Policy Brief #180

	EXECUTIVE SUMMARY
	The year 2010 in Afghanistan had some encouraging signs but on balance it was less positive than had been hoped. In 2011, therefore, it is important to do two things: first, look for further improvements in our strategy; and second, develop a backup plan, should the current approach not yield the kind of progress that is necessary and expected. This policy brief addresses the first challenge, improving the U.S./NATO counterinsurgency campaign. The basic logic of current strategy is accepted, but several new initiatives or ideas are explored to make it more promising and more effective. Three main ideas are developed: Promoting Afghan political organizations built around ideas and platforms, not individuals and ethnicities, in a change from longstanding American policy that could improve the quality of governance in the country. Taking pressure off the bilateral U.S.-Afghan relationship on the issue of anticorruption, largely by creation of an international advisory board consisting of prominent individuals from key developing countries like Indonesia and Tanzania that have had considerable success improving their own nations' governance in recent times. Offering a civilian nuclear energy deal to Pakistan, conditional on clear action by Islamabad to shut down insurgent sanctuaries that are currently using its territory to attack the Afghan government as well as NATO forces.

The past year was not without good news in Afghanistan. It saw a successful deployment of nearly another 40,000 NATO troops to Afghanistan; twice as much growth in Afghan security forces together with a much more robust approach to their training; increases in American civilian capacity in Kabul and in the field; and highly effective targeting of Afghan (and Pakistani) insurgents within Afghanistan and just over the border with Pakistan. I would also count the September parliamentary elections as more good than bad, since it was Afghans who held other Afghans accountable for infractions, and since the Karzai government appears on balance to be tolerating an outcome that will reduce the strength of its cronies in the elected assembly (though this issue remains a work in progress). Finally, NATO's decision at the November Lisbon Summit to emphasize the year 2014 as the time when Afghanistan would assume full control of security operations-rather than President Obama's earlier preference to emphasize July 2011 as the point when the U.S. departure would begin-clarified the American and international commitments to get the job done right before going home. Among other benefits, this change should help convince more Afghan and Pakistani fence-sitters that they can count on us, rather than encouraging hedging behavior out of fear of a premature, hurried NATO exit.

However, 2010 also witnessed a roughly 50 percent increase in the overall level of violence that can only partially be explained by our increased presence and tempo of operations. That increase reflects a very resilient insurgency. Problematic relations between the Obama administration and the Karzai government have also continued, the corruption problem has remained intractable (largely fueled by the western presence with all of its trappings), and the Pakistani government still tolerates sanctuaries for the Haqqani network and the "Quetta Shura Taliban" (that is, the Afghan Taliban) on its territory.

For the most part, the strategy of the International Security Assistance Force (ISAF) under General David Petraeus, and the efforts of the international community more broadly, seem sound. The paramount goal in Afghanistan is to put the country's government in a position to control its own territory. That is the way to ensure that no large terrorist sanctuaries re-emerge there that could threaten the United States, nuclear-armed Pakistan, or other core western interests. But to achieve that goal, a comprehensive counterinsurgency approach that helps build up the Afghan state is needed, because establishing control of territory requires that the government possess a certain legitimacy among its people-which in turn requires some measure of economic and political progress. Hence, to achieve a fairly simple goal, we have properly undertaken a fairly ambitious strategy, after having tried the opposite, minimalist approach for the first half dozen years of the war only to see the Taliban make a comeback. Yet the strategy still needs improvement to address its two main vulnerabilities: the weakness and corruption of the Afghan government, and the schizophrenic approach to the war on the part the Pakistani government. This policy brief proposes ideas to address each of these problems. The proposals would also improve the prospects of any sound backup plan that might have to be considered this year, such as the concept that Brookings Senior Fellow Bruce Riedel and I have recently developed that we call a "Plan A-" for the country.

Afghan Governance and Anti-Corruption Efforts

Working with the Karzai government is an inherently complex matter. On the one hand, we have no choice but to partner with Afghanistan's elected leader, who in fact remains reasonably popular among his own people with a 62 percent favorability rating according to the latest polls. On the other hand, the government is widely seen as ineffective by many of its own citizens, helping generate motivation and recruits for the insurgency. So do we work with Karzai, or work around him? In fact, we must do both. We need a better way to help the Afghan government improve its performance without inciting periodic public spats along the way that set back our efforts to cooperate. And we also need a way to help build for Afghanistan's post-Karzai future, the sooner the better.

Improving Afghan Governance and Fighting Corruption

General Stanley McChrystal's 2009 assessment of the situation in Afghanistan famously and dramatically concluded that corruption in the Afghan government was comparable to the insurgency itself in posing a serious threat to the country. As such, General Petraeus has been right to focus intently on corruption since assuming command, including assigning the formidable Brigadier General HR McMaster to the task, and some positive things are happening as a result. More intelligence assets are being devoted to the problem. Field commanders and development specialists are more aware of the need to understand the power of money, and to be cognizant of whom they are empowering or embittering through their contracting processes and economic development efforts.

Yet problems remain. Corruption remains very serious. And disputes about corruption with President Karzai still go public too often. The United States and the international community more generally should reframe the issue of fighting corruption, as Marine Colonel Greg Douquet and I have previously argued. The challenge should be seen and described primarily as one of improving governance in Afghanistan rather than tackling a culture of criminality.

Blantant, extreme corruption must be prosecuted. But by criminalizing routine corruption, we not only encourage unrealistic expectations in the U.S. Congress and elsewhere about the progress that is achievable over the next few years, we may miss opportunities to work with Afghan "reconciliables"-individuals who may have had some corrupt tendencies yet also try to provide a certain level of effective governance. We also fail to recognize our own past role in the dynamic. Pumping billions of dollars a year into a poor economy, and inadvertently favoring certain power brokers and tribes over others in the process, feeds the very corruption that we so abhor.

Research on fighting corruption and improving governance points to a better way of thinking about this problem. One key insight from renowned development expert Paul Collier and others is that young democracies with weak checks on presidential powers and an easy source of cash tend to have major problems with corruption-so Afghanistan's challenges, rather than being viewed primarily as criminal, should be expected in some ways. Taking this tone with the Karzai government can improve atmospherics and bolster our odds of eliciting cooperative behavior from Kabul.

Another key finding from MIT's Benjamin Olken and other researchers is that trained, independent auditors deployed from the central government to various parts of the country can improve the quality of government performance. Government auditors could also counter the "inverse pyramid" patronage network that is common in the Karzai administration, a network in which corrupt officials "invest" in purchasing government positions and their "dividends" are paid to them in the form of bribes and extortion. Reforming Afghanistan's government will require reversing this trend, or at least mitigating it, through such auditors and other governmental improvements.

And perhaps most important of all, the development literature shows that a number of countries around the world have made headway in combating corruption and improving governance over the years. Brookings and World Bank scholars Daniel Kaufmann, Aart Kraay and Pablo Zoido-Lobaton document progress in places including Indonesia, Hong Kong, Georgia, Albania, Tanzania and Rwanda. We should try to involve more experts from such countries in the effort. President Karzai and others might react more positively to hearing suggestions about how to reduce bribes, check nepotism, and improve governance from Indonesians or Tanzanians rather than Americans.

With U.S. assistance, Afghanistan's government has improved. We are now seeing points of light in the anticorruption effort, such as President Karzai's new specialized anticorruption agency-the High Office of Oversight. Several key ministers in the Karzai cabinet are also exemplary on this front, including for example Minister of Interior Mohammadi. We should emphasize their sound efforts more often. But there is clearly a long way to go, and an international contact group may help.

Strengthening Afghan Political Parties and Institutions

Afghanistan's corruption problem is largely rooted in the fact that the young political system is still too driven by personalities-and to a lesser extent ethnicity-and not enough by ideas.

Part of the challenge is to make sure that Mr. Karzai relinquishes power in 2014, when he reaches the constitutional limit of two full presidential terms. Prudence requires that we assume Mr. Karzai will seek to change the constitution or otherwise manipulate the electoral and legal process to stay in office-not out of any megalomania, but as much as anything out of fear for himself and his friends and relatives given the uncertainty of who might follow him in office. As such, it is possible that Karzai could declare martial law and suspend future elections. He could seek a peace deal with insurgents that makes him the compromise candidate under a future modified constitution. He could even consider a military coup.

It is important to deflate this possibility before it gains momentum. U.S. policymakers should, for example, mention publicly that Mr. Karzai will no longer be president after 2014. This is unobjectionable as a point of legal fact-at least right now-so there is no reason to shy away from saying so. Talking about it enough will help clarify the international community's intentions and expectations. And given Afghanistan's long-term need for international security and economic assistance, Afghan leaders would have to take notice.

The second imperative is to strengthen Afghan political organizations. That means helping Afghanistan's reformers and patriots, of whom there are many, to form strong political movements. Mr. Karzai has chosen some good cabinet officials and governors, but these are just a few individuals. Afghanistan's organized political parties are very weak. There are some fledgling new movements-like the one spearheaded by former foreign minister and presidential candidate Abdullah Abdullah. But they are loosely organized and have relatively vague policy platforms.

Afghanistan needs political movements tied to ideas and governing principles rather than ethnicity or individuals. Mr. Karzai has so far discouraged their formation. He has argued that Afghans dislike political parties because of the legacy of Communist Party abuses in the late 1970s and 1980s. But the 1980s are increasingly ancient history. Those who oppose parties today seem motivated mostly by their own desire to divide and conquer a weak, inchoate opposition.

It is time for the U.S. government and the many other governmental and nongovernmental organizations present in Afghanistan to strongly support the activities of new political movements. They should encourage and fund Afghans as they hold policy conferences, create research institutes, do grass-roots political organizing, and talk policy and politics in print, on television and on the radio. This approach need not be anti-Karzai; the president himself could form a party.

Such dynamics could affect even the shorter-term calculations of Afghan politicians. If Afghan voters in 2014 and thereafter are empowered to make real policy choices, candidates will take notice and start developing ideas they can run on. That may be as good an antidote to weak governance and rampant corruption as we can find-not only for the future but for today as well.

Getting Pakistan Off the Fence

Pakistan arguably remains the most complex ally the United States has ever had in wartime. Nine years into the campaign, we still cannot clearly answer the question of whether Pakistan is with us or against us. America needs bold new policy measures to help Islamabad-in all its many dimensions and factions-make up its mind.

