Friday, July 12, 2013

Random questions: Which African countries have the most white people?

Not a comprehensive list, just some random observations, courtesy mostly of the CIA World Factbook:
  1. South Africa is obviously the highest with a white population of 9.6% of their total population.  South Africa is also 2.5% Asian/South Asian.  I didn't tally all of the countries, but it seems likely that there are more white South Africans than white Africans from the rest of the continent combined.  
  2. Botswana is 7% white.  I don't think I've ever met anyone from Botswana, white or black. There are only 2 million Botswanans.  
  3. There are a ton of Lebanese in the Cote d'Ivoire -- 130,000 as of 1998.  14,000 French as well.  The total percentage of "Other" is 2.8% according to the Factbook. 
  4. Angola is 1% European and 2% mixed European and African.  
  5. Somewhat surprisingly (for those who have seen Nowhere in Africa), Europeans and Asians combine to make up only 1% of Kenya's population.  
  6. Former Rhodesia: Zimbabwe is now less than 1% white, down from 5.4% of the population (270,000 people) in the 1970s.  Only 0.5% of Zambians are white or Asian. 
  7. Tanzania is 1% European, Asian and Arab combined. 
  8. Senegal is 1% European and Lebanese combined. 
  9. No info from CIA Factbook on Nigeria.  Wiki Answers says that there are 50,000 white people, which comes out to only 0.0003% of the population.  50,000 is still a pretty significant number though compared to most of these countries. 
  10. I couldn't find a good number for Ghana.  CIA Factbook says that 1.6% of their population is "Other." 

Links I liked

  1. Is transparency overrated?  
  2. Using money to buy happiness (I agree with most of these) 
  3. An articulate anti-Morsi perspective on recent events in Egypt  
  4. Similar, but from a 12 year old boy 
  5. To help the world's poor, give them real jobs (on why sweat shops are so important)

On the ethics of randomized clinical trials (RCTs) in global health

In the Lancet's new global heath blog, Paul Farmer argues against the excesses of RCTs in the global health sector: 
This kind of study can only be carried out ethically if the intervention being assessed is in equipoise, meaning that the medical community is in genuine doubt about its clinical merits...
The world we inhabit, as researchers and clinicians and policy-makers and journal readers, is not in equipoise. It is one in which great disparities of risk for disease, and for unequal access to already proven preventions and remedies, are marked and often extreme. For example, it has been demonstrated in HaitiCambodia, and in settings across Africa, that, among patients with active tuberculosis and advanced HIV infection, even brief delays in the initiation of ART are associated with increased mortality. In fact, it has been shown in every study in which this question has been proposed and evaluated. It’s not clear that randomized, controlled trials are necessary to show this yet again, especially in settings in which HIV disease and tuberculosis are the ranking causes of young adult death. This is one of the reasons that the recent publication of one South African trial, which sought to compare outcomes with delayed ART to concurrent initiation of combination chemotherapy for both diseases, occasioned recrimination from some ethicists. 
Dr. Farmer's suggestion solution: 
So what then is the charge of a global health journal? First, to recognize that the information gleaned from a rigorous observational study may be more useful to programme implementation than information derived from what are now reified as clinical trials. In terms rarely used in research circles, such observational methods should be deemed pertinent to clinical trials of equity. When journals recognize this by publishing more such studies, research funding will likely follow, shifting funding to studies conceived to improve the delivery of prevention and care and to learning through the process of implementation. Second, journal editors can help ensure that results are presented in such a way that any study’s methods can be understood and assessed by implementers and by those setting and revising health policy regarding life-and-death matters, including those mentioned above and many others now emerging. Like Rwanda, these are settings of rapid change in both burdens of disease and in the tools available to address them. Finally, journal editors might favour, for review and publication, research that reflects meaningful involvement of the implementers and managers, as research generated in this manner is most likely to address the needs and constraints of health programmes in settings of poverty and high burdens of disease.

Thursday, July 11, 2013

How not to do negotiated rulemaking

The first paper I ever published (co-authored, to be specific) was written to answer the question, "how to improve the administration of the health system in developing countries."  The goals was to come up with ways that the health ministry could regulate the health sector at low cost, since developing country governments generally lack the resources to undertake more vigorous regulations.  

