Wednesday, 29 February 2012

KNOTS blogger

KNOTS blogger


Posted: 28 Feb 2012 12:56 PM PST

If you are going to be at the Planet Under Pressure event in London in March, we would be delighted if you joined us for drinks at 5.30pm on the evening of Day 2 - Tuesday 27 March - to celebrate the launch of our Pathways to Sustainability book series, published by Routledge-Earthscan.

Melissa Leach, director of the STEPS Centre, will be at the event and we will be joined byJohan Rockström, executive director of the Stockholm Resilience Centre, who will say a few words.
As well as two new books in the series to discuss - there will be drinks and nibbles and plenty of opportunity to wind down and chat after a hard day's conferencing.
The STEPS Centre book series launch is taking place in the Connaught Room of the Ramada Docklands Hotel right next to the Excel Centre (so no Planet Under Pressure registration is required to attend our event) from 5.30pm, immediately following the close of the day's main conference sessions.

Monday, 27 February 2012

KNOTS blogger

KNOTS blogger


Posted: 27 Feb 2012 06:54 AM PST

The Center for Public Policy (CPP) at the Indian Institute of Management Bangalore (IIMB) and the STEPS Centre, with Infosys and climate3C, are hosting a conference to focus on "Risk, Competitiveness and Sustainability", challenging companies in India to embrace 'sustainable' business models in order to effectively meet business, social and environmental risks.

The conference is being held at Infosys in Bangalore, 27 - 28 February 2012.
More about the conference

Panel discussions and keynote speeches will make a case for a shift in attitude and to overcome the inertia towards 'sustainability' within businesses. Case studies will be presented by companies that have structured their business models around sustainability along with valuable insights and forecasts provided by environmental consultancies, global organizations, leading accountancy firms, universities and government. This event is sponsored by the UK-India Education Research Initiative (UKIERI) through a grant to the STEPS Centre and CPP.

The event follows a recent seminar on Biotechnology in Bangalore.

Friday, 24 February 2012

KNOTS blogger

KNOTS blogger

Urban Myths and Rural Futures for Africa’s Young People

Posted: 24 Feb 2012 04:20 AM PST

Are people in Africa really moving en masse in one direction - into towns and cities, - as commonly believed?

There are more young people in the African population than ever before – approximately 70% of Africa's one billion people is under the age of 30. Furthermore, continuing a long-term trend, many rural youths are reportedly choosing not to pursue livelihoods in the agriculture sector, especially as farmers. This story of young people apparently turning their back on farming forms a compelling narrative that is linked to others around de-agrarianisation in rural Africa and of entrenched, high and rising youth unemployment. The argument goes that the future for most young people lies not on the farm or even in agriculture, but in new jobs and new sectors in Africa's burgeoning towns and cities.

Young people and agrifood in Africa: is it time for some good old fashioned planning?

Posted: 24 Feb 2012 03:47 AM PST

Photo: Pakalinding farmers, The Gambia by gerrypops on Flickr

Has anyone yet properly analysed the human resources that will be needed in the agricultural sector in Africa in 10 or 15 years? And if not, why not?

Let me explain. If a government concludes that over a given planning horizon there will likely be a shortage of secondary school teachers, it might create additional incentives (bursaries, one-off grants etc) to attract young graduates to a one-year teacher training course. Similarly, if a manufacturing sector expects that a shortage of qualified engineers will hinder its future competitiveness, it might push government to expand the teaching capabilities of university engineering departments and then work to make engineering a more attractive career choice in the eyes of young people.

2012 Call for Proposals: Grant Awards for Global Environmental Change Research in Africa

Posted: 24 Feb 2012 03:33 AM PST

START's 2011 Grants for Global Environmental Change (GEC) Research in Africa are one-year projects in support of science-based research to build the capacity of individual scientists and their affiliated institutions in Africa.


Posted: 24 Feb 2012 01:53 AM PST

A decade ago, biotechnology was being hyped as the next big thing in Bangalore, India. Building on the successes of the IT sector, BT (biotech) was, it was argued, going to provide a platform for growth, innovation, job creation and more. So what happened next?

A recent seminar (programme here) jointly convened by the Centre for Public Policy at the Indian Institute of Management in Bangalore, the Association for Biotechnology Led Enterprises and the STEPS Centre, and supported by UKIERI, explored this question.

Debates focused on the trajectory of biotech businesses and the challenges of regulating biotechnology. This work builds on the long-running work by STEPS Centre members on the politics of policy surrounding biotechnology across the world. Ian Scoones, STEPS Centre director, who was at the workshop, has written some longer pieces about the issues (see below).

Related posts by Ian Scoones



Posted: 24 Feb 2012 01:48 AM PST

by Ian Scoones, STEPS Centre co-director

Biotechnology offers many potentials but also dangers. Regulation is clearly essential. But how, over what and with what measures is less clear. The debate about how to regulate emerging technologies associated with biotechnology is a hot one the world over. In India, it's about to become much hotter.

Photo: No to Bt Brinjal, from joeathialy on Flickr

In July 2011, the Biotechnology Regulatory Authority of India (BRAI) Bill (pdf link) was presented by the minister of science and technology to parliament. It has been long in the making, building on a series of commissions – on agriculture and health – led by Professors Swaminathan and Mashelkar in 2004 and 2005. The proposals contained in the Bill were the subject of a panel discussion at the recent seminar jointly convened by the Centre for Public Policy at the Indian Institute of Management in Bangalore, the Association for Biotechnology Led Enterprises and the STEPS Centre, and supported by UKIERI.

Everyone agrees that biotech regulation in India needs an overhaul. There are too many overlapping responsibilities, unclear mandates and lots of red tape. Regulatory delays result in losses of revenues for businesses, and the lack of transparency and unclear procedures are frustrating for applicants and opponents alike. The debacle over Bt brinjal (aubergine/egg plant), which dominated the headlines in 2010, illustrated the limits of the current system, with conflicting scientific reports and mismanagement of the process by the GEAC (Genetic Engineering Approval Committee). An independent authority with a clear mandate and streamlined procedures was supposed to get over the chaos and confusion that has dominated the regulatory scene in the past years. But will the BRAI achieve this?