Despite allowing massive NATO logistics operations through its territory and helping the United States pursue al Qaeda operatives, Pakistan tolerates sanctuaries on its soil for the major insurgencies fighting in Afghanistan. These include the Afghan Taliban (known as the Quetta Shura Taliban because its principle base remains in Quetta in the Pakistani province of Baluchistan) as well as the Haqqani and Hezb-i-Islami Gulbuddin (HiG) networks. The Haqqanis straddle the border between the Afghan provinces of Khost, Paktia, and Paktika as well as North Waziristan and other tribal areas within Pakistan; HiG is further north, operating in and around the Khyber Pass connecting Kabul and Jalalabad in Afghanistan with Peshawar and points east in Pakistan. Thus, all three major Afghan insurgent groups have home bases in Pakistan, and despite the occasional drone strike are generally beyond NATO's reach as a result.

Pakistan has taken some worthy actions against extremists in its remote northern and western areas in recent years. Specifically, it has recognized the so-called Pakistani Taliban (the Tehrik-i-Taliban Pakistan, or TTP) as a mortal threat to the Pakistani state and responded accordingly in some tribal areas. Pakistanis argue, however, that limited numbers of ground troops combined with the past year's devastating floods prevent them from doing more. Quetta, North Waziristan, and other key places remain dens of iniquity, havens for extremists who continue to attack NATO and Afghan troops across the border and then return home for rest, regrouping, and fresh recruiting. Major command-and-control hubs are permanently located within Pakistan as well, and key insurgent leaders like Mullah Omar (to say nothing of Osama bin Laden) probably remain safely ensconced on Pakistani territory where U.S. forces cannot get at them. But it is perhaps not just a matter of available troops. Pakistan would rather have the Taliban and the Haqqanis back in power, especially in the country's south and east, than any group like the former Northern Alliance, which it views as too close to India. Since Islamabad cannot be sure that the current Afghan political system will survive, therefore, it keeps a backup plan based largely on the Taliban and its associates.

Under these circumstances, part of the right policy is to keep doing more of what the Obama administration has been doing with Pakistan-building trust, as with last fall's strategic dialogue in Washington; increasing aid incrementally, as with the new five-year, $2 billion aid package announced during that dialogue; encouraging Pakistan-India dialogue (which would help persuade Islamabad it could safely move more military forces from its eastern border to its western regions) and coordinating militarily across the Afghanistan-Pakistan border region. But President Barack Obama needs to think bigger. The clarification that the U.S.-led ISAF mission will continue until 2014, and indeed beyond, at the November Lisbon summit was a step in the right direction but more is needed.

Obama should offer Islamabad a much more expansive U.S.-Pakistani relationship if it helps win this war. Two major incentives would have particular appeal to Pakistan. One is a civilian nuclear energy deal like that being provided to India, with full safeguards on associated reactors. Pakistan's progress on export controls in the wake of the A.Q. Khan debacle has been good enough so far to allow a provisional approval of such a deal if other things fall into place as well, including Islamabad’s compliance with any future fissile production cutoff treaty. Second is a free trade accord. Struggling economically, Pakistan needs such a shot in the arm, and a trade deal could arguably do even more than aid at this point.

But the key point is this: Pakistan should be told that these deals will only be possible if the United States and its allies prevail in Afghanistan. Small gestures of greater helpfulness are not adequate; bottom-line results are what count and what are needed. If Afghanistan turns around in a year or two, the deals can be set in motion and implemented over a longer period that will allow the United States to continually monitor subsequent Pakistani cooperation in the war. These terms are really just common sense, and they are based on political realism about America's domestic politics as well as its strategic interests, since there is no way the Congress would support such a nuclear deal if Pakistani policy ultimately contributed to our losing the war in Afghanistan.

Conclusion

Current strategy in Afghanistan is built on reasonably sound counterinsurgency principles and is fairly promising in its prospects for the year ahead. But every such operation is different. That is a basic corollary of counterinsurgency theory, with its emphasis on local politics, conditions, and personalities-meaning that there is no reason to believe that current strategy is good enough just because its fundamentals are time-tested.

A number of other policy reforms, beyond those discussed here, may be worth considering in the coming months as well. The numerical goal for the Afghan security forces is probably still too low, and should approach 400,000 uniformed personnel rather than the current 305,000 target (this debate is well underway as of this writing). The legal system remains weak, with glaring problems such as a major dearth of judges and severely inadequate pay for prosecutors, as well as no clear strategy for linking the formal justice system to the local, traditional justice systems that remain important in Afghanistan today. Finally, in the aftermath of the September 2010 parliamentary elections, some patchwork solution to the disenfranchisement of Pashtuns in provinces like Ghazni where many of them could not vote (or had their votes thrown out) is probably needed. Perhaps some additional modest number of Pashtuns could be given non-voting adjunct status in the parliament, allowing their voices to be heard even if they were ultimately not able to win seats.

But the three changes to our current approach discussed in this policy brief are central, and have not received their due attention. On the anticorruption front, adoption of a less bilateral approach that includes a high-level international advisory body on good governance for the Karzai government could improve the tone and substance of the effort. On the Afghan politics front, the international community should be unapologetic about supporting Afghan political parties built on ideas and agendas more than personalities and ethnicities. And finally, in regard to Pakistan, an informal but public U.S. offer to pursue a bilateral civilian nuclear energy deal should Pakistan help us win the war by clamping down on insurgent sanctuaries, might motivate greater efforts by our on-again off-again allies across the border. Adoption of these recommendations would improve our prospects for at least moderate success in Afghanistan and help make 2011 the belated turnaround year that we so badly need.

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Nigeria is facing a confluence of troubles: dramatically reduced oil prices have pummeled a country that depends on oil exports for two-thirds of its national revenues; the Boko Haram insurgency continues to wreak havoc particularly in the north of the country, where suicide bombings (many of which are now carried out by kidnapped girls) have killed hundreds; and corruption remains a drain on the country, which ranked 136th out of 168 countries on Transparency International’s 2015 Corruptions Perceptions Index.

But amidst this, Nigeria completed its first peaceful transition of power nine months ago—to Muhammadu Buhari, who has since made some progress in reforming the military, sacking corrupt leaders, and injecting energy into the counter-Boko Haram campaign. 

On February 29, the Africa Security Initiative at Brookings hosted a discussion on the current state of Nigeria, featuring EJ Hogendoorn of the International Crisis Group, Madeline Rose of Mercy Corps, Mausi Segun of Human Rights Watch, and Amadou Sy from Brookings. Brookings’s Mike O’Hanlon moderated the conversation.

As O’Hanlon argued at the start, Nigeria is one of the most important countries in the world, but appears little in policy debates. Nigeria is sub-Saharan Africa’s largest economy, and security risks emanating in the country can have spillover effects. All of the participants stressed that Nigeria should factor more centrally in conversations about international security, economic development, and humanitarian issues.

Nigeria’s ups and downs

O’Hanlon started by framing three overlapping challenges in Nigeria:

• The struggle against Boko Haram, which is more complicated than a pure terror group, but has also pledged loyalty to ISIS.
• The question of reform, to include the army, the police, and the entire government.
• The state of the economy, since Nigerian livelihoods need to be improved if there is any hope to handle the first two situations. 

Hogendoorn praised the peaceful transition of power to President Buhari, calling it a “stunning achievement” for the country and those who helped from the outside. However, the problems facing Nigeria—namely the insurgency in the Niger Delta, declining oil prices, and corruption and government mismanagement (at state and federal levels)—are large, he said. He argued that declining oil prices and income are impacting the government’s ability to fulfill promises, and that state governments are powerful and difficult to reform. He praised some anti-corruption institutions in Nigeria, as well as a number of effective governors who have changed corruption situation dramatically over a short period of time. But in the end, he said, it comes down to good leadership. The Nigerian people must demand accountability. 

Rose detailed how things have changed in Nigeria since Mercy Corps became heavily involved in the area in 2012. Mercy Corps’ main missions there include violence reduction, education, and creating opportunity for young girls, as well as humanitarian response. While there has been progress on chronic violence in Nigeria, particularly in the northeast of the country, Rose stressed that there is much to be done. She concluded that there is not enough attention to the human element of the crisis. For example, Rose noted that displacement is common across the Northeast. The displaced are mainly women and children. In the displaced groups, the eldest becomes de facto head of household—sometimes forcing leading adolescent girls to turn to selling sex for food or money for food. Rose called on the government to address this. 

Segun agreed that the focus needs to change regarding crisis response in Nigeria. In the past, the focus has been almost entirely on a military response. This has not been a workable plan, she said, partly because the “military operates above the law.” The reforms in Nigeria must have a social component, Segun argued. Lack of access to opportunity, economic problems, and desertification of major water bodies have all combined to drive farmers and fisherman from the Northeast and into the heart of the conflict. 

Sy returned to the importance of economic interests in resolving the crises in Nigeria. He reminded the audience that the country is the largest economy of sub-Saharan Africa, and that is important for the entire continent. Since two-thirds of the government revenue comes from oil, the oil shock has dealt a huge blow. But there is hope for Nigeria, Sy noted. One reason is stimulus via investment outside the oil sector. There has been an increase in infrastructure spending, as well as on human development (namely in education and health). In both cases, he said the biggest issue will be implementation. Sy gave four recommendations to the Nigerian government: 1) increase infrastructure expenditure, 2) make government more lean and cost-effective, 3) increase taxation in non-oil revenue items, and 4) reduce corruption. 

Overall, the participants expressed cautious hope for Nigeria despite the problems it faces. The government there still has a long list of to-do’s, but there is reason to believe that it is on the right general track.

      

       

Legislative proposals to accelerate and improve the development of innovative drugs and medical devices generally focus on reforming the clinical development and regulatory review processes that occur before a product gets to market. Many of these proposals – such as boosting federal funding for basic science, streamlining the clinical trials process, improving incentives for development in areas of unmet medical need, or creating expedited FDA review pathways for promising treatments – are worthy pursuits and justifiably part of ongoing efforts to strengthen biomedical innovation in the United States, such as the 21^st Century Cures initiative in the House and a parallel effort taking shape in the Senate.

What has largely been missing from these recent policy discussions, however, is an equal and concerted focus on the role that postmarket evidence can play in creating a more robust and efficient innovation process. Data on medical product safety, efficacy, and associated patient outcomes accrued through routine medical practice and through practical research involving a broad range of medical practices could not only bolster our understanding of how well novel treatments are achieving their intended effects, but reinforce many of the premarket reforms currently under consideration. Below and in a new paper, we highlight the importance of postmarket evidence development and present a number of immediately achievable proposals that could help lay the foundation for future cures.

Why is postmarket evidence development important?

