strong mission, we quickly realized that to the outside world, there was nothing to differentiate us from other ophthalmic clinics spread across the city. But what exactly was ERC Eye Care? We had initially set it up as a sole proprietorship, as it was the cheapest and easiest registration process, but we weren’t strictly a for-profit business. Were we a NGO? Or were we something else entirely?
Heather Lanthorn describes the design of the Affordable Medicines Facility- malaria, a financing mechanism for expanding access to antimalarial medication, as well as some of the questions countries faced as they decided to participate in its pilot, particularly those related to risk and reputation.
I examine, in my never-ending thesis, the political-economy of adopting and implementing a large global health program, the Affordable Medicines Facility – malaria or the “AMFm”. This program was designed at the global level, meaning largely in Washington, DC and Geneva, with tweaking workshops in assorted African capitals. Global actors invited select sub-Saharan African countries to apply to pilot the AMFm for two years before any decision would be made to continue, modify, scale-up, or terminate the program. One key point I make is that implementing stakeholders see pilot experiments with uncertain follow-up plans as risky: they take time and effort to set-up and they often have unclear lines of accountability, presenting risk to personal, organizational, and even national reputations. This can lead to stakeholder resistance to being involved in experimental pilots.
It should be noted from the outset that it was not fully clear what role the evidence from the pilot would play in the board’s decision or how the evidence would be interpreted. As I highlight below, this lack of clarity helped to foster feelings of risk as well as a resistance among some of the national-level stakeholders about participating in the pilot. Several critics have noted that the scale and scope and requisite new systems and relationships involved in the AMFm disqualify it from being considered a ‘pilot,’ though I use that term for continuity with most other AMFm-related writing.
In my research, my focus is on the national and sub-national processes of deciding to participate in the initial pilot (‘phase I’) stage, focusing specifically on Ghana. Besides being notable for the project scale and resources mobilized, one thing that stood out about this project is that there was a reasonable amount of resistance to piloting this program among stakeholders in several of the invited countries. I have been lucky and grateful that a set of key informants in Ghana, as well as my committee and other reviewers, have been willing to converse openly with me over several years as I have tried to untangle the reasons behind the support and resistance and to try to get the story ‘right’.
What’s the best way to advertise healthcare options to young people in the United States? Have the President make fun of himself for a BuzzFeed video, of course.
U.S. President Barack Obama’s flagship initiative, the Affordable Care Act (Obamacare), increases the quality and affordability of health insurance by expanding public and private insurance coverage. Each year, the insurance market is opened up for a few months so people can sign up for coverage or change the coverage selections they previously made. With time running out in this year’s enrollment period, Obama turned to BuzzFeed to help spread the word.
The result was a 2-minute video titled “Things Everyone Does But Doesn’t Talk About,” in which the President uses a selfie stick in the White House library, makes funny faces in the mirror, and practices lines from a speech. “February 15th. February 15th,” he repeats, adding, “in many cases you can get health insurance for less than $100 a month. Just go to Healthcare.gov.”
The debate over how to ensure good health services for all while assuring affordability is nothing new.
However, it has recently acquired new impetus under the guise of Universal Health Coverage (UHC). Discussions around UHC are contentious and as Tim Evans recently pointed out, “a lot of the discussion gets stuck on whether financing of the system will be through government revenue, through taxes, or through contributions to insurance.”
New approaches to medical care can improve health outcomes (Credit: World Bank, Flickr)
In many poor countries, a large proportion of health services is provided by the private sector, including services to the poor. However, the private sector is highly fragmented and the quality of services varies widely. Private health markets consist of providers with very diverse levels of qualification, ranging from formally trained doctors with medical degrees to informal practitioners without any formal medical training. According to Jishnu Das, in rural Madhya Pradesh— one of the poorest states in India, households can access on average 7.5 private providers, 0.6 public providers and 3.04 public paramedical staff. Of those identified as doctors, 65% had no formal medical training and of every 100 visits to healthcare providers, eight were to the public sector and 70 to untrained private sector providers.
On August 23th, in Santa Clara, California, I attended business plan presentations of 19 competitively selected social entrepreneurs, who delivered their pitches to a panel of experienced professionals plus a general audience. These presentations marked the culmination of the 10th annual Global Social Benefit Incubator (GSBI™) program organized by Santa Clara University. The Development Marketplace has been one of its partners since its beginning. The program includes intensive work by each entrepreneur with two to three designated mentors, and a series of on-campus classes. Its main objective is to strengthen material that each entrepreneur already has available, refine their business models and develop professional organizational documentation that can be presented to attract investors.