Some argue that self-regulation and industry oversight is all that is needed. A light-touch approval process would speed up innovation, and allow Indian biotech to flourish. Surely, the regulation-sceptics argue, India can make use of regulatory approvals elsewhere in the world, and not get mired in repeat assessments locally. GM crops are often cited as an example. If Americans can eat Bt foods, why not Indians? they argue. Equivalence and harmonisation should characterise an internationalised regulatory system, with simplicity and efficiency as the watchwords.

No-one at the seminar argued this way, however (although there are still plenty who do). Instead, seminar presenters argued that regulation is essential. Vijay Chandru (Strand Life Sciences) argued that the "genie is out of the bottle". Biotechnology is massively powerful, but also potentially hugely dangerous, he said. We are only on the cusp of realising some of its potentials, with sequencing times reducing dramatically and costs halving every five months. The initial sequencing of the human genome cost $2.7bn, while today it can be done for about $1000, he claimed. Before long, what he dubbed "home-brew DIY genomics" will be possible, with DNA printers able to reveal full human gene sequences for a few hundred dollars. "There are obvious dangers", he observed. Take synthetic biology – new organisms including lethal viruses could be manufactured. "We really need to have a good regulatory process in place", he noted. "And we need to do it soon, or there will be all kinds of chaos".

So what are the key ingredients of a regulatory system? Efficiency and cutting down on red-tape is important for sure. And so is the sort of expert "domain knowledge", emphasised by Ravi Kumar (XCyton). Good information, based on solid science, outlining all the uncertainties is essential, he argued. Avoiding what he termed "the agony of local clearance" was a must. A "clean slate" was needed, he said, as "the current system is just not working". But for regulation to have purchase, and to be regarded as legitimate and authoritative, it must also be trusted. An "all powerful" institution, no matter what its high-sounding aims are at the beginning, will, Ravi Kumar argued, be corrupted in time. Today, he commented, "we suspect every institution and its integrity". The lack of faith in public regulatory institutions is of course not just an Indian experience. This has happened in Europe and elsewhere. Rebuilding trust is essential. And the global lessons suggest that this requires a solid commitment to public participation and democratic accountability. As the seminar discussed, it is on these issues in particular that the BRAI proposals remain severely lacking.

Leo Saldhana (Environment Support Group) presented the results of a comprehensive critique of the Bill he undertook with his colleague, Bhargavi Rao. The critique is damning on a number of fronts. The proposed BRAI is seen to centralise authority; mix sector promotion with regulation, creating a conflict of interest; be democratically unaccountable, failing to recognise the multiple tiers of government; be excessively reliant on narrow technocratic expertise; override other important legislation (including the Right to Information Act); and ignore public concerns, making objection and protest impossible. Their recommendation is that the Bill is potentially unconstitutional and should be rejected. The paper provides the details, but the panel and plenary discussion that ensued concurred that "a major rethink is required". Vijay Chandru suggested that an alternative "marked up" version of the Bill be produced, and submitted to Parliament.

Like so many other attempts to streamline regulation in favour of industry interests in order to promote efficiency and growth, the BRAI Bill appears to fall into the same traps. It assumes that democratic deliberation on alternatives, and the risks and costs of each, represents an inefficient 'bottle-neck', rather than a necessary way of creating public legitimacy for regulatory decisions. It sees only one narrow form of expertise as necessary, rather than a more inclusive approach that recognises diverse, plural views, including those of the public. It frames the response in terms of 'risk', assuming that probability of outcomes are known and can be managed technocratically through expert decision-making, rather than recognising uncertainty or deeper ignorance as the norm. Under such situations, a precautionary approach is required, which acknowledges we often don't know what we don't know - especially when the "genie is out of the bottle". It creates unaccountable governance arrangements that actively exclude public participation, which is seen as a time-wasting diversion from the important priorities of growth and economic progress. But in a vibrantly democratic country like India, avoiding public debate, as the experience of the past decade has shown, is not an option. Inclusion, participation, accountability and democracy must be central to any regulatory system. Many at the seminar agreed that a top-down, elitist, technocratic, expert led system will not, in the end, serve industry or the public well.

The dilemmas are well illustrated by the regulatory debate surrounding Bt brinjal (genetically modified aubergine) which exploded during 2010. Public disquiet about the first GM food crop was heightened by the fact that brinjal is a widely used vegetable, of significant cultural and biodiversity importance. Scientists too were divided on the interpretation of the safety tests, and, as ever, Monsanto mishandled the public relations fomenting media debate and public concern. The then minister, Jairam Ramesh, decided that public involvement was vital, and hosted a series of well-attended 'town hall' debates across the country. Some dismissed these are populist political theatre, captured by an elite middle class group of environmentalists and campaigners, who did not have the views of farmers in mind. Others regarded this move as a brave shift to wrest the control of the regulatory process from a scientific elite, captured by industry. In reality it was probably a bit of both; but the overall outcome was important, not only for the specific Bt brinjal case, but for Indian biotechnology regulation overall. Minister Ramesh provided a statement in February 2010 "in order to ensure complete transparency and public accountability":

" is my duty to adopt a cautious, precautionary principle-based approach and impose a moratorium on the release of Bt-brinjal, till such time independent scientific studies establish, to the satisfaction of both the public and professionals, the safety of the product from the point of view of its long-term impact.... "

Here two important moves are made by the Minister. He argues for a precautionary approach, accepting uncertainty, and he argues that publics must be involved in assessing the evidence. Both these principles are essential for any regulation of any technology where risks are real but also uncertain.

It appears that the BRAI Bill has not taken on board these lessons, but it would be wise to do so. It is to be hoped that the democratic deliberations in the Indian parliament, as well as any of the legal challenges which will undoubtedly follow, will help to create the appropriate revisions to make a more effective, democratic and accountable regulatory system for Indian biotechnology.

This posting includes an audio/video/photo media file: Download Now


Posted: 24 Feb 2012 01:30 AM PST

By Ian Scoones, STEPS Centre co-director

A decade ago, biotechnology was being hyped as the next big thing. Building on the successes of the IT sector, BT (biotech) was, it was argued, going to provide a platform for growth, innovation, job creation and more. So what happened next?

Picture: BT cotton, by nostri-imago on Flickr.

A recent seminar jointly convened by the Centre for Public Policy at the Indian Institute of Management in Bangalore, the Association for Biotechnology Led Enterprises and the STEPS Centre, and supported by UKIERI, explored this question.