There are a number of reasons why evidence developed after a medical product’s approval should be considered an integral part of legislative efforts to improve biomedical innovation. First and foremost, learning from clinical experiences with medical products in large patient populations can allow providers to better target and treat individuals, matching the right drug or device to the right patient based on real-world evidence. Such knowledge can in turn support changes in care that lead to better outcomes and thus higher value realized by any given medical product.

Similarly, data developed on outcomes, disease progression, and associated genetic and other characteristics that suggest differences in disease course or response to treatment can form the foundation of future breakthrough medical products. As we continue to move toward an era of increasingly-targeted treatments, this important of this type of real-world data cannot be discounted.

Finally, organized efforts to improve postmarket evidence development can further establish infrastructure and robust data sources for ensuring the safety and effectiveness of FDA-approved products, protecting patient lives. This is especially important as Congress, the Administration, and others continue to seek novel policies for further expediting the pre-market regulatory review process for high-priority treatments. Without a reliable postmarket evidence development infrastructure in place, attempts to further shorten the time it takes to move a product from clinical development to FDA approval may run up against the barrier of limited capabilities to gather the postmarket data needed to refine a product’s safety and effectiveness profile. While this is particularly important for medical devices – the “life cycle” of a medical device often involves many important revisions in the device itself and in how and by whom it is used after approval – it is also important for breakthrough drugs, which may increasingly be approved based on biomarkers that predict clinical response and in particular subpopulations of patients.

What can be done now?

The last decade has seen progress in the availability of postmarket data and the production of postmarket evidence. Biomedical researchers, product developers, health care plans, and providers are doing more to collect and analyze clinical and outcomes data. Multiple independent efforts – including the U.S. Food and Drug Administration’s Sentinel Initiative for active postmarket drug safety surveillance, the Patient-Centered Outcomes Research Institute’s PCORnet for clinical effectiveness studies, the Medical Device Epidemiology Network (MDEpiNet) for developing better methods and medical device registries for medical device surveillance and a number of dedicated, product-specific outcomes registries – have demonstrated the powerful effects that rigorous, systematic postmarket data collection can have on our understanding of how medical products perform in the real-world and of the course of underlying diseases that they are designed to treat.

These and other postmarket data systems now hold the potential to contribute to data analysis and improved population-based evidence development on a wider scale. Federal support for strengthening the processes and tools through which data on important health outcomes can be leveraged to improve evidence on the safety, effectiveness, and value of care; for creating transparent and timely access to such data; and for building on current evidence development activities will help to make the use of postmarket data more robust, routine, and reliable.

Toward that end, we put forward a number of targeted proposals that current legislative efforts should consider as the 2015 policy agenda continues to take shape:

Evaluate the potential use of postmarket evidence in regulatory decision-making. The initial Cures discussion draft mandated FDA to establish a process by which pharmaceutical manufacturers could submit real-world evidence to support Agency regulatory decisions. While this is an important part of further establishing methods and mechanisms for harnessing data developed in the postmarket space, the proposed timelines (roughly 12 months to first Guidance for Industry) and wide scope of the program do not allow for a thoughtfully-, collaboratively-considered approach to utilizing real-world evidence. Future proposals should allow FDA to take a longer, multi-stakeholder approach to identify the current sources of real-world data, gaps in such collection activities, standards and methodologies for collection, and priority areas where more work is needed to understand how real-world data could be used.

Expand the Sentinel System’s data collection activities to include data on effectiveness. Established by Congress in 2007, Sentinel is a robust surveillance system geared toward monitoring the safety of drugs and biologics. In parallel to the program for evaluating the use of RWE outlined above, FDA could work with stakeholders to identify and pursue targeted extensions of the Sentinel system that begin to pilot collection of such data. Demonstration projects could enable faster and more effective RWE development to characterize treatment utilization patterns, further refine a product’s efficacy profile, or address pressing public health concerns – all by testing strategic linkages to data elements outside of Sentinel’s safety focus.

Establish an active postmarket safety surveillance system for medical devices. Congress has already acted once to establish device surveillance, mandating in 2012 that Sentinel be expanded to include safety data on medical devices. To date, however, there has been no additional support for such surveillance or even the capability of individually tracking medical devices in-use. With the recently finalized Unique Device Identifier rule going effect and the ability to perform such tracking on the horizon, the time is now to adopt recent proposals from FDA’s National Medical Device Postmarket Surveillance System Planning Board. With Congressional authorization for FDA to establish an implementation plan and adequate appropriations, the true foundation for such a system could finally be put into place.

These next steps are practical, immediately achievable, and key to fully realizing the intended effect of other policy efforts aimed at both improving the biomedical innovation process and strengthening the move to value-based health care.

      

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The role of clinical pharmacology and experimental medicine

The high failure rate of investigational compounds during drug development, especially in late stages of the clinical development process, is widely seen as a key contributor to the outsize amount of time and resources necessary to develop new drugs. Advances in clinical pharmacology and experimental medicine have the potential to rebalance these trends by providing researchers with the tools to more efficiently and systematically identify promising targets and compounds, appropriate patient populations, and adequate doses for study much earlier in development. 

On July 28, the Center for Health Policy at Brookings, in collaboration with the International Consortium for Innovation & Quality in Pharmaceutical Development and the U.S. Food and Drug Administration (FDA), hosted a public meeting to tackle these issues. Through presentations and case studies, leading experts from industry, academia, and government agencies explored the evolving role of clinical pharmacology tools in pre-clinical and clinical development, existing gaps in the application of those tools, and how emerging science could be better leveraged to improve the efficiency of drug development programs and better optimize treatments. Discussion at this event will potentially be harnessed to inform downstream guidance documents, to establish best practices for the application of emerging clinical pharmacology tools, or to support academic publications. Speakers will convene privately to discuss such downstream deliverables and key takeaways from the conference.

Click here to access the full event agenda.

Video

• Introductory keynotes: Framing the issues
• Optimizing target and compound selection to enhance early stage decision-making
• The right dose for the right patient: Challenges and opportunities in dose optimization
• Precision medicine: Trial enrichment, biomarker science, and mechanistic reasoning to optimize patient selection
• Applications of clinical pharmacology to support demonstration of efficacy

Event Materials

• Event Slide Deck
• Clinical Pharmacology Public Conference
• Clinical Pharmacology Backgrounder
• Clinical Pharmacology Private Roundtable

       

EXECUTIVE SUMMARY

Parents, educators, government ministers and policymakers in all contexts and countries around the world are concerned with learning and how to improve it. There are many reasons for this, but none is more important than the fact that learning is at the heart of success at the individual, community and global levels. Learning First is the title of this report, with the strong implication that learning should be the foremost goal of education policies worldwide.

The present review seeks not only to explain why this is the case but also focuses on what we need to know—that is, what research is needed—in order to improve learning in the decades to come, particularly among those children most in need. This question is addressed in the following six sections.

1. Learning Goals and Research. The first section begins with a historical synopsis of international education goals put forward in 1990 at the World Conference on Education for All in Jomtien (Thailand), in 2000 at the Education for All conference in Dakar, and later in 2000 as a part of the UN Millennium Development Goals for 2015. In 2011, the Center for Universal Education at the Brookings Institution published A Global Compact on Learning: Taking Action on Education in Developing Countries, which stated that there is a “global learning crisis—which affects children and youth who are out of school with limited learning opportunities and those who are in school but not learning the skills they need for their futures.” The present review of learning research in low-income countries follows from that report. The overall purpose is to explore the most pressing learning issues today that require further research attention in the years to come.
    
2. Learning Definitions and Contexts. This section reviews how the field of education has defined learning over the years. Here, learning is defined as a modification of behavior due to experience—such as in knowledge, skills, attitudes and values. Three main principles of effective learning are suggested: individual active involvement, social participation, and meaningful engagement. As a way to emphasize the importance of learning contexts, three individual stories—Illa, a four-year-old Quechua-speaking girl in Peru; Pawan, an eight-year-old primary school student in urban India; and Rachida, a young illiterate woman in rural Morocco—are provided in order to better explain the importance of learning as a culturally specific phenomenon. These stories help to illustrate a more general learning framework, encompassing the relationship between two dimensions of learning—its processes and contexts. A discussion follows concerning the need to disaggregate learners and their learning contexts—between countries and within countries—as a way to overcome frequent and simplistic generalizations about how the “average” child learns.
    
3. Global Change and the Contexts of Learning. This section considers the issue of global change on how learning and learning contexts are being transformed around the world. For example, researchers need to pay more attention to the impact of migration on children’s learning and on educational systems more broadly. In each instance of translocation, children confront the challenges of adapting to a new environment that may include different languages, dialects or cultures within the nonformal learning contexts of daily life. Similarly, in formal education contexts, student migrants have to cope with contrasts in culture, lifestyle and language of schooling, and demonstrate skills and achievement that may vary dramatically with their culture of origin. Other changes due to globalization include increased multilingualism in schools, growing overcrowding in classrooms, inability to keep up with teacher training, changes in intergenerational learning, and the growing importance of 21st-century skills. Based on these observations, it is suggested that learning contexts and needs should be understood as a shifting target.

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Youth summer jobs programs have experienced a resurgence of interest and investment since the Great Recession, driven by concerns about high unemployment rates among young people, particularly those who are low-income, black, or Hispanic. Recent research points to summer jobs programs as a positive lever for change by reducing violence, incarceration, and mortality and improving academic outcomes.They are often a jurisdiction’s most high-profile youth employment initiative.

But good intentions do not always lead to results. Research has not yet linked summer jobs programs to improved employment outcomes, evaluations to date are silent on effective program design, and in the absence of agreed-upon standards and best practices, there is no guarantee of quality.They are complicated and labor-intensive to operate, and many jurisdictions had to re-build their programs after a long hiatus following the end of dedicated federal funding in the late 1990s.

On Thursday, July 14, the Brookings Metropolitan Policy Program hosted an event that explored core elements associated with high-performing programs and made recommendations to strengthen summer jobs programs. The event featured a presentation on the finding of a new paper by Brookings fellow Martha Ross and co-author Richard Kazis, titled, “Youth Summer Jobs Programs: Aligning Ends and Means,” followed by a response panel, comprised of leaders from metro areas across the country.  