I didn't know what I was doing, but I did some research and I came up with a number of answers, none very satisfying.  These included: 1) alternative dispute resolution; 2) the use of ombudsmen; 3) self-regulation; and 4) negotiated rulemaking.  In retrospect, I have my doubts about some of these tools.  These methods are inexpensive, sure, but they don't seem likely to produce much in the way of behavioral change, especially in countries where regulatory capacity is pretty minimal.  

To my chagrin, the Washington Monthly published an article this month about the deep flaws in the negotiated rulemaking process used by Medicare to set health care payment rates in the U.S.: 
"In a free market society, there’s a name for this kind of thing—for when a roomful of professionals from the same trade meet behind closed doors to agree on how much their services should be worth. It’s called price-fixing. And in any other industry, it’s illegal—grounds for a federal investigation into antitrust abuse, at the least. 
But this, dear readers, is not any other industry. This is the health care industry, and here, this kind of “price-fixing” is not only perfectly legal, it’s sanctioned by the U.S. government. At the end of each of these meetings, RUC members vote anonymously on a list of “recommended values,” which are then sent to the Centers for Medicare and Medicaid Services (CMS), the federal agency that runs those programs. For the last twenty-two years, the CMS has accepted about 90 percent of the RUC’s recommended values—essentially transferring the committee’s decisions directly into law.
The RUC, in other words, enjoys basically de facto control over how roughly $85 billion in U.S. taxpayer money is divvied up every year. And that’s just the start of it. Because of the way the system is set up, the values the RUC comes up with wind up shaping the very structure of the U.S. health care sector, creating the perverse financial incentives that dictate how our doctors behave, and affecting the annual expenditure of nearly one-fifth of our GDP." 
For what it's worth, this certainly seems like an area where more government spending -- on regulators who would actually examine these prices -- could likely lead to lower government spending -- on Medicare reimbursement.  
Medicare is not legally required to accept the RUC’s recommended values for doctors’ services and procedures, but the truth is, it doesn’t have much of a choice. There is no other advisory body currently capable of recommending alternative prices, and Congress has never given the CMS the resources necessary to do the job itself.
In fact, spending on regulators to examine and negotiate these prices might lead to lower health spending in the private market as well.  
The consequences of this set-up are pretty staggering. Allowing a small group of doctors to determine the fees that they and their colleagues will be paid not only drives up the cost of Medicare over time, it also drives up the cost of health care in this country writ large. That’s because private insurance companies also use Medicare’s fee schedule as a baseline for negotiating prices with hospitals and other providers. So if the RUC inflates the base price Medicare pays for a specific procedure, that inflationary effect ripples up through the health care industry as a whole.
The only good news is that the ACA does provide a few potential mechanisms for improving the situation:
The Affordable Care Act also takes some incremental steps toward reforming the payment system. It requires that the CMS create new “mechanisms” for establishing the physician fee schedule, which can include increasing its own in-house data collection and analysis to correct, corroborate, or refute the RUC’s recommendations, especially for inputs that are more easily measured empirically, like determining how long on average a given surgery takes. To comply, the CMS recently commissioned two reports from the RAND Corporation and the Urban Institute to advise the agency on how best to do that...
Some reformers point to a provision in Obamacare that might allow for an end run around Congress. The law creates a new entity, the Independent Payment Advisory Board, which, if Medicare costs outstrip the Consumer Price Index, will have the power to cut or change Medicare provider payments unilaterally. Its decisions can be overturned by Congress only if lawmakers pass alternative cost-cutting measures of equal size. Statutorily, IPAB could create a government-run equivalent of the RUC. Whether it will ever get a chance to exercise that power, however, is an open question: IPAB is a major political target for both Republicans who are demanding its immediate abolition and some Democrats who enjoy close ties to the medical drug and device industry.
The second option to solving the RUC problem would be to get Medicare out of the business of funding fee-for-service medicine. Reformers have been complaining for years that paying providers per procedure creates incentives for gaming and overuse that are difficult, if not impossible, to overcome. Under Obamacare, the CMS is already taking modest steps away from fee-for-service billing by expanding experiments in “bundled payments,” whereby providers are paid a lump sum to take care of patients with certain conditions, like diabetes or heart disease. The AMA, aware of the growing backlash in Washington against fee-for-service, has endorsed some of Medicare’s bundling initiatives.