Certainly the hype around biotechnology has not gone away. The Karnataka State Government's website proclaims:

"Karnataka has emerged as an undisputed investment destination for investors worldwide, offering vast business opportunities across sectors....Its capital, Bangalore, now a global brand has the largest biotechnology cluster in India, aptly named as Biotech Capital of India. Bangalore has sky-rocketed into the new millennium. A pulsating megapolis, a haven to IT-BT and Fortune -500 companies and today the world's most preferred investment destination".

But what are the realities behind the spin?

At the seminar, Ian Scoones (STEPS Centre) reflected on some of the changes over the past decade since he carried out research on the emerging biotech sector. Across India the sector has certainly grown. According to the Biospectrum-ABLE survey of 2011, it crossed the $4bn revenue mark. But it did not grow as fast as expected, nor create as many jobs. The 'big hit' patents promised a decade ago as part of the pipelines of the start-ups did not materialise, and regulatory challenges have continued to plague the industry.

That said, some important successes have been recorded. Biocon, the flagship biotech company in Bangalore led by Kiran Muzumdar Shaw, has gone from strength to strength. A massively oversubscribed flotation in 2004, has led to year on year growth since. Overall, the biotech sector has grown around 20% each year, even through the global downturn of the late 2000s. A comparison of the 'top 15' companies (see slide 11 of Ian Scoones' presentation) by total revenue in the sector in 2003-04 and 2010-11 shows a dominance of home-grown companies. A noticeable trend has been the growth of the agri-biotech sector. A decade ago, Bt cotton was formally released by Monsanto-Mayhco, and has since expanded on a massive scale, with a whole array of companies taking on the proprietary genetics and incorporating it into their germplasm. The result is that in 2010-11, a third of the 'top 15' biotech companies in India are trading Bt cotton.

However, with a few exceptions (perhaps only Biocon, Serum Institute and Panacea Biotec), most biotech companies remain small, dependent on external alliances, and in the case of agri-biotech almost completely reliant on Monsanto's Bt technology. So what happened to the discovery and innovation model that was touted in 2002, whereby local companies would grow on the basis of new technologies, fostered through R and D investment? This has happened in important areas, however, the big breakthroughs have not emerged. As Vijay Chandru (Strand Life Sciences and ABLE) put it "There has been no second Biocon".

Why is this? Is the Bangalore biotech innovation system somehow deficient, or is this a normal pattern, reflected elsewhere in the world? The seminar discussion reflected on this. Certainly in the US, the biotech sector is dominated by a few big companies, with many others supporting these in a highly dynamic, fast-turnover setting. Technology clusters are supposed to be the drivers of growth, drawing on geographical synergies, links to academic establishments and strategic state investments. Has this happened in India? In India, clusters have emerged – in Bangalore, Hyderabad, Mumbai, Pune and elsewhere – but how dynamic have they been? Participants at the seminar suggested that it is taking time for such clusters to mature, and that distinct comparative advantages are only now being found. There were mixed views on the benefits of competition between clusters – say between Bangalore and Hyderabad – and a sense that the full advantage of proximity to top-rank scientific institutions was not being realised.

Indeed, one of the big selling points of Bangalore as a biotech destination has always been the presence of the prestigious Indian Institute of Science and the National Centre for Biological Sciences, along with whole host of engineering and technology colleges. Top flight scientific expertise in the biological, information and engineering sciences should, so the theory goes, result in greater innovation capacity. While moves have been made at IISc, NCBS and elsewhere to link basic science with commercial applications, this has only influenced the culture and practice of science in such institutions at the margins over the past decade, and the links between science and business remain weak.

And what about the application of science for development? With the science-business model being influenced by funding flows, patent ownership and market control, the opportunity of biotech businesses to develop technologies responding to the massive local needs of poverty, ill-health, poor environmental conditions, agrarian distress and so on remain structurally limited. The Prime Minister, Manmohan Singh, argued at the Indian Science Congress in January 2012 needs to begin "grappling with the challenges of poverty and development". He continued:"It is said that science is often preoccupied with problems of the rich, ignoring the enormous and in many ways more challenging problems of the poor and the underprivileged". Innovation, he argued, should be for social benefit, not just for profit.

These are fine words. They are often repeated in the Indian context where poverty and inequality continue to grow, while the GDP shows 7% (or more) growth rates. In India, there is a vast demand for low-cost, appropriate biotechnologies in India, and many of those at the 'bottom of the pyramid' can increasingly afford them. A growing middle class also has new demands – there are, it was noted, 50m diabetics in India. However, the current structure of the biotech industry, with some notable exceptions, cannot respond to these demands. The patents are held by the big companies, the financing is geared to northern markets, and the technological and business capacities are influenced by a US/European model.

So what new 'inclusive' innovations exist? As Ravi Kumar from XCyton explained, medical diagnostics is an important growth area, improving the effectiveness of public health responses, and reducing patient costs. The potentials of portable PCR kits for diagnostics in rural health care are significant, for example. Equally, as Vijay Chandru pointed out, there are growing potentials in the field of 'biosimilars' (off-patent generic biological compounds). Low cost production of important pharma products may well open up, Chirantan Chatterjee (IIM-B) explained, as hundreds of important products are released from patent restrictions in the next few years. The market in biologics is estimated to be around $270bn, with huge potentials for the development low cost alternatives. Indeed, as Vijay Chandru observed, while 'Brand India' (and perhaps particularly Bangalore) is dominated by the IT sector, perhaps the greatest global contribution in the technology field over the past few decades has been the development and supply of low-cost generic drugs to the world.

How then can a more appropriately Indian biotech sector emerge? There has been much talk of state support and investment, the 'midwifery' that Peter Evans talks of. But has state support been well directed over the last decade? Most believe it hasn't. The Bangalore Helix Biotech Park has been plagued by controversy, and has only just got off the ground. State support for early financing has improved, but what about the next-stage financing?, participants asked. In a complex industry like biotech, returns are often slow and uncertain. The parallels with IT and the software development successes of Infosys, Wipro and the rest are inappropriate, it was argued. While there has been renewed interest in 'state capitalism' because of the models of China and Brazil, Bangalore has long had a tradition of state support to emergent industries. The Dewan of Mysore, Ishmael Mizra, commented in 1926:

"We in Mysore have always been alive to the economic functions of government and have endeavoured, where there was any practical hope of success, to aid and encourage the growth and the starting of new enterprises by private capitalists and in special cases to undertake their complete management. The main objective has been, not merely to increase the wealth of the state, but to provide the technical ability and business acumen which form so important a part of the nation's wealth".