Join the conversation on Twitter at #SummerJobs

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Presentation by Martha Ross

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From left to right: Richard Kazis, Nonresident Fellow, The Brookings Institution; Kerry Sullivan, President, Bank of America Charitable Foundation; Honorable Michael A. Nutter, Former Mayor, City of Philadelphia;  Ana Galeas, Summer Camp Counselor, DC Scores, and Participant, Mayor Marion S. Barry Summer Youth Employment Program; Michael Gritton, Executive Directlor, KentuckianaWorks

Video

• Welcome and presentation
• Panel discussion
• Closing remarks

Audio

• Improving youth summer jobs programs

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160714_youth_jobs_transcript

       

William Galston and E.J. Dionne, Jr. make the case for universal voting – a new electoral system in which voting would be regarded as a required, civic duty. Why not treat showing up at the polls in the same way we treat a jury summons, which compels us to present ourselves at the court? Galston and Dionne argue that universal voting would enhance the legitimacy of our governing institutions, greatly increasing turnout and the diversity of the American voter base, and ease the intense partisan polarization that weakens our governing capacity.

Citing the implementation of universal voting in Australia in 1924, the authors conclude that universal voting increases citizen participation in the political process. In the United States, they write, universal voting would promote participation among citizens who are not likely to vote—those with lower levels of income and education, young adults, and recent immigrants. By evening out disparities in the electorate, universal voting would put the state on the side of promoting broad civic participation.

In addition to expanding voter participation, universal voting would improve electoral competition and curb hyperpolarization. Galston and Dionne assert that the addition of less partisan voters in the electorate, would force candidates to shift their focus from mobilizing partisan bases to persuading moderates and less committed voters. Reducing partisan rhetoric would help ease polarization and increase prospects for compromise.. Rather than focusing on symbolic, political gestures, Washington might have an incentive to tackle serious issues and solve problems.

Galston and Dionne believe that American democracy cannot be strong if citizenship is weak. And right now, they contend citizenship is strong on rights but weak on responsibilities. Making voting universal would begin to right this balance and send an important message: we all have the duty to help shape the country that has given us so much.

Galston and Dionne recognize that the majority of Americans are far from ready to endorse universal voting. By advancing a proposal that stands outside the perimeter of what the majority of Americans are likely to support, Galston and Dionne aim to enrich public debate—in the short term, by advancing the cause of more modest reforms that would increase participation; in the long term, by expanding public understanding of institutional remedies to political dysfunction. 

Downloads

• Download the paper

Audio

• Dionne and Galston discuss their paper on universal voting

      

It’s easy to imagine a future in a decade or less when most people will have a smartphone. In our recent paper Pathways to Smarter Digital Financial Inclusion, we explore the benefits of extending financial services to the mass of lower-income people in developing countries who are currently dubious of the value that financial services can bring to them, distrustful of formal financial institutions, or uncomfortable with the treatment they expect to receive.

The report analyzes six inherent characteristics of smartphones that have the potential to change market dynamics relative to the status quo of simple mobile phones and cards. 

Customer-Facing Changes:

1. The graphical user interface.
2. The ability to attach a variety of peripheral devices to it (such as a card reader or a small printer issuing receipts).
3. The lower marginal cost of mobile data communications relative to traditional mobile channels (such as SMS or USSD).

Service Provider Changes:

4. Greater freedom to program services without requiring the acquiescence or active participation of the telco.
5. Greater flexibility to distribute service logic between the handset (apps) and the network (servers).
6. More opportunities to capture more customer data with which to enhance customer value and stickiness.

Taken together, these changes may lower the costs of designing for lower-income people dramatically, and the designs ought to take advantage of continuous feedback from users. This should give low-end customers a stronger sense of choice over the services that are relevant to them, and voice over how they wish to be served and treated.

Traditionally poor people have been invisible to service providers because so little was known about their preferences that it was not possible build a service proposition or business case around them. The paper describes three pathways that will allow providers to design services on smartphones that will enable an increasingly granular understanding of their customers. Each of the three pathways offers providers a different approach to discover what they need to know about prospective customers in order to begin engaging with them. 

Pathway One: Through Big Data

Providers will piece together information on potential low-income customers directly, by assembling available data from disparate sources (e.g. history of airtime top-ups and bill payment, activity on online social networks, neighborhood or village-level socio-demographic data, etc.) and by accelerating data acquisition cycles (e.g. inferring behavior from granting of small loans in rapid succession, administering selected psychometric questions, or conducting A/B tests with special offers). There is a growing number of data analytics companies that are applying big data in this way to benefit the poor.

Pathway Two: Through local Businesses

Smartphones will have a special impact on micro and small enterprises, which will see increasing business benefits from recording and transacting more of their business digitally. As their business data becomes more visible to financial institutions, local firms will increasingly channel financial services, and particularly credit, to their customers, employees, and suppliers. Financial institutions will backstop their credit, which in effect turns smaller businesses into front-line distribution partners into local communities.

Pathway Three: Through Socio-Financial Networks

Firms view individuals primarily as managers of a web of socio-financial relationships that may or may not allow them access to formal financial services. Beyond providing loans to “creditworthy” people, financial institutions can provide transactional engines, similar to the crowdfunding platforms that enable all people to locate potential funding sources within their existing social networks. A provider equipped with appropriate network analysis tools could then promote rather than displace people´s own funding relationships and activities. This would provide financial service firms valuable insight into how people manage their financial needs.

The pathways are intended as an exploration of how smartphones could support the development of a healthier and more inclusive digital financial service ecosystem, by addressing the two critical deficiencies of the current mass-market digital finance systems. Smartphones could enable stronger customer value propositions, leading to much higher levels of customer engagement, leading to more revelation of customer data and more robust business cases for the providers involved. Mobile technology could also lead to a broader diversity of players coming into the space, each playing to their specific interests and contributing their specific set of skills, but together delivering customer value through the right combination of collaboration and competition.

      

       

       

       

       

       

       

“If the Americans and their regional allies want to pass through the Strait of Hormuz and threaten us, we will not allow any entry,” said deputy commander of Iran’s Revolutionary Guards, Hossein Salami, last Wednesday. Iran has a long history of making threats against this critical waterway, through which some 17 million barrels of oil exports pass daily, though it has not carried them out. But multiple regional security threats highlight threats to energy transit from and through the Middle East and North Africa (MENA)—and demand new thinking about solutions.

Weak spots

Hormuz attracts attention because of its evident vulnerability. But recent years have seen severe disruptions to energy flows across the region: port blockades in Libya; pipeline sabotage in Egypt’s Sinai, Yemen, Baluchistan in Pakistan, and Turkey’s southeast; attacks on oil and gas installations across Syria and Iraq; piracy off Somalia. Energy security is threatened at all scales, from local community disturbances and strikes, up to major regional military confrontations.

Of course, it would be best to mitigate these energy security vulnerabilities by tackling the root causes of conflict across the region. But while disruption and violence persist, energy exporters and consumers alike should guard against complacency.

A glut of oil and gas supplies globally—with low prices, growing U.S. self-sufficiency, and the conclusion of the Iranian nuclear deal—may seem to have reduced the urgency: markets have hardly responded to recent flare-ups. But major economies – even the United States – still remain dependent, directly or indirectly, on energy supplies from the MENA region. Spare oil production capacity is at unusually low levels, leaving the balance vulnerable to even a moderate interruption.

Most concern has focused on oil exports, given their importance to the world economy. But the security of liquefied natural gas (LNG) shipments is an under-appreciated risk, particularly for countries such as Japan and South Korea which are heavily dependent on LNG. A disruption would also have severe consequences for countries in the Middle East and North Africa, depriving them not only of revenues but potentially of critical imports.

Doing better 

There are three broad groups of approaches to mitigating the risk of energy transit disruptions: infrastructure, institutions, and market. 

1. Infrastructure includes the construction of bypass pipelines avoiding key choke-points and strategic storage.
   
   Existing bypass pipelines include SUMED (which avoids the Suez Canal); the Habshan-Fujairah pipeline in the UAE (bypassing Hormuz); and the Saudi Petroline, which runs to the Red Sea, hence offering an alternative to the Gulf and Hormuz. Proposed projects include a link from other Gulf Cooperation Council (GCC) countries to Oman’s planned oil terminal at Duqm on the Indian Ocean; new or rehabilitated pipelines from Iraq across Jordan and Turkey; an expansion of Petroline; and a new terminal in southern Iran at Jask.
   
   Strategic storage can be held by oil exporters, by importers, or a combination (in which exporters hold oil close to their customers’ territory, as with arrangements between Saudi Arabia and Japan, and between Abu Dhabi and Japan and India).


2. Institutional approaches include mechanisms to deal with disruptions, such as cooperative sharing arrangements.
   
   More analysis has focused on infrastructure than on institutional and market mitigation. Yet these approaches have to work together. Physical infrastructure is not enough: it has to be embedded in a suitable framework of regulation, legislation, and diplomacy. Cross-border or multilateral pipelines require agreements on international cooperation; strategic storage is most effective when rules for its use are clear, and when holders of storage agree not to hoard scarce supplies. 
   
   The effective combination of infrastructure and institutions has a strategic benefit even if it is never used. By making oil exporters and consumers less vulnerable to threats, it makes it less likely that such threats will be carried out.
   
   Alliances can be useful for mutual security and coordination. However, they raise the difficult question of whom they are directed against. Mutually-hostile alliances would be a threat to regional energy security rather than a guarantor. Organizations such as the International Energy Agency (IEA), the International Energy Forum (IEF), Organization of Petroleum Exporting Countries (OPEC), Gulf Cooperation Council, and the Association of Southeast Asian Nations (ASEAN) could all have roles, but none is ideally placed. Rather than creating another organization, reaching an understanding between existing bodies may be more effective.


3. In general, markets cope well with the task of allocating scarce supplies. Better and timelier data, such as that gathered by the IEF, can greatly improve the functioning of markets. Governments do have a role in protecting the most vulnerable consumers and ensuring sufficient energy for critical services, but price controls, rationing, and export bans have usually been counterproductive, and many of the worst consequences of so-called energy crises have come from well-meaning government interference with the normal market process of adjustment.
   
   However, it is generally difficult or impossible for a single company or country to capture all the benefits of building strategic infrastructure—which, as with a bypass pipeline, may only be required for a few months over a period of decades. International financing, perhaps backed by a major energy importer—mostly likely China—can help support such projects, particularly at a time of fiscal austerity in the Middle East.

Energy exporters within the MENA region may often find their interests divergent. But the field of energy security is one area for more fruitful cooperation—at least between groups of states, and some external players, particularly their increasingly important Asian customers. If regional tensions and conflicts cannot be easily solved, such action at least alleviates one of the serious risks of the region’s turmoil.

For more on this topic, read Robin Mills’ new analysis paper “Risky routes: Energy transit in the Middle East.”