Things could be better: recent numbers on HIV and malaria treatment in sub-Saharan Africa

According to NACA DG, on the continent, only 54 per cent of those eligible for Anti Retro Viral (ARV) treatment have access and only 10.9 per cent of children under-five years who suffered from malaria during 24 hours were treated according to national guidelines. He said the emergence of multidrug-resistant tuberculosis is a major concern given the significant costs involved in its treatment.
The Guardian Nigeria with more on the upcoming Abuja +12 Summit.  

Wednesday, July 10, 2013

Describing the regulatory process

Effective regulation is a complex and demanding process.  First an appropriate regulatory strategy needs to be developed--decisions mad about what and how to regulate.  Then agencies have to be established, including the recruitment of staff and the collection of data.  Then the detailed rules have to be written.  Next they have to be applied to specific cases.  Monitoring processes need to be established so that violators can be identified and either persuaded to change their behavior or penalized if they do not.  All of this must be done in a context in which those being regulated will protest and seek to influence the agency to treat them more leniently.  Effective regulation thus requires a demanding combination of technical expertise, administrative capacity, and political support that is not always easy for nations to provide.  
From Roberts and Hsiao.  From certain vantage points, it's a wonder that any countries or states have high-functioning, well-respected regulatory systems.  And certainly not a surprise that poorly financed governments have such trouble enacting effective regulatory systems.  

TNC on Wanderlust

I really liked these sentences from Ta-Nehisi Coates, on the terrifying and thrilling adventure of immersing yourself in a foreign country where you don't speak language:  
There is something about being down, about being lost, about being estranged that is narcotic. It is that hit of fear you get the first time you swim in the deep end and understand that your feet can not touch the bottom. 
So I blame it all on my wife. But I specifically blame this post on Jim and Deb Fallows, who are heroic to me and my small family, who are, together, our own Gandalf. I don't want to go into other people's business. But I think it's public information that they have made a life together, raising children and traveling the world. I didn't even know people who knew people who did things like that. And now it is so much of what I want. I blame them for talking to me about it and urging me and Kenyatta on. You can't hear them and not feel the glamour. It is the sorcery of the wide world. It is the song of the wanderers. It is the knowledge of a one-shot life. Who can truly live, hear such music, and decline to dance? 
Every time I've moved abroad, the first week was lonely and terrifying, so much so that I'm surprised I ever left my cocoon.  But having endured, and then emerged to experience the exhilaration of exploring a new culture and language and place, I can't ever go back.  These are some of the best memories I have, and I'll spend the rest of my life chasing new ones.  

Sunday, July 7, 2013

Ownership in the health care system

More from Roberts and Hsiao:
We also need to stress that health care ownership choices are more complex than the classic public-private dichotomy suggests.  There is often a "third way" in the form of nonprofit, non-government organizations.  Such NGOs often combine incentives to and accountability of managers with a board of directors that is not solely profit oriented.  At their best, such NGOs can produce greater "technical efficiency than rigid public organizations.  Moreover, they can recruit staff with different skills and motives than either for-profit business or classic bureaucracies... 
 How, then, should health reformers choose between using the public and private sectors to deliver services?  We believe this decision should depend on several features of a nation's circumstances and of the particular activity under consideration: 
  • Regulatory capacity: A government with greater technical expertise, a relatively law-abiding citizenry and a well-functioning legal and administrative apparatus can more easily control the excesses of private sector providers. 
  • Reform priorities: Markets do better on efficiency but worse on equity.  The choice of ownership may well depend on the relative importance of these goals...  
(There) is a deep irony that the nations least-equipped to make their public sector function effectively are often those least able to discipline private markets to achieve public goals.  
In the frenzied debate between market supporters and adversaries, it is often lost that there may be different best practices for countries at different stages of development.  One of the strengths of Roberts and Hsiao's book is that it embraces this complexity and recommends different levels of government intervention depending on a country's stage of development.

As Roberts and Hsiao argue, there is no good system of ownership for developing country health providers, just competing bad alternatives.  Nevertheless, there seem to be sounder argument in favor of keeping hospital ownership private in developing countries.  In the short-term, it seems that expanding the proverbial pie is a higher priority than equitably distributing the pie.  Once a country increases the supply of health care and the efficiency of its distribution, there seems to be an increasing role for government, as China is now learning, and as Western European countries (and even the U.S.) have all learned.