Biotech in Bangalore retains the hype and much of the hope of a decade ago. Today, however, commentators are more sanguine about the potentials. The sector is clearly thriving, but in a different way to what was envisaged. As Chirantan Chatterjee explained, more hybrid science-business models are emerging which switch between innovation/discovery and generics imitation/contract research. This may be a more realistic expectation, and one that can capture the potentials of biosimilars production, genomics-based diagnostics and more. However, direction of innovation remains a concern, as well as the diversity of applications and the distribution of benefits. The seminar concluded that much more could be done by states and the union government to build the industry, incentivise entrepreneurs, foster links with the diaspora, forge links between science, engineering and management training, protect and support emerging companies, and direct innovation towards the principles that the Prime Minister talks about - inclusivity, poverty reduction and sustainability.

Tuesday, 21 February 2012

KNOTS blogger

KNOTS blogger


Posted: 21 Feb 2012 07:47 AM PST

A new IDS Bulletin, published on 2 March, will focus on STEPS work on water and sanitation. Entitled "Some for All? Pathways and Politics Since New Delhi 1990", it brings together papers from participants at our 2011 Water Symposium, including Barbara Frost, Gourisankar Ghosh and Kamal Kar.

A selection of papers from the Bulletin will be available to view online, for free, for one month from March 2.

We will be launching the Bulletin at the World Water Forum in Marseille with a side event on Thursday15 March at 7.15pm focusing on wellbeing and equity in water and sanitation.

Jeremy Allouche, Lyla Metha and Alan Nichol, from the STEPS Centre, will talk about the Bulletin, and why they wanted to revisit 'Some for All', followed by a panel discussion and an audience debate. Drinks and nibbles will be available. So if you are going to be at the WWF in Marseille, do come along and join us.

Saturday, 18 February 2012

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KNOTS blogger

Food price volatility - debating causes and consequences

Posted: 17 Feb 2012 12:05 PM PST

by Stephen Spratt, Institute of Development Studies

On 6 February 2012 the Future Agricultures Consortium and IDS hosted a workshop on food price volatility and financial markets. We posed three questions:

Why does volatility matter?
What impact, if any, do financial speculators have?
What, if anything, should be done about this?

The mining boom: will residents of mineral rich countries benefit?

Posted: 17 Feb 2012 04:10 AM PST


As part of my ongoing work investigating health markets and the role of non-state actors in provision of health services, I am involved in a project concerning the role of mining companies in supporting the provision of health services to their employees and the wider community in mineral rich countries. This provided me with the opportunity to participate in the Mining Indaba 2012 in Cape Town in early February. This is an annual event for managers of mining companies, financiers, officials of multi-lateral organisations and Ministers from many African countries. The meeting was an eye-opener.

I had not been sufficiently aware of the magnitude of the present boom in the demand for minerals, which seems to be associated with rapid economic growth in many low- and middle-income countries and the enormous investments being made in the infrastructure of many large cities.

I was impressed by the size of investments being made in a number of African countries. Several new finds will provide large revenue streams for many years. There was a lot of discussion of ‘resource nationalism’, stimulated by high mineral prices. There was a view that companies need to earn their ‘licence to operate’ over the many years needed to recoup the large investment in a new mine. This was seen to involve much more than ‘traditional’ investments in corporate social responsibility.

Mamphela Ramphele, who chairs the Board of Gold Fields, presented a vision of a partnership between large corporations, community social investment organisations and national and local governments aimed at solving major problems with the provision of education, delivery of health services and the development of communities where mines are located. She called on large mining companies to play a leadership role in helping governments address these problems, suggesting that they operate on a time frame longer than the usual political cycle.

The unspoken alternative, of course, was the possibility that calls to nationalise mines could gain political support and that mining companies from countries where demand for minerals is growing rapidly might be potential partners for joint ventures with governments.

The take home message from the Indaba is that we are in the midst of a major mining boom. If mining companies, governments and civil society organisations can create effective partnerships for development, many people living in mineral rich countries will benefit a great deal. Otherwise, we may be witnessing another turn in a boom and bust cycle that enriches few and leaves many more in poverty.

[EDITOR'S NOTE: This blog originally appeared on the IDS Globalisation and Development blog. See also the IDS Globalisation Team’s Business and Development seminar series. Three of the five seminars under last autumn’s theme ‘Conflicting Interests: How Businesses Operate in Areas of Conflict’ focused on mining.]

Health dragons or health hydras? The challenges of regulation in Asian health systems

Posted: 18 Dec 2011 10:45 PM PST

Dr Asha George of JHSPH discusses rural medical practitioners in India at HSRA


Like most aspects of life in Asia, health systems have undergone massive changes in the last twenty years. And if we’ve seen some economic dragons, we’ve also seen some health dragons – with several countries posting impressive gains in health outcomes. For example, official figures indicate China has already achieved MDG 4 by reducing infant mortality rates from over 50 per 1000 live births in 1991 to under 14 in 2009, while under-five mortality has also dropped from 61 per 1000 live births in 1991 to just over 17 in 2009.

But ‘health dragons’ doesn’t quite capture the full picture. For the most part these changes have not been happening as a result of a controlled change process. Rather, they’ve been emerging from the diverse, unguided responses of some of the most populous countries in the world. This means they look more like another mythical creature: the many-headed hydra. 

This was made very apparent at this year’s Health System Reform in Asia conference held from 10-12 December at Hong Kong University. Organised by Elsevier and their journal, Social Science and Medicine (be on the lookout for a special issue from the conference out in 2012), the conference brought together some of the biggest names in health systems in Asia. The organisers of the 2nd Global Symposium on Health System Research, which will be held in November 2012 in Beijing, had a strong presence, for example.

As I presented at the conference, the story of the Indian health system is a good example of the health hydra. Following significant economic reforms in the 1990s, the private sector soon outstripped the public in terms of health service provision – not only in hard-to-reach rural areas, but even in major urban hubs. Utilisation of in-patient care by private providers, for instance, jumped from less than 40% in the late 80s to more than 60% in the last decade. And outpatient care has even higher private sector penetration at roughly 77% across the country. 