      

       

       

       

       

There are now more than 335 Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in 47 states, DC, and Puerto Rico. Early results show that most Medicare ACOs are succeeding at meeting their quality benchmarks, but only about a quarter of MSSP participants have been able to reduce their spending enough below projected financial targets to qualify for shared savings. While these results are encouraging, especially given the financial and practice transformation necessary to succeed as an ACO, they also suggest that more work is needed from both CMS and the providers to ensure continued sustainability of the MSSP ACOs.

Given that the first three year cycle of MSSP ends in 2015 and more providers will likely be entering the MSSP in the coming years , the Centers for Medicare and Medicaid Services (CMS) has indicated that they intend to release a Notice of Proposed Rulemaking (NPRM) that will establish the rule for participation in the Medicare ACO program. In anticipation of these coming changes, the Engelberg Center for Health Care Reform released an issue brief that identifies the "Top Eight ACO Challenges" to encourage further discussion and considerations for ensuring the continued success of ACOs. These potential policy alternatives build on discussions with ACO Learning Network members and other related stakeholders implementing accountable care across the country and include the following issues.

These issues, and many others, will be a focus of the discussions at the upcoming Fifth National ACO Summit later this week.

Top Eight Medicare ACO Challenges

1. Make Technical Adjustments to Benchmarks and Payments
In order for ACOs to qualify for shared savings, they must be able to hold spending below a financial benchmark set using historical spending patterns and meet a certain threshold of person and population-level quality metrics. A number of issues should be considered that affect the ACO’s chances of being able to attain shared savings and have more predictability about their performance: benchmark calculation methodology, how to adjust for regional variation in performance, and risk adjustment.

2. Transition to More Person-Based Payments
The ultimate goal of an ACO is to improve quality at the patient and population level and control the growth of health care costs. In order to successfully achieve this mission, ACOs must over time make a transition to payments that involve the assumption of more risk by the provider organization with a reward for better health outcomes for groups of patients. ACOs must have a clear transition path for increasing accountability and assumption of more risk for patient health outcomes.

3. Increase Beneficiary Engagement
Patients can play a critical role in helping to achieve the goals of an ACO. Health outcomes are determined by whether patients follow prescribed therapies. Increasing beneficiary engagement holds the potential to make patients more activated members of the ACO who can contribute to its success. A number of issues should be considered to improve beneficiary engagement, including adjusting attribution methods, creating more incentives for patients to seek care within the ACO, and finding opportunities to activate patients as part of the care team.

4. Enhance and Improve Alignment of Performance Measures
A central tenet of Medicare ACOs is delivering high quality health care as determined by performance on 33 measures established by CMS. ACOs must meet performance benchmarks in order to be eligible for shared savings, ensuring that these organizations are delivering high value, rather than simply cheaper, care. A number of barriers exist to achieving better performance measurement, including administrative burdens, lack of measure alignment among payers, lack of rewards for quality improvement, and concerns about measure selection.

5. Enable Better and More Consistent Supporting Data
In order to succeed as an ACO, organizations must be able to effectively collect, interpret, and use clinical and claims data to transform care of their patients. ACOs need to adopt new health IT systems and other technologies in order to collect and use the growing amount of data. ACOs currently struggle with reconciling data between different sources, dealing with patients who opt out of data sharing, lack of timeliness for receiving data, difficulty of tracking patients through the health system, and delays in performance feedback.

6. Link to Additional Value-Based Payment Reforms
ACOs are just one of many payment reforms that health care organizations across the country are implementing to improve quality and reduce costs. Aligning the vision and components of these other initiatives with ACO reforms has the potential to reinforce the shared goals and fundamentally change the health system. However, there are barriers to achieving this alignment such as lacks of linkages to bundled payments and other new payment models, multi-payer ACOs with different payment systems, and inability for organizations to participate in multiple CMS payment innovations.

7. Develop Bonus Payments and Other Incentives to Participate
In order to effectively transform clinical practice, ACOs must create or procure significant financial and human capital, as well as transform their information technology and delivery infrastructure. A recent survey estimates the average start-up cost for creating an ACO to be $2 million, with some ACOs investing significantly more in their first few years. Many ACOs, especially smaller ones, struggle to find sufficient start-up capital, are uncertain if they can assume the level of risk required for an ACO, and need significant staff and clinical change to effectively transform care.

8. Support Clinical Transformation
Becoming and succeeding as an ACO is a vast undertaking that requires immediately beginning to transform practice, finance, and operations. However, many providers, particularly those that are less experienced at systemic practice transformation, need more support in undertaking clinical transformation.

Downloads

• Issue Brief: Improving the Medicare ACO Program

      

Contributors: Alice M. Rivlin and Christine Dang-Vu

Recent data suggest that Accountable Care Organizations (ACOs) are improving important aspects of care and some are achieving early cost savings, but there is a long way to go. Not all ACOs will be successful at meeting the quality and cost aims of accountable care. The private sector has to date allowed more flexibility in terms of varying risk arrangements—there are now over 250 accountable care arrangements with private payers in all parts of the country—with notable success in some cases, particularly in ACOs that have been able to move farther away from fee-for-service payments. Future growth of the Medicare ACO program will depend on providers having the incentives to become an ACO and the flexibility to assume different levels of risk, ranging from exclusively upside arrangements to partial or fully capitated payment models.

Given that the first three year cycle of Medicare ACOs ends in 2015 and more providers will be entering accountable care in the coming years, the Centers for Medicare and Medicaid Services (CMS) has indicated that they intend to release a Notice of Proposed Rulemaking (NPRM) affecting the Medicare ACO program.

In anticipation of these coming changes, the Engelberg Center for Health Care Reform has identified the "Top Eight ACO Challenges" that warrant further discussion and considerations for ensuring the continued success of ACOs across the country. To support that discussion, we also present some potential alternatives to current Medicare policies that address these concerns. These findings build on the experiences of the Engelberg Center’s ACO Learning Network members and other stakeholders implementing accountable care across the country.  In some cases, the alternatives might have short-term costs, but could also improve the predictability and feasibility of Medicare ACOs, potentially leading to bigger impacts on improving care and reducing costs over time.  In other cases, the alternatives could lead to more savings even in the short term. In every case, thoughtful discussion and debate about these issues will help lead to a more effective Medicare ACO program.

Top Eight ACO Challenges

1. Make technical adjustments to benchmarks and payments
2. Transition to more person-based payments
3. Increase beneficiary engagement
4. Enhance and improve alignment of performance measures
5. Enable better and more consistent supporting data
6. Link to additional value-based payment reforms
7. Develop bonus payments and other incentives to participate
8. Support clinical transformation

Downloads

• Issue Brief: Improving the Medicare ACO Program

      

The Centers for Medicare and Medicaid Services (CMS) recently reported more optimistic news about the Medicare Accountable Care (ACO) Program, which began in 2012.  CMS released final first year financial and quality results for the Medicare Shared Savings Program (MSSP) ACOs and preliminary year two financial and quality results for the Pioneer ACO Model (Pioneer ACOs).

Financial Results: To date, the two programs have generated savings of $817 million—$372 million of which has been saved by Medicare and another $445 that has been returned to the ACOs through shared savings. While these savings are not final calculations, they suggest that both programs have produced modest savings in the first two years with some variability across ACOs.

Pioneer ACOs: Pioneers, generally considered more advanced ACOs, were able to generate more total program savings in year two than in year one ($96 million vs. $87 million), while also qualifying for shared savings payments of $68 million. The Medicare Trust Fund saved approximately $41 million in year two of the Pioneer program. In total, Pioneer ACOs were able to achieve an approximately 1% lower spending trend overall for the Medicare population than fee-for-service (1.4 vs. 0.45 percent lower per capita growth). Seventeen of the 23 Pioneer ACOs had positive or neutral financial performance, eleven of which were able to slow health spending enough to share in savings. On average, those ACOs saved $4.2 million in 2013, up from $2.7 million in 2012; shared savings grew from $1.2 million to $13 million. Six Pioneers generated losses, three of which were significant enough to require those Pioneer ACOs to share in the losses. While remaining Pioneers have been able to attain bigger savings in year two of the program, almost a third of original participants have left the program—some have moved to the lower risk MSSP, while others have focused on commercial ACO contracts or higher levels of risk in MA programs.

MSSP ACOs: MSSP ACOs were likewise able to reduce overall cost trend by slightly less than 1 percent. Of the 220 MSSP ACOs that started in 2012 or 2013, roughly one-quarter (53) were able to reduce spending enough to qualify for total shared savings of over $300 million. An additional 52 ACOs reduced spending compared to their benchmarks, but not enough to qualify for shared savings. One ACO that opted for track two (two-sided financial risk) overspent its benchmark by $10 million and owed shared savings of $4 million. MSSP ACOs as a whole were able to reduce spending by $652 million below their financial benchmarks and saved the Medicare Trust Fund $345 million, including repayment for the track 2 ACO losses.

Quality Results
Medicare ACOs continue to improve significantly on overall quality scores.  Both Pioneer ACOs and MSSPs have been able to attain higher average performance than quality benchmarks and better performance than Medicare fee-for-service on measures with data, such as colorectal screening, tobacco cessation, and depression screening.

Pioneer ACOs: All 23 Pioneer ACOs that remain in the program out of the initial 32 successfully reported their quality measures in their first two years.  The mean quality scores for Pioneer ACOs increased by 19 percent, from 71.8 percent in 2012 to 85.2% in 2013. Pioneer ACOs increased average improvement by 14.8 percent across all quality measures and overall improvement on 28 of 33 quality measures. Patients also report a positive experience receiving care from Pioneer ACOs—the ACOs improved average performance scores for patient and caregiver experience across 6 out of 7 measures.

MSSP ACOs: MSSP ACOs, as a group, posted even more improvement in quality scores than the Pioneer ACOs. MSSP ACOs starting in 2012 and 2013 were able to improve 30 of 33 quality measures, including measures such as patients’ rating of clinicians’ communication, beneficiaries rating of doctors, health promotion and education, screening for tobacco use and cessation, and screening for high blood pressure. In total, MSSP ACOs are experiencing higher CAHPS patient experience survey scores than Medicare fee-for-service, suggesting that patients are engaged and satisfied with being a part of an ACO. Additionally, MSSP ACOs achieved higher average performance rates on 17 of 22 Group Practice Reporting Option (GPRO) Web Interface measures reported by other large physician group fee-for-service providers.  Over 125,000 eligible providers or supplier members of ACOs qualified for incentive payments through PQRS (Physician Quality Reporting System) in 2013. Unfortunately, nine MSSP ACOs failed to successfully report their quality scores, four of which would have otherwise qualified for shared savings.

