Social marketing campaigns in the Cote d'Ivoire

Baobab has a good post on corruption in the Cote d'Ivoire, which is poor even by sub-Saharan African standards, but which seems to be improving under President Ouattara: 

One of the indicators in the ruling justly category is control of corruption, an area in which Côte d’Ivoire fares particularly poorly. The World Bank’s most recent corruption rankings, from 2011, put it 38th out of 49 African countries. Transparency International ranked it 130th out of 176 countries last year in its Corruption Perceptions Index, ahead of Nigeria and Guinea but well behind neighbouring Liberia, Burkina Faso and Ghana. 

Progress has been made under President Alassane Ouattara, who came to power in May 2011. The Transparency International ranking is a big improvement over past years when Côte d’Ivoire hovered around 150th. Mr Ouattara is credited with curbing the corruption that prevailed under his predecessor, though many Ivorians insist shady dealings remain as prevalent as ever, if slightly better concealed.

But the government recently began a publicity campaign against corruption: 

The ostensible idea of the publicity campaign is to create a popular groundswell against corruption to compel elected officials to clean up their acts. Yet the adverts seem to have been met mostly with indifference. Baobab’s unscientific polling over the past few days suggests many Abidjaners think the billboards are adverts for Orange, a mobile service provider.  

A tough new anti-corruption law might be more helpful. But the one being drafted, which would establish an authority to investigate allegations of impropriety, is riddled with loopholes. Many of the original draft’s provisions have been heavily watered down, according to a source close to the process. The latest version reduces the statute of limitations on corruption-related offenses from ten years to three, making it extremely difficult to prosecute cases in time.

It's not a particularly well executed campaign thus far, but I tend to think that such campaigns have the capacity to do more good than new laws.  Even if the government were to pass a model law -- which seems unlikely -- the greater problem lies with enforcement.  In countries such as Rwanda, campaigns aimed at changing norms have met with impressive success, and such campaigns have much to recommend them.  Ultimately, however, the success of either approach will depend on leadership and how well the government's leaders are willing to prioritize the issue.

How to provide health services at low cost in poor countries

A 2010 McKinsey study proposes "three innovative delivery models to improve low cost primary care" in Tanzania's health care system: 

1. Community health workers have only limited training but undertake health promotion activities and serve as liaisons to more highly trained colleagues. Because almost every village can have its own community health worker, the basics of health care delivery are available to all. 
2. Mobile health care is a way to extend the reach of dispensaries and health centers. Health workers regularly travel to surrounding unserved villages (one day a week, for example), bringing basic medical supplies and communication tools. 
3. Call centers staffed by nurses (with oversight from doctors) can support both community and mobile health workers, who use mobile phones or other communication technologies to consult with call center staff.

Another suggestion (that Dan will enjoy) is to encourage more private ownership of health facilities: 

Many countries encourage ownership of some forms of care delivery...  One innovation that has been used successfully elsewhere is to encourage nonprofit and private organizations to provide more primary care. In some developing countries, dispensaries and health centers that are owner-operated or managed through a social-franchising model complement public-sector facilities. In Kenya, for example, more than 65 franchised dispensaries provide health care to more than 350,000 patients annually. The cost of these facilities is covered not only by government spending and donor contributions but also by payments from patients—which gives staff an incentive to improve care delivery. 

Let urbanisation flourish?

Such evidence has one critical implication. There's need to re-consider the role of public investment in urban areas for poverty reduction. In fact it is a popular tenet that investments in Zambia need to be concentrated in rural areas in order to reduce poverty, as our poorest people are mainly concentrated there. However, investments in rural areas are often very onerous as substantial resources are needed to reach a population which is scattered around vast territories. To the extent that urbanisation may have substantial poverty reducing effects on rural areas, urban investments may become an important complement to rural ones in poverty reduction strategies.

More from Zambian Economist here.

Does economic development inevitably lead to democracy?

Dan and I discussed this awhile back in regard to China (certainly the most important case study).  In light of the recent protests in several emerging countries, the Economist chimed in with some thoughts:

CHAMPIONS of modernisation theory—the idea that prosperity begets democracy—are upbeat. Street protests in Brazil, India and Turkey have rallied mostly middle-class crowds demanding better public services and an end to corruption. Proof, surely, of the American sociologist Barrington Moore’s dictum: “No bourgeoisie, no democracy”...