Of course, when I say the ‘private sector’ the majority of those providers, especially in the outpatient care market, have little to no formal medical training. My colleague at JHSPH, Dr Asha George, presented a more detailed discussion of who these informal ‘rural medical providers’ are and why they play such an important role in the Indian health system. And indeed, the Future Health Systems consortium has a substantial body of work on the role of informal providers not just in Bangladesh and India, but also in Nigeria.

Our recent study of health care service provision in the Sundarbans of West Bengal paints an even messier picture. In addition to the publicly funded health clinics and hospitals and the raft of informal providers, the area is also serviced by an array of both local and international NGOs. Coupled with rapid advances in health technologies and pharmaceuticals – not to mention a fragile environment susceptible to frequent climate shocks, like Cyclone Aila which devastated the area in 2009 – it’s easy to understand how the system became so complex. 

But this poses a significant challenge: how can we improve these systems, with all their perverse incentives, to better serve the poor? In other words, how can we better regulate these health markets?

One phrase that kept popping up throughout the conference was the idea of ‘command and control’ – that through strong government intervention we could make significant and intentional changes in the way these health systems worked. But there was an even larger group who suggested that, when working in complex adaptive systems, ‘command and control’ is inefficient. There are simply too many interconnections that we cannot understand, which lead to a variety of unintended consequences when we intervene in these systems. 

Finding a model that works somewhere between ‘command and control’ and utter chaos was one of the challenges my colleague at IDS, Dr Gerry Bloom, put forward to the conference.

This led to a lot of discussion about ‘poly-centric governance models’, where the challenge of regulation doesn’t lie simply in the hands of the government. Rather, the argument goes, we must be working on all fronts: institutionalising professional bodies and standards to promote self-regulation in the private sector; establishing patient support groups – like the diabetes-related peer group MoPoTsyo in Cambodia – and improving their access to health information; and recognising non-traditional actors as part of the health system.

We tend to overlook the role that non-traditional actors, like social change entrepreneurs, the media and advertisers play in health markets. However, Dr Sachiko Ozawa’s presentation on trust in injections in Cambodia underscores this point. The average Cambodian receives six injections per year, usually because they think injections are more efficacious than other forms of treatment (e.g. oral tablets). This is such a firmly held belief that often patients will seek care outside of the formal sector (who usually deny inappropriate injections) to get what they want. Although her research didn’t delve too deeply into why there was such misplaced trust in injections, it might be at least in part due to substantial vaccination education campaigns from public health advocates. Working with media and advertisers will be an important part of improving knowledge here about appropriate use of injections.

They say that the best way to fight fire is with fire. Perhaps this ‘poly-centric governance structure’ is attempting just that – fighting hydra with hydra. I would expect to be hearing much more about what this model might look like in different Asian contexts in the near future.

CHMI highlights five emerging models for health service delivery and financing

Posted: 30 Nov 2011 06:43 AM PST


New approaches to improve health access and quality being pioneered by Future Health Systems

6000 Ugandan women die every year from preventable pregnancy and childbirth related complications. If women could only deliver under skilled care, about 80 percent of these deaths could be prevented. Enter Future Health System’s Safe Deliveries initiative: The program offers vouchers for transport and maternal services as well as training for health workers and provision of essential equipment, drugs and supplies. Its impact? The number of facility deliveries more than tripled during the pilot phase.

Vouchers are an example of a ‘health market innovation,’ a program that harnesses the private sector in low- and middle-income countries to deliver better health and financial protection for the poor. While many governments promise well-functioning, state-run public health systems, what often happens is much more chaotic and less centrally managed, with patients seeking care from a plethora of providers, including drug shops, village doctors, non-governmental organization (NGO) clinics, private hospitals, as well as government clinics.

Health market innovations help health systems improve quality, access, affordability and efficiency in transactions between patients and providers, promoting better health with less financial risk, especially for the poorest and most vulnerable. In 2010, the Center for Health Market Innovations (CHMI) was launched to serve as a global information source on these programs and policies—implemented by governments, NGOs, social entrepreneurs or private companies—that have the potential to improve the way health markets operate. 

With eight partners based in 16 countries, CHMI has identified more than 1000 programs in 108 countries—including several programs FHS studies.  These programs work to: 

  • Better organize fragmented providers
  • Mobilize funds and create financing mechanisms to provide purchasing power to the poor
  • Set quality standards and monitor provider performance
  • Educate consumers and providers to ensure that appropriate care is both demanded and provided
  • Enhance quality and efficiency through standardized operational processes and innovative information technologies

In its 2011 Annual Highlights Report, CHMI identified five innovative emerging models that show promise, and may ultimately improve the performance of health markets in low- and middle-income countries.


1. Low-cost, high-quality retail pharmacies

Small family-owned drug shops line the streets of cities and villages across low- and middle-income countries. Unfortunately the quality of their offerings is equally all over the map, with many shops offering counterfeit drugs that don’t work and can be toxic. Professionalized pharmacy chains and franchise networks proliferating in Asia may improve drug quality and operational efficiency to keep prices low. In the Philippines, Botika ng Bayan and Generics Pharmacy are two popular franchise networks that have seen success. Similarly, in India, the pharmacy chain MedPlus originated in tech-hub Hyderabad and has since spread nationally.


2. Affordable Primary Care Clinic Chains

These chains—often for-profit—are set up to standardize quality and give low-income people more care options. Many chains operate in urban areas where large volumes can help them keep prices down. Inspired by the U.S. drug store chain CVS and its Minute Clinics, Saúde 10 opened in 2011 in Rio de Janeiro, Brazil. In Nairobi, LiveWell's main clinic provides consultation, diagnosis, and treatment for a wide range of illnesses, while qualified clinical officers and registered nurses run satellite clinics. 


3. Vouchers

Vouchers—distributed for free as with FHS’s Safe Deliveries project in Uganda, or sold for a small fee, as with Kenya’s Output Based Aid Voucher Program—increase access to key health services by allowing low-income people to “purchase” (through demand-side donor or government subsidies) a specific package of services from approved clinics which often include both public and private facilities. Private maternity clinics have been able to expand their services and extend their customer base to poorer clients as a result.


4. Telemedicine

In many countries doctors and specialists cluster in urban areas leaving rural areas underserved. Telemedicine shows promise in bridging the rural-urban health divide. In one example of how this model works, World Health Partners is a promising not-for-profit chain using technology that allows doctors in urban areas to monitor vital signs, diagnose illnesses, and recommend treatment for patients in India’s rural north.