Digging Deeper into the Results
While program level analysis of financial performance is meaningful, a deeper analysis of the data and organizational characteristics of those MSSP ACOs that earned shared savings reveals some interesting trends. A little over half of those earning shared savings were physician-led ACOs (26/49) and more than a third of these physician led ACOs operate in Florida (10/26). The continued success of physician-led ACOs is consistent with previous findings that these ACOs may be better positioned than institutionally-based ACO to reduce overall costs. In addition, analysis by The Center for Medicare and Medicaid Innovation (CMMI) found that there is no relationship between savings/loss performances and whether the ACO included a hospital. Hospital-led ACOs were overall less likely to share in savings than physician-led ACOs. These two findings together suggest that ACOs can experience success even without an official hospital affiliation, paving the way for more physician practices to join and excel at accountable care.

Interesting regional trends are beginning to emerge from the data. Florida and Texas had the highest concentration of ACOs sharing in savings. Of the 30 Florida-based MSSP ACOs, more than a third (11) were able to share in savings, while almost half (7/15) Texas-based MSSP ACOs qualified for shared savings. Furthermore, the top two earning MSSP ACOs were from Texas (Memorial Herman with $28.34 million) and Florida (Palm Beach ACO with $19.34 million), respectively. The concentration of shared savings in these two states raises important questions about what is driving the high level performance. Are these MSSPs more likely to succeed because of a higher financial benchmark based on disproportionately greater regional Medicare spending? Do these ACOs have a leg up from the start because of their patient population and historical spending trend? Are physician ACOs more likely to form and succeed in these higher-cost areas? The success of these programs should not be understated, but further analysis may be needed to better understand performance drivers so appropriate program adjustments may be considered to level the playing field among MSSP ACOs across all regions.

Next Steps
While these latest Medicare ACO results are encouraging, more work needs to be done. The Pioneer Program recently lost its tenth program participant, Sharp Healthcare, bringing the total number of Pioneers down to 22. Like some other Pioneers that have exited the program, Sharp was dissatisfied with the benchmark and payment methodology and was no longer willing to assume financial risk that they felt was too great. This is just one among many policy and implementation issues with which Medicare ACOs are struggling. In June, we published a set of recommendations to ensure the long-term sustainability of the Medicare ACO program by addressing eight major ACO challenges. These results seem to reinforce the need for several of these recommendations for change in the Medicare ACO Program.

CMMI, which administers the Pioneer ACO Program, has recognized some of these challenges and has begun giving ACOs some greater flexibility in operating within the program. These changes include allowing them to move to population-based payments, waiving the 3-day hospitalization rule to allow ACOs to directly admit qualified patients to skilled nursing facilities, and experimenting with “voluntary alignment” to allow beneficiaries to attest to a primary care physician to offset some of the limitations of the existing attribution process. These are moves in the right direction; however CMS must continue to engage providers across the country to make sure the program remains viable.

Meanwhile, the MSSP will add another round of participants in January 2015 and CMS is expected to release a notice of proposed rulemaking that will amend the current operating requirements for the MSSP program later this year. The scope and nature of changes could dramatically impact the interest of new organization, as well as the continued participation of current MSSP and Pioneer ACOs.  Medicare ACOs will likely be encouraged to continue innovating to improve quality and reduce costs in the Medicare program, but the Medicare ACO program must continue to evolve to meet provider and beneficiary needs to ensure continued success.

Note: This blog has been corrected since its original posting on September 22 to reflect more accurate data.

Downloads

• Changes to Medicare ACO Program

       

Editor's Note: this article originally appeared in the 2012 Print Version of AARP: The Journal.

Using one platform to offer a variety of services

Known in the UK under the term “corporate platform” to indicate that it expands options available on the employer’s benefit platform, the development allows employees to use the employer’s retirement savings mechanism to save and invest for additional nonretirement purposes. When the corporate platform is fully implemented, employees will be able to man­age almost all of their investments and savings plans from one location, thus giving them a con­solidated view of their entire financial status. If carried to its full potential, the expanded saving platform will allow employees to shop for sav­ings products, among options that are available on the platform, instead of having to seek them out from individual suppliers—a search that often takes up work hours. Of even greater value, it gives employees one source to go to for indi­vidualized advice or financial literacy training.

The enhancement has special significance in the UK, where by fall 2012, the larger employers that don’t offer any other type of pension or retirement savings plan, must begin to automatically enroll their employees into basic retirement savings accounts. This requirement is causing a great deal of discussion about the future role of employer-provided benefits, as well as recon­sideration of the fees and services included in a traditional package. The platform enhancements allow an employer to differentiate its employee benefit package from the required basic account structure. It also gives younger employees a benefit of more immediate value, than they would have from a retirement savings account that they won’t access for a good 40 years.

Presentations from a variety of service providers at an October 2011 summit hosted by Pensions Insight, a UK trade journal, showed that the platform can be easily customized to meet the special needs of a specific workforce. Using a single computer interface, employees can select from a wide variety of savings and investment options that are appropriate for their income level and stage of life. Thus, an upper income manager who manages his or her own finances could see more sophisticated products, while an entry-level worker sees more basic sav­ings products. Live presentations by financial professionals who explain what is available on the computer platform add to the system’s value and increase its use.

A place to provide choice and to build financial literacy

The platform will have special value for moderate- and lower-income employees. While higher salaried employees may appreciate the opportunity to build their investments, the real value of the platform will be to enable moder­ate- and lower-income workers to find savings opportunities that they might otherwise miss because they don’t know where to go, are uncertain about what is a fair price, or for a variety of other reasons. Because employees tend to believe that services included on the corporate platform are implicitly endorsed by the employer, they usually have greater faith that the services are from legitimate providers at a fair price.

Employees at all levels can also use the site to receive guidance on individual products or basic financial literacy training. Individuals can choose from a range of options, from short videos on a specific topic by experts or fellow employees, to longer connected courses designed to meet the needs of specific age or income groups. Use is increased when employ­ees receive emails or text messages geared to birthdays or other life events, or generated after the employee visits a specific part of the website.

Understanding the value of peer evaluations to motivate others, some providers include a place where employees can post feedback about spe­cific products or savings choices. These postings help to guide other employees’ decisions and build the reputation of the platform as a source of unbiased information. The site can also include links to outside advisors who can answer specific questions, guide employees to another site for more information, or perform other services either online or over the telephone.

Differing age groups can be contacted and guided through different technologies. At the UK platform summit, David Harris, of Tor Financial Consulting, showed that younger employees preferred different communication methods than either older workers or the usual way employers provide information. However, the platform is able to use a wide variety of methods and is equally effective no matter which is used.

The platform’s value to international policy makers

Although the UK’s platform is intended as an enhancement to employer-provided benefits, it can also be used for a wide variety of policy goals, as the basic structure can be easily adapted to meet almost any nation’s specific tax and savings system. In the United States alone, policy experts have proposed dedicated savings accounts for nonretirement purposes ranging from unemployment benefits and retraining, home purchases, health care, and long-term health care coverage, to repaying student loans or building college balances for children or grandchildren. However, if all of these various accounts were established and funded, it is doubtful the employee would have any money left for food, clothing, and shelter.

Rather than having a host of specific savings programs, employees may be better served by more flexible accounts usable for a variety of purposes, as outside developments or chang­ing needs dictate. The platform concept would allow individuals to choose which purposes they need to save for and how much to save for each. Combined with targeted guidance or education, this structure could expose individuals to pos­sibilities they might not have considered before.

The structure is ideally suited to employment situations, but it could also be used by the self-employed or by consultants at sites aimed specifically at them and sponsored by trade associations, unions, or even government agen­cies. While their circumstances may preclude payroll deductions, the same products could be offered through direct debits to bank accounts.

The added value of nudge

The flexibility of the platform allows it to be used by employees with all levels of financial sophistication, but new participants would benefit from a variation on automatic enroll­ment that places certain amounts, in addition to the retirement savings amount, into a general savings account or similar vehicle. The automatic savings amounts deducted need not be large, and where the law allows, could vary according to employee age, with a larger proportion of the overall deduction going to nonretirement purpose for younger employees and to retirement for older ones.

As with automatic retirement enrollment, the employee would have the ability to vary amounts, divide the total among various accounts, and even stop all future contributions. However, automatic enrollment would offer workers direct experience with the nonretire­ment side of the platform. By varying enrollment in various accounts according to employees’ age, automatic enrollment could encourage them to consider saving for various purposes, such as a first home, college tuition for children, or additional health services.

Improving retirement security

Although the platform is applicable to a wide variety of other uses, its primary purpose is to build retirement security. Before retirement, the platform helps employees understand how to save, what they have, and how much more they need for a comfortable lifestyle. The other savings provide funds that can be used in the event of an emergency, thus helping to reduce leakage from retirement accounts in countries that allow early access to that money. At retire­ment, the platform helps individuals to see what other assets are available, and what loans or other liabilities must be factored in. In the UK, it is also being used to encourage individuals to use annuities and add them to their invest­ments. The UK experience can help to guide US policymakers in their efforts to increase the use of similar products.

The enhanced information and flexibility of the corporate platform should help individuals to better understand their finances and how to meet their goals. It moves retirement savings plans from a minor part of employees’ financial lives, to a central feature that has many more uses than just an event many years in the future. This promotes regular use of the platform, and a fuller understanding of what is necessary for a comfortable retirement.

      

Increasingly, many Marylanders are unprepared for retirement.

The US has the broadest range of retirement savings options in the world. There are thousands of retirement products offered. But most Marylanders don’t use them.

The need is growing. The Baby Boomers are the largest generation in history. They will live longer in retirement than any generation in history.

But – financially – many are not prepared. Many have virtually no retirement savings: more than a third those within ten years of retirement age have saved less than $10,000. $10,000 invested and spent over the average person’s retirement works out to about $1,000 of income per year. Even with Social Security, that’s not much to live on.

Fears about retirement are the #1 economic concern. Many Marylanders know they’re unprepared – and they’re worried about it. Concerns about retirement security are now more broadly based than the cost of health care, fear of job loss or other economic concerns – and have been for over a decade.3 Those concerns have grown since the financial crisis, even though the stock market has recovered. Many know they’ll have to defer retirement—and many fear they will never be able to afford to retire at all.

The key to retirement saving is having a retirement plan and contributing to it every paycheck. But many businesses, including most smaller businesses, don’t offer retirement plans. As a result 1,000,000 Marylanders working in private businesses across the State don’t have a retirement plan. There are, of course, individual retirement accounts (IRAs) -- but almost no one uses them who didn’t get access through an employer-based plan via payroll deduction.