Yet exceptions abound. Mostly middling earners in Chile supported Augusto Pinochet’s coup in 1973. Few among China’s 800m-strong middle class have demanded democracy. Nor is protest a middle-class monopoly. “Miners and diggers stood up for democracy” in 19th-century Australia, says Daron Acemoglu, an economist at MIT. Their struggle brought secret balloting. In South Korea prosperity and democracy arrived together—but unions and students, not the well-off, called for liberal government. India’s democratic constitution long predated its middle class; and Botswana’s fair institutions took root when it had only a few graduates. 

I agree that the protests from the past few months are a strong point in favor of the idea that development begets democracy, but the issue is far from settled.  The arguments about India and Botswana are neither here nor there.  The question is not whether democracy can exist in the absence of development, but whether authoritarianism can be maintained in a developed economy.

How should government set payment levels for physicians and providers?

Lessons from Roberts and Hsiao about reforming health payment methods:

• Fee-for-service payment encourages health-care cost increases.  Nations would be wise to avoid this method unless there are strong reasons to do otherwise.  
• The salary-plus-bonus payment method is superior to salary only.  The former can motivate health professionals to increase productivity and improve quality of services.  This advantage is especially evident for specialists, provided they are employed by organizations such as hospitals or insurance programs. 
• Capitation payment for primary care has much to recommend it, especially when there are competing services in the same community. 
• For high- and middle-income countries, per-admission payment and simplified DRG payment to hospitals have desirable incentive effects but also create administrative complexity.  For hospitals in low-income countries, global budgets may be preferable because of their more limited administrative requirements. 

And here are recommendations for setting payment levels for physicians: 

Setting the right payment level is a contentious and sensitive affair.  Competitive bidding has much to recommend it when there are competing providers and the process can be combined with selective contracting...  Attempting to set a reasonable payment level based on cost data is also likely to be controversial; payers and providers will rarely accept one common set of data as truly objective.  

International experience shows that bilateral negotiation can produce mutually acceptable results in certain circumstances.  But once governments become involved and the situation becomes politicized, governments are likely to find themselves under substantial pressure from well-organized provider groups to devote additional resources to health-care salaries. 

On the fee-for-service model

It increases access to health care, but drives up costs:

This is the only form of payment under which the provider does not have any incentive to select healthier patients; in fact, the opposite is true.  Under FFS, the provider bears no risk for the cost of treatment.  The payer, the insurer, or the patient is entirely at risk for the cost of care.  Theoretically, patients and third-party payers have a reason to question the need for additional services and negotiate lower payments.  In reality, however, patients and third-party payers can seldom negotiate effectively due to the professional power of physicians.  

Studies in many countries, both developed and developing, have found that a fee-for-service system promotes an excessive use of services and an increase in costs (Barnum et al. 1995).  Comparing resource utilization under two provider-payment methods (FFS and capitation) in Thailand, Yip et all (2001) found a significant difference in the average length of stay, drug charges per admission, and lab costs per case.  Under FFS, resource utilization was consistently greater.  A study in the United States (Krawelski et al. 2000) found similar results.  Costs were significantly lower under medical group practices paid by capitation than those paid by FFS.  

That's from Roberts and Hsiao, in their chapter on Payment.

Middle class life in the Cote d'Ivoire

BBC Africa gives two examples of what middle class life is like in the Cote d'Ivoire.  On the good side, the economy sounds much stronger than it did a few years ago:  

During the crisis I had to stop working; I lost everything; I had to spend all my savings just to live, to eat.

Now I put money aside every day. I started my savings again just five months ago because I want to buy a computer. Maybe in three months I will have enough money to buy one.

Right now I don't find I have enough money to do what I want to do because I need to pay for so many things so it's not easy to start a good business.

If one of my brothers calls me and says he needs money, I give him some money. I have two younger brothers and three sisters; I'm the eldest.

I cannot say I'm wealthy but I cannot say I'm poor because if I'm living it means I can sustain my life.

Unfortunately, there are still serious repercussions from the crisis: 

My father died in 2004 and that's when I stopped going to school because I had to work to find money.

It was hard to find work then because it was just after the first crisis. Everyone fled to Abidjan and everybody needed jobs.

I don't have any savings or any emergency fund. There is nothing in my bank account. 

Everything I earn goes on rent, bills and food. There's nothing left for savings. 

When there's a death in my family I go to my friends for help, to give me a little something. It's like that.

Yes I am scared if I lose my job because there will be nothing to pay for my rent.