5. Health Hotlines

Health hotlines provide basic health information and connections to available health services. HealthLine — run by Dhaka’s Telemedicine Reference Center, an FHS partner — connects providers and patients in Bangladesh through a mobile phone based hotline number (789) to a call center manned by licensed physicians that provide medical consultations 24/7. MeraDoctor is a for-profit health line just launched in Mumbai. Popular throughout South Asia, these well-utilized businesses may soon be replicated in East Africa.


These models offer promising solutions to key health system challenges, but the question remains: do they really work in the long term? What programs are actually improving quality, affordability, and access? We look forward to working with Future Health Systems and other partners to collect and share better evidence, and then promote the scale-up and replication of high-impact programs. 

M4P Hub Conference proceedings series: Making informal health providers work better for the poor

Posted: 22 Nov 2011 09:30 AM PST

EDITORS NOTE: This blog is a repost from the M4P Hub Conference news.


My presentation at the M4P Hub Conference reflects work by several members of the Future Health Systems Consortium on the implications of the rapid spread of markets for health-related goods and services.  These markets are complex with a variety of sellers of health related goods in terms of ownership, mission, reputation and relationship to the regulatory system. Poor people frequently use providers in unorganised markets. Studies in Nigeria and Bangladesh found that more than half of people seeking treatment for malaria in the former used a patent medicine vendor and sixty-five percent of people who visited a health provider in a rural district in the latter went to an informal village doctor. In both cases there were serious problems with safety, effectiveness and cost. The behaviour of informal providers of drugs and health services is influenced by their source of knowledge (formal training, informal apprenticeships, advertising, marketing by drug wholesalers and so forth), financial incentives (including profits from selling drugs and commissions from drug wholesalers) and strategies to build and maintain their reputation. In both countries, interventions sought to convince informal providers to pay more attention to the quality of drugs and appropriateness of prescriptions through training and the involvement of trade associations and local government leaders in measures to monitor their performance and build their reputation. Governments and other stakeholders need to find effective ways to engage with pervasive health markets to protect the interests of the poor.
The following lessons should be taken into account:
  • Interventions should be based on an analysis of the market system including the drug distribution network and the growing role of knowledge intermediaries, such as mobile telephone companies.
  • Effective interventions are likely to involve partnerships between organisations with different agendas and different capacities.
  • ustainable interventions need to include realistic business models for informal providers and for other intervention partners.
  • Politics and interests strongly influence outcomes when going to scale and effective strategic leadership is needed.
Dr Bloom describes the response at the conference: “There was a lot of discussion about whether the special characteristics of the health sector mean that the M4P approach is not applicable to it. We discussed how unregulated markets for health-related goods and services can expose individuals to risk from dangerous or ineffective treatment and also lead to the emergence of diseases that are resistant to the available drugs. We also discussed the many ways that health markets are similar to markets in other sectors. We agreed that the design and implementation of interventions to improve the performance of health markets needs to combine expertise in health and health systems with expertise in engaging with markets. There was some discussion of the difficulties in combining these approaches. However, there was general agreement on both the magnitude of the health problems in many low income countries and the degree to which health markets have spread in them. We concluded that it is time for serious work to develop practical approaches for improving the performance of health markets in meeting the needs of the poor”.

Complexity, complexity, complexity

Posted: 03 Oct 2011 06:04 AM PDT


‘Simplicity, simplicity, simplicity!’ The mantra may have worked for Henry David Thoreau as he sat around Walden pond, but there’s a growing recognition within the health systems, development and humanitarian relief communities that ‘complexity, complexity, complexity’ is more appropriate these days. Complexity science isn’t new, but applying it in these fields is relatively recent. My new paper with Ligia Paina, ‘Understanding pathways for scaling up health services through the lens of complex adaptive systems’, begins to unpack the implications for health systems if we take a complex adaptive system (CAS) lens to understand initiatives and scale up health services.

And while this blog looks at how a CAS approach can help us design and deliver better programs, Ben Ramalingam (a visiting fellow at the Institute of Development Studies and an expert on complexity science) and I have also recently sat down with Jeff Knezovich from FHS to produce a podcast looking at the issue in more depth. You can listen to the podcast below.



Complex adaptive systems are described as such because, in addition to being comprised of many interacting components and agents, they have the capability to self-organize, adapt or learn from experience – what are sometimes known as emergent properties. Most social, biological and economic systems can be considered CAS, as well as many complex physical systems, such as those related to weather. The interactions of system components are non-linear, and are not easily controlled or predictable in detail.

Whereas scientific enquiry attempts to simplify understanding and create simple and elegant solutions, the CAS approach is important, as often our simpler models just aren’t good predictors of behavior. X doesn’t necessarily lead to Y, and indeed it might not even lead to one specific point. This can be a big problem when planning interventions.

Keeping a few CAS concepts in mind while framing projects and programs can certainly help improve them. In the paper, we look at several of these concepts and how they can be applied to health systems. In particular we look at: emergent behavior, path dependency, feedback loops, scale-free networks, and phase transitions. I encourage you to read the paper or see my presentation for more information about these concepts.

Focusing on ‘emergent behavior’, the first phase of FHS has shown us why this is important. The ‘Safe Deliveries’ intervention, which was led by the FHS Uganda team at Makerere University, worked both on the demand-side and supply-side to improve access to institutional deliveries in rural areas of Eastern Uganda. On the supply side, it led trainings for health workers and provided essential equipment, drugs and supplies. On the demand side, the program organized a significant voucher scheme for both maternal and newborn services (including antenatal screenings, delivery and newborn care) and for transport to clinics via boda boda (motorcycle taxis), as transport to facilities was a big factor preventing institutional deliveries. 

One of the interesting – if unexpected – things to happen, was that the boda boda drivers actually organised themselves in such a way that they started to keep track of and encourage pregnant women to go for care. Obviously there was a built in financial incentive, but this level of ‘enforcement’ had not been planned for – it emerged from the complex system. More importantly, it ended up playing a significant part in tripling the average monthly number of births in facilities.