Having a plan is essential, but not a panacea. Even when plans are available, many employees don’t join. Many who do contribute and save less than they need to meet their own goals. Even with plans, many will need to save more.

The challenge continues at retirement, because most of these plans are paid out in a single lump sum payment—few plans offer reliable retirement income for life that traditional pensions do. Since most retirees do not consult financial advisors and are not financial experts themselves, some who live longer than average or are unlucky in their investments will find that they haven’t saved enough and will exhaust their savings.

They will, of course, have Social Security. That’s why it’s so important that Social Security be both preserved and strengthened. But the average monthly benefit in Maryland is about $1,300 and for most people Social Security covers only a fraction of their basic needs in retirement. Most Marylanders will need additional income from retirement savings – and the State of Maryland can help them get it.

Other states and other governments are making it easier for people to save and for private employers to help them do it. Maryland should, too. Acting now will save Maryland taxpayers millions in the future.

California, Massachusetts, and Illinois have already enacted legislation. Illinois created a new program that requires employers who have no retirement plan to automatically enroll their employees in a state-created program. Massachusetts authorized a program for uncovered employees of non-profits. California created a board to plan and propose program similar to that in Illinois. Similar legislation is being or has been introduced in some fifteen other states – states all across the country with varying political orientations, populations, and economic bases.

Although there are many variations under consideration, these programs generally provide for an automatic payroll deduction of a set amount unless the employee opts out. Funds are to be invested professionally and may be pooled to achieve higher returns and lower costs. Those who cannot or do not want to make complex financial decisions are not required to do so – their contributions are placed automatically into a reliable fund or set of funds.

In order to ensure that employers – many of whom are small businesses – can participate in a program, it must be designed to help them avoid significant disruption, expense or administrative burden. This can be accomplished by enabling employers to use current payroll processes to help their employees to build retirement security, without requiring employers to make contributions themselves.

If Maryland doesn’t act now, Maryland taxpayers will face higher costs for decades to come.

These plans are designed to be self-sustaining: their operating costs are paid for by plan contributions and the State would not assume any obligations. In practice, however, these plans will end up saving taxpayer funds: If Maryland doesn’t act now, Maryland taxpayers will face higher costs for decades to come, as retirees are forced to turn to State assistance instead of living on their own savings.

There are many ways to improve retirement security. The key is for businesses to help their employees save, without becoming overburdened themselves.

Task Force is not recommending any one approach, but strongly recommends that Maryland join other states, by developing and implementing a plan that helps Marylanders have more secure retirements.We recommend development of a specific state-based program that meets Maryland’s needs from the options discussed in our report.

Downloads

• Download the full report

       

When a new drug is approved in the United States, it is virtually impossible to know all of the risks that a population may encounter when using that product. Even though the U.S. Food and Drug Administration (FDA) requires drug manufacturers to meet rigorous standards demonstrating the drug’s safety and effectiveness for its intended use, once approved, drugs can be used by many more patients than were studied in clinical trials. This may include patients with unique clinical conditions, differing health status, ethnicity, age, or other characteristics which were not well-represented before the drug’s approval. Further, the drugs themselves can be used in different ways and in different settings than were studied. Until recently, FDA did not have the necessary tools and data access to rapidly and consistently track the risks of serious side effects of regulated drugs after approval. Recognizing this challenge, FDA has developed a pilot system to make the best use of available electronic health data using a new data and research network capable of evaluating the safety of medical products in the U.S. 

Authorized by the Food and Drug Administration Amendments Act (FDAAA) of 2007, this pilot is known as Mini-Sentinel, and is part of FDA’s larger Sentinel Initiative. Sentinel was envisioned as a national electronic system to track the safety of regulated medical products, through the use of existing health insurance claims and electronic clinical data that are generated as part of routine care. In the four years since its inception, Mini-Sentinel has made tremendous progress toward developing this system. Mini-Sentinel is comprised of insurance claims and clinical data from 18 participating data-partners, including some of the largest private health plans in the United States. In order to best protect patient privacy, the data from each partner is maintained behind each individual health plan fire-wall. This “distributed data” approach allows a single coordinating center to distribute FDA safety questions in the form of “queries,” to each of the participating data partners to be run against their own data. Aggregated summary results are then sent back to the coordinating center for final analysis. This process allows FDA to access data that can help in addressing safety questions in near real-time.  

Through Mini-Sentinel, FDA has the capability to better understand the safety outcomes using electronic health care data of approximately 169 million covered lives. This accumulation of data represents the capture of 382 million person-years of observation time and billions of prescription dispensings.[1] Examples of the types of safety questions that have already been addressed by Mini-Sentinel include the following:

• Safety concerns with drugs used to treat high blood pressure and the incidence of angioedema;
• Safety concerns with a new diabetes treatment and the incidence of heart attacks; and
• Impact of FDA regulatory actions (i.e. drug label changes) intended to mitigate serious risks of drugs.

The Mini-Sentinel pilot has demonstrated substantial progress and has proven to be a very useful tool for FDA, largely due to the strong partnerships developed between FDA, collaborating academic institutions, and private health plans. However, in order to ensure continued progress and long-term sustainability, it will be critical for progress to continue in several key areas. 

First, continued methods development and data understanding will be necessary to ensure FDA has access to the most innovative tools. The field of pharmacoepidemiology and drug safety surveillance is still young and the continued development of better study designs and analytic tools to quantify risks of serious adverse events, while accounting for many confounding factors that are inherent on observational data, will be critical. Further, as health reforms impact that way health care is delivered and financed (e.g., development of accountable care organizations and increased use of bundled payments), the electronic health data will change. It will be important to focus efforts on understanding how these changes will impact data used for safety evaluations. 

Second, it is clear that Sentinel’s contributions may extend well beyond FDA’s medical product assessments. The tools and infrastructure that have been developed by FDA over the last four years could be used as a platform to establish a national resource for a more evidence-based learning health care system. This system will enable a better understanding of not only the risks, but also benefits and best uses, of drugs in the post-market settings. 

FDA has initiated steps to ensure the long-term sustainability and impact of Sentinel infrastructure and tools. Within the next few years, FDA has proposed that Sentinel be transitioned into three main components: the Sentinel Operations Center, the Nation Resource Data Infrastructure, and the Methodological Resource for Medical Product Surveillance using Electronic Healthcare Databases. FDA has indicated that while the Sentinel Operations Center will continue to serve as FDA’s portal to the distributed database, the Nation Resource Data Infrastructure could potentially be used by other groups to support broader evidence generation. Potential groups with interest in improving our understanding of the impact of medical products and who could benefit from this framework include the National Institutes of Health, the Regan-Udall Foundation, the Patient Centered Outcomes Research Institute, and other possible stakeholder groups, such as the private industry. 

Collectively, these components will ensure that FDA continues to have the tools to engage in medical product surveillance, while ensuring the long-term sustainability of the system. In just four years, the Sentinel Initiative has laid the groundwork to transform how FDA, and the nation, benefits from electronic health care data. This network continues to foster a community of stakeholders committed the evidence generation, which will ultimately contribute to a learning health care system.

For more information on these issues, including discussion by leaders from Sentinel stakeholders, please visit the Sentinel Initiative Public Workshop event page. There you will find archived video, presentations, and further reading.

Video

• New Advances in Medical Records Reflects the Realities of the U.S. Healthcare System

       

       

Editor’s Note: This blog post is one in a series of posts in which guest bloggers respond to the Brookings paper, “The potential and limitations of impact bonds: Lessons from the first five years of experience worldwide."

Constitutional mandate for ECD in Kenya

In 2014, clause 5 (1) of the County Early Childhood Education Bill 2014 declared free and compulsory early childhood education a right for all children in Kenya. Early childhood education (ECE) in Kenya has historically been located outside of the realm of government and placed under the purview of the community, religious institutions, and the private sector. The disparate and unstructured nature of ECE in the country has led to a proliferation of unregistered informal schools particularly in underprivileged communities. Most of these schools still charge relatively high fees and ancillary costs yet largely offer poor quality of education. Children from these preschools have poor cognitive development and inadequate school readiness upon entry into primary school.

Task to the county government

The Kenyan constitution places the responsibility and mandate of providing free, compulsory, and quality ECE on the county governments. It is an onerous challenge for these sub-national governments in taking on a large-scale critical function that has until now principally existed outside of government.

In Nairobi City County, out of over 250,000 ECE eligible children, only about 12,000 attend public preschools. Except for one or two notable public preschools, most have a poor reputation with parents. Due to limited access and demand for quality, the majority of Nairobi’s preschool eligible children are enrolled in private and informal schools. A recent study of the Mukuru slum of Nairobi shows that over 80 percent of 4- and 5-year-olds in this large slum area are enrolled in preschool, with 94 percent of them attending informal private schools.

In early 2015, the Governor of Nairobi City County, Dr. Evans Kidero, commissioned a taskforce to look into factors affecting access, equity, and quality of education in the county. The taskforce identified significant constraints including human capital and capacity gaps, material and infrastructure deficiencies, management and systemic inefficiencies that have led to a steady deterioration of education in the city to a point where the county consistently underperforms relative to other less resourced counties. 

Potential role of impact bonds

Nairobi City County now faces the challenge of designing and implementing a scalable model that will ensure access to quality early childhood education for all eligible children in the city by 2030. The sub-national government’s resources and implementation capacity are woefully inadequate to attain universal access in the near term, nor by the Sustainable Development Goal (SDG) deadline of 2030. However, there are potential opportunities to leverage emerging mechanisms for development financing to provide requisite resource additionality, private sector rigor, and performance management that will enable Nairobi to significantly advance the objective of ensuring ECE is available to all children in the county.

Social impact bonds (SIBs) are one form of innovative financing mechanism that have been used in developed countries to tap external resources to facilitate early childhood initiatives. This mechanism seeks to harness private finance to enable and support the implementation of social services. Government repays the investor contingent on the attainment of targeted outcomes. Where a donor agency is the outcomes funder instead of government, the mechanism is referred to as a development impact bond (DIB).

The recent Brookings study highlights some of the potential and limitations of impact bonds by researching in-depth the 38 impact bonds that had been contracted globally as of March, 2015. On the upside, the study shows that impact bonds have been successful in achieving a shift of government and service providers to outcomes. In addition, impact bonds have been able to foster collaboration among stakeholders including across levels of government, government agencies, and between the public and private sector. Another strength of impact bonds is their ability to build systems of monitoring and evaluation and establish processes of adaptive learning, both critical to achieving desirable ECD outcomes. On the downside, the report highlights some particular challenges and limitations of the impact bonds to date. These include the cost and complexity of putting the deals together, the need for appropriate legal and political environments and impact bonds’ inability thus far to demonstrate a large dent in the ever present challenge of achieving scale.

