KNOTS blogger |
- Food price volatility - debating causes and consequences
- The mining boom: will residents of mineral rich countries benefit?
- Health dragons or health hydras? The challenges of regulation in Asian health systems
- CHMI highlights five emerging models for health service delivery and financing
- M4P Hub Conference proceedings series: Making informal health providers work better for the poor
- Complexity, complexity, complexity
- The future of Future Health Systems
- Blog roundup from iHEA 2011
- From private sector to health markets
- Going to Extremes
- The scale and scope of private contributions to health systems
| 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: |
| The mining boom: will residents of mineral rich countries benefit? Posted: 17 Feb 2012 04:10 AM PST BY GERRY BLOOM, RESEARCH FELLOW, IDS 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
BY BARUN KANJILAL, IIHMR 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 BY ROSE REIS, CENTER FOR HEALTH MARKET INNOVATIONS 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:
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. BY DR GERALD BLOOM, INSTITUTE OF DEVELOPMENT STUDIES
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:
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 BY PROFESSOR DAVID H PETERS, JHSPH ‘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:
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 BY DR SARA BENNETT, CEO OF FUTURE HEALTH SYSTEMS, JHSPH 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:
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. |
| 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 By DR GERALD BLOOM, INSTITUTE OF DEVELOPMENT STUDIES 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. |
| 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 BY HEALTHER KINLAW, GUEST BLOGGER FROM THE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, GLOBAL HEALTH GROUP
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 (SF4Health.org), the Center for Health Market Innovation (healthmarketinnovations.org), Strengthening Health Outcomes through the Private Sector (shopsproject.org), 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. |
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