All of these phenomena have an implication for what it means to create change. What a CAS approach tells us is that, when designing and delivering programs, we need to:

  • Plan differently: Don’t expect to control change. Expect complexity. Expect emergent behavior (and feedback loops, and all those concepts I mentioned above) and expect the unexpected. This means looking beyond where a typical research program might be shining its light. In a complex adaptive system, a specific intervention is likely to cause shifts in other parts of the system, whether it’s through displacement or new actors or something else. In order to keep an understanding of what is happening in other parts of the system, this may also mean involving a wide number of stakeholders in both the planning process and the implementation phase.
  • Plan to re-plan: We need to avoid too much of an emphasis on the first planning cycle and get away from blueprints. Detailed planning almost never works, and if it does, it probably didn’t need to be planned for in the first place. Allow for course correction by creating mechanisms that allow ‘learning by doing’. One approach to this might be to create more iterative, rapid learning cycles. This might include changing an intervention or, in research, changing what is being measured.
  • Use mixed-methods research approaches: Having multiple perspectives and multiple methods helps to better identify changes in a system. Working with complexity is a data rich process. Having good access to information, and from multiple sources, makes it easier to make relevant decisions. Don’t just ask whether or not something works, look at how and look at why – both of which might be important for scaling up the interventions.

These are principles that we’re trying to embed into the next phase of the Future Health Systems project. Already we’ve had a training workshop with our FHS China team in Beijing to orient them to the approach and to help them make sure their research design incorporates some of these ideas. 

If you’re interested in finding out more about our growing body of work on complex adaptive systems, visit our theme page for more resources.

The future of Future Health Systems

Posted: 28 Jul 2011 12:07 AM PDT


Future Health Systems (FHS) entered its second phase at the end of 2010 with a new six-year, £7.5 million grant from the UK Department for International Development (DFID). In the roughly eight months from the beginning of our inception planning, we find ourselves in a fundamentally different world. 

In late January, we saw the Arab Spring blossom across northern Africa and into the Middle East. We’ve seen both Europe and the US locked in a series of debt crises. And we continue to see the emergence of new technologies that are changing lives around the world – sometimes emerging from unexpected places. The locus of global transformation is largely shifting to large middle-income countries like China and India – two countries where FHS has strong institutional partners, CNHDRC in China and IIHMR in India.

During our inception phase, we’ve been seeking to ensure that FHS has a strong foundation to succeed in these shifting sands. At its core, the next phase of FHS will be addressing the question of how we can get new services and technologies out to the most vulnerable in a way that is sustainable and scalable.

We’re excited to be working towards that objective through three cross-cutting themes:

  1. Unlocking community capabilities – The Arab Spring is a testament to the power of civil society to generate change and hold governments accountable. And while those grand revolutions were happening at the national level, we’ve been witnessing the same power on a smaller scale at the community-level. Community involvement is a core part of health, health promotion, and health service delivery. But often we’ve thought about the role of communities in quite a traditional way – with community health workers or village health committees. The next phase of FHS is interested in thinking more about how we can engage less traditional actors – like informal health care providers, but also those who have resources of one sort or another, whether that’s motorbikes that can help get pregnant women to hospital (like MakSPH have promoted in Eastern Uganda), or whether it’s access to information that can help transfer health knowledge and hold health system actors to account.
  2. Stimulating innovation – Innovation in health systems takes many forms, from technical innovations – like new products and new vaccines – to organizational innovations and new ways of working. This phase of FHS is interested in understanding how to encourage the uptake of those innovations across health systems. This will involve learning from what’s going on and sharing innovation across innovators about what’s working and what’s not working. Our partner in Bangladesh, ICDDR,B, is on the cutting edge, working with telemedicine centers and other new technologies to extend the reach of formal health services to rural poor.
  3. Learning by doing – Health systems are complex, dynamic, adaptive systems that change and respond to individual actors and external events. Because of this, we think it’s important to look at how actors within health systems learn, how knowledge spreads across health systems, and how we can adapt our interventions to changing circumstances.

FHS has always been future-oriented – it’s in the name. But before we embark upon this new journey, it’s also important to take stock of the successes of the first phase of the program. I encourage you to look at our stories of success from Uganda and Bangladesh.

One of the things FHS became known for in its first phase was its work on health markets, especially around the role that informal providers play. FHS helped us understand how the likes of rural medical practitioners and drug vendors work and how they engage with the rest of the health care system within a country. Although we’re in a transition phase, this work continues and is clearly represented in some of the recent journal articles produced by FHS researchers, especially in a special supplement to Health Policy and Practice on the private sector in health.

We look forward to building on this strong foundation going forward. When this phase of FHS started, we couldn’t predict the ensuing global changes. And as the program continues, this will continue to be the case. But by building in learning mechanisms and tracking these changes, we’re confident that we will be as relevant in five years as we are today.

Blog roundup from iHEA 2011

Posted: 13 Jul 2011 06:16 AM PDT

In addition to Future Health Systems, several other large-scale projects have been sharing their thoughts and reactions to the 8th World Congress on Health Economics (iHEA 2011).

The Center for Health Market Innovations (CHMI) has recently posted two interesting blogs from the event. The first blog provides an overview of some interesting sessions and presentations. They highlight two from FHS:

The second blog is a guest post by Birger Forsberg on a special issue of Health Policy and Planning that looks at the role of the private sector in health. FHS also contributed to this special issue, with an article entitled 'Making health markets work better for poor people: the case of informal providers'.

The SHOPS project posted about their participation in the pre-congress session on Private Sector in Health.

Karen Grepin (NYU) has also been actively sharing her reactions to various iHEA sessions, both on Twitter and on her blog. She too highlights the pre-session symposium on the private sector in health and reviews the special issue of Health Policy and Planning. She notes that all presentations from the symposium are available at Dominic Montagu's (UCSF) website, 'Private Healthcare in Developing Countries'.

Jed Friedman of the World Bank focuses more on pay-for-performance innovations in health systems, citing presentations from Rwanda and the Philippines.

From private sector to health markets

Posted: 10 Jul 2011 08:45 AM PDT


At a plenary discussion during the iHEA pre-congress session on 'the Private Sector in Health', Gerry suggests an important reframing of the terms of engagement. No longer are we talking about working with the private sector, but rather we are now 'engaging with health markets'. In the video below he looks to the future and suggests that we must focus on regulatory frameworks and the shift in the locus of innovation, especially to rapidly growing middle-income countries.

Going to Extremes

Posted: 09 Jul 2011 10:20 AM PDT

BY DR. DAVID BISHAI, Johns Hopkins Bloomberg School of Public Health

In his plenary speech on July 9, 2011 to the iHEA pre-session on Private Sector in Health in Toronto, Tim Evans, Dean of BRAC University of the Health Sciences, laid out the poles of the debate on universal access to health care.

At one extreme there would be model of all medical care financed and delivered by the state. At the other extreme there would be no state intervention in private markets for health insurance and medical care.  What is supposed to happen next, according to the standard script of the dialectic, is a triumphal arrival at the golden middle.

However, something has derailed our arrival there.

Neither pole is especially attractive or realistic.  The discussion should have moved on by now. Why does this unnecessary “either-or” debate go on and on?  In my opinion the explanation lies in the advantages of being provocative.

Passion and enthusiasm are critical parts of the communication of ideas: The heat generated by an  idea is inverse to its distance from the middle.

By “heat”, I mean the ability of an idea to generate the excitement of journal editors, conference organizers, and bloggers.  With heat comes a desire by those in agreement to start movements and finance studies. With heat also come movements and finance by those opposed. In the past the mutual desire for truth would have moved the poles closer together. When provocation doesn’t matter, successive thinkers looking for truth would be disinclined to stray further and further from the mass of thought. These days, straining the pole even further away from the middle can be a winning strategy in the struggle to get attention and support.

The irony is that most people who think about health reform benefit more from discourse on non-polarizing options. Textbook economics treatments of the problems of health care do not support either pole. The welfare theorems suggest that unregulated health care markets will fail to provide adequate quality and will fail to protect the poor. Economists’ professional attraction to market solutions is based on shared recognition that they are seldom trouble-free. The public goods problems in health care (and other sectors) warrant collective action of some sort, but do not automatically support a solution based on 100% collective finance and provision.

This week at the International Health Economics Association, professional economists from around the world will gather to discuss and hone their craft. They mostly realize that health reform will have to be based on solving public goods problems. The toolkit for these solutions will need to include the best features of markets and the best features of enlightened collective action. The best solutions will not be the hottest—they will be squarely in the middle.  Let’s hope the light that shines from them makes up for their lack of heat.

* Editor's note: FHS will be participating in a wide variety of activities at this year's iHEA congress. See a list of activities, and stay tuned for future blogs and updates live from the event.

The scale and scope of private contributions to health systems

Posted: 07 Dec 2010 08:02 AM PST


The private sector provides more than half of the health services in Africa and Asia, measured both by source of financing for health services, and place of health service delivery.  While new data and better mapping of providers are improving the understanding of the scale of private healthcare services in low- and middle-income countries (LMICs), issues of dual public-private employment, undercounting of unregistered practitioners, and public sector distrust remain barriers to a full accounting of the size or the activities of the sector. To encourage filling this knowledge gap, in May 2010, the 63rd World Health Assembly passed a resolution called, “Strengthening the capacity of governments to constructively engage the private sector in providing essential health-care services,” which acknowledged that private providers are a major source of care in most countries, that private provision of services can lead to innovation as well as great challenges,  and that governments in LMICs can more effectively engage with and regulate private providers.

On November 17, 2010 researchers held a session entitled “The scale and scope of private contributions to health systems” as part of the First Global Symposium on Health Systems Research (HSR) - Science to Accelerate Universal Health Coverage hosted by the World Health Organization (WHO) and partners in Montreux, Switzerland to provide updates of current research on the private sector, highlight innovative financing mechanisms, and address future topics for research. The session was conducted as a “fishbowl conversation” to encourage audience participation; the design includes speaker chairs arranged in an inner circle that represents the fishbowl with one chair left empty for any member of the audience to occupy, at any time, at which point an existing member of the fishbowl must voluntarily leave to free a chair.  Speakers represented a growing group of researchers that have met regularly for the last five years to share findings and advances in research methods for studying the private sector from the perspective of public health, epidemiology, health economics, public policy, and management.  They included:

  • Sara Bennett,  Johns Hopkins Bloomberg School of Public Health (chair)
  • Ruth Berg, Abt Associates
  • Gerry Bloom, Institute of Development Studies
  • Tania Boler, Marie Stopes International
  • Kara Hanson, London School of Tropical Medicine and Hygiene
  • Birger Forsberg, Karolinska Instituet
  • Gina Lagomarsino, Results for Development Institute
  • Dominic Montagu, Global Health Group, University of California, San Francisco
  • Stefan Nachuk, Rockefeller Foundation
  • Gustavo Humberto Nigenda Lopez, National Institute of Public Health, Mexico

Speakers were asked to share their individual and institutional experience on innovative financing mechanisms which included: the Affordable Medicines Facility – malaria (AMFm), several national health insurance experiences, and public-private partnerships for regulation and otherwise.  Speakers also addressed communities of practice and other tool-sharing platforms that aim to make advances towards adoption of standardized methods for assessing private practitioners, their patients, and private funding flows using both secondary data sources and primary data collection, including: Social Franchising 4 Health (, the Center for Health Market Innovation (, Strengthening Health Outcomes through the Private Sector (, The Alliance for Health Policy and Systems Research, Future Health Systems, Eldis on health systems, id21, and more by the World Bank and others.

Speakers and audience members suggested the following areas for future research: more anthropological studies around private provider behavior, motivations, and incentives; regulating counterfeit drugs within the private sector; consideration of the human resource aspects of the private sector, including recruitment and training, in their work; payment mechanisms and incentiving patients as well as providers; the increase of “payer” attention to the private sector, including governments; the role of purchasing (financial accounting, standards, etc.); the efficacy of various regulatory partnerships; quality of clinical service delivery; quality of chemical sellers (given that one longitudinal study by KEMRI found no significant difference between quality of chemical shops routinely inspected and those not).

Speakers reported on several upcoming literature reviews underway around the private sector: the Global Health Group at UCSF is conducting a Cochrane Review on health outcomes in publicly-vs-privately provided settings in LMICs and a review with Results for Development and the CHMI on informal providers.  At least one systematic review on voucher programs and health is also in progress.

Throughout the session, speakers also emphasized the economic booms occurring in Asia, and the private health sector growth that has quickly followed and stressed that in many significant amounts of delivery and care are happening outside of the regulatory system, including a prominent informal sector in many countries.  Finally, speakers called for greater transparency around public-private partnerships to ensure efficacy and lesson sharing.