Challenges in implementing social impact bonds in Kenya

In the Kenyan context, especially at the sub-national level, there are two key challenges in implementing impact bonds.

To begin with, in the Kenyan context, the use of a SIB would invoke public-private partnership legislation, which prescribes highly stringent measures and extensive pre-qualification processes that are administered by the National Treasury and not at the county level. The complexity arises from the fact that SIBs constitute an inherent contingent liability to government as they expose it to fiscal risk resulting from a potential future public payment obligation to the private party in the project.

Another key challenge in a SIB is the fact that Government must pay for outcomes achieved and for often significant transaction costs, yet the SIB does not explicitly encompass financial additionality. Since government pays for outcomes in the end, the transaction costs and obligation to pay for outcomes could reduce interest from key decision-makers in government.

A modified model to deliver ECE in Nairobi City County

The above challenges notwithstanding, a combined approach of results-based financing and impact investing has high potential to mobilize both requisite resources and efficient capacity to deliver quality ECE in Nairobi City County. To establish an enabling foundation for the future inclusion of impact investing whilst beginning to address the immediate ECE challenge, Nairobi City County has designed and is in the process of rolling out a modified DIB. In this model, a pool of donor funds for education will be leveraged through the new Nairobi City County Education Trust (NCCET).

The model seeks to apply the basic principles of results-based financing, but in a structure adjusted to address aforementioned constraints. Whereas in the classical SIB and DIB mechanisms investors provide upfront capital and government and donors respectively repay the investment with a return for attained outcomes, the modified structure will incorporate only grant funding with no possibility for return of principal. Private service providers will be engaged to operate ECE centers, financed by the donor-funded NCCET. The operators will receive pre-set funding from the NCCET, but the county government will progressively absorb their costs as they achieve targeted outcomes, including salaries for top-performing teachers. As a result, high-performing providers will be able to make a small profit. The system is designed to incentivize teachers and progressively provide greater income for effective school operators, while enabling an ordered handover of funding responsibilities to government, thus providing for program sustainability.

Nairobi City County plans to build 97 new ECE centers, all of which are to be located in the slum areas. NCCET will complement this undertaking by structuring and implementing the new funding model to operationalize the schools. The structure aims to coordinate the actors involved in the program—donors, service providers, evaluators—whilst sensitizing and preparing government to engage the private sector in the provision of social services and the payment of outcomes thereof.

      

       

If you live in a city or suburb, chances are your regional government has tried to get your attention. Did you notice? Many of the issues your regional government is grappling with are actually important to you: the quality of the air you breathe, the quality of public transportation, the availability of green open space, and more.

As important as these issues are, I can almost guarantee that planners from your region have had to work extra hard to convince the press -- not to mention the citizens that live and work there -- to pay attention. The problem is, regional planning is about as exciting to the public as televised bowling and the press don’t seem to find the topic as newsworthy as it should be.

And then there is Paris. In one year, approximately a hundred articles and editorials on Grand Paris, a new regional effort, were printed in the city’s main paper, Le Monde. Grand Paris has also been covered by UK newspapers, such as the Telegraph and The Guardian, and by US newspapers, such as The New York Times and The Christian Science Monitor. In my interviews with Parisian architects, economists, and sociologists, they tell me that it’s not only the press that is paying attention. Ordinary citizens on the streets and cafes are talking about Grand Paris and Paris as a region.

So what happened?

Turns out, President Sarkozy created a political and media frenzy this past year when he announced his intention to design a new Paris that incorporates the suburbs. Looking at his effort from a socio-economic perspective, Sarkozy should be lauded for his effort to reconnect the isolated suburbs to the economic heart of Paris. The 2005 riots by African immigrants in some of these suburbs gave the world a real peek into some of the inequities found here.

His push has been to look past local political boundaries and acknowledge the new Paris that is emerging -- one that is both larger in geography and socio-economically more diverse. In 2007, the metropolitan area produced more than a quarter of France’s GDP, with a Gross Metropolitan Product of $731.3 billion.

Yet, his national government cites that Paris is underdeveloped in important sectors, and that the region’s economic growth has been slowing over the past two decades. Sarkozy also saw this as an opportunity to redefine the region in a post-Kyoto era, where sustainable development is no longer an afterthought.

Sarkozy retained 10 architectural teams with heavy hitters, such as Richard Rodgers, and asked them to “think big” on how to physically redefine the Paris region. In response, they offered lofty ideas for new economic centers, new high density housing hubs, and even a Paris covered with green roofs. For a moment, one could even argue that these teams breathed a new life of possibility for Paris. 

But politics is local—even when the French President is involved. 

As it turns out, Paris already has a plan for their region; one that was formally approved by the local jurisdictions and leaders and is now simply waiting for sign off by Sarkozy’s government. This plan addresses many of the issues Sarkozy argues that the region lacks, such as the need to address the 20 years of underinvestment in public infrastructure.

It also turns out that Grand Paris flies directly in the face of the regional coalition building effort under way. An important number of leaders that comprise the region’s 1,231 jurisdictions are already forging a common agenda on cross cutting issues such as transportation and economic development. These are just two of the several missteps that have made the idea turn sour.

So what seems to have started as a visionary act to physically remake the region has turned into a story on jurisdictional entanglements and hurt egos -- and the press ate it up. Interestingly, this controversy and all the press it generated has actually been an important win for regionalism in the end.

      

November's U.S. Bureau of Labor Statistics (BLS) employment report showed continued improvement in the job market, with employers adding 211,000 workers to their payrolls and hourly pay edging up compared with its level a year ago. The pace of job growth was similar to that over the past year and somewhat slower than the pace in 2014. For the 69^th consecutive month, private-sector payrolls increased. Since the economic recovery began in the third quarter of 2009, all the nation’s employment gains have occurred as a result of expansion in private-sector payrolls. Government employment has shrunk by more than half a million workers, or about 2.5 percent. In the past twelve months, however, public payrolls edged up by 93,000.

The good news on employment gains in November was sweetened by revised estimates of job gains in the previous two months. Revisions added 8,000 to estimated job growth in September and 27,000 to job gains in October. The BLS now estimates that payrolls increased 298,000 in October, a big rebound compared with the more modest gains in August and September, when payrolls grew an average of about 150,000 a month.

Average hourly pay in November was 2.3 percent higher than its level 12 months earlier. This is a slightly faster rate of improvement compared with the gains we saw between 2010 and 2014. A tighter job market may mean that employers are now facing modestly higher pressure to boost employee compensation. The exceptionally low level of consumer price inflation means that the slow rate of nominal wage growth translates into a healthy rate of real wage improvement. The latest BLS numbers show that real weekly and hourly earnings in October were 2.4 percent above their levels one year earlier. Not only have employers added more than 2.6 million workers to their payrolls over the past year, the purchasing power of workers' earnings have been boosted by the slightly faster pace of wage gain and falling prices for oil and other commodities.

The BLS household survey also shows robust job gains last month. Employment rose 244,000 in November, following a jump of 320,000 in October. More than 270,000 adults entered the labor force in November, so the number of unemployed increased slightly, leaving the unemployment rate unchanged at 5.0 percent. In view of the low level of the jobless rate, the median duration of unemployment spells remains surprisingly long, 10.8 weeks. Between 1967 and the onset of the Great Recession, the median duration of unemployment was 10.8 weeks or higher in just seven months. Since the middle of the Great Recession, the median duration of unemployment has been 10.8 weeks or longer for 82 consecutive months. The reason, of course, is that many of the unemployed have been looking for work for a long time. More than one-quarter of the unemployed—slightly more than two million job seekers—have been jobless for at least 6 months.  That number has been dropping for more than five years, but remains high relative to our experience before the Great Recession.

If there is bad news in the latest employment report, it's the sluggish response of labor force participation to a brighter job picture. The participation rate of Americans 16 and older edged up 0.1 point in November but still remains 3.5 percentage points below its level before the Great Recession. About half the decline can be explained by an aging adult population, but a sizeable part of the decline remains unexplained. The participation rate of men and women between 25 and 54 years old is now 80.8 percent, exactly the same level it was a year ago but 2.2 points lower than it was before the Great Recession. Despite the fact that real wages are higher and job finding is now easier than was the case earlier in the recovery, the prime-age labor force participation rate remains stuck well below its level before the recession. How strong must the recovery be before prime-age adults are induced to come back into the work force? Even though the recovery is now 6 and a half years old, we still do not know.

      

Washington is again paralyzed and pulling back on clean energy economic development. Deficit politics and partisanship are firmly entrenched and the raft of federal financial supports made available through the 2009 stimulus law and elsewhere is starting to expire.

No wonder it’s hard to imagine—especially if you’re sitting in the nation’s capital—how the next phase of American clean energy industry growth will be financed or its next generation of technologies and firms supported.

And yet, one source of action lies hidden in plain sight. With federal clean energy activities largely on hold, a new paper we are releasing today as part of the Brookings-Rockefeller Project on State and Metropolitan Innovation argues that U.S. states hold out tremendous promise for the continued design and implementation of smart clean energy finance solutions and economic development.

Specifically, we contend that the nearly two dozen clean energy funds (CEFs) now running in a variety of mostly northern states stand as one of the most important clean energy forces at work in the nation and offer at least one partial response to the failure of Washington to deliver a sensible clean energy development approach.

To date, over 20 states have created a varied array of these public investment vehicles to invest in clean energy pursuits with revenues often derived from small public-benefit surcharges on electric utility bills. Over the last decade, state CEFs have invested over $2.7 billion in state dollars to support renewable energy markets, counting very conservatively.  Meanwhile, they have leveraged another $9.7 billion in additional federal and private sector investment, with the resulting $12 billion flowing to the deployment of over 72,000 projects in the United States ranging from solar installations on homes and businesses to wind turbines in communities to large wind farms, hydrokinetic projects in rivers, and biomass generation plants on farms. 

In so doing, the funds stand well positioned—along with state economic development and other officials—to build on a pragmatic success and take up the challenge left by the current federal abdication of a role on clean energy economic development.

Yet here is the rub: For all the good the funds have achieved, project-only financing—as needed as it is—will not be sufficient to drive the growth of large and innovative new companies or to create the broader economic development taxpayers demand from public investments.  Also needed will be a greater focus on the deeper-going economic development work that can help spawn whole new industries. 

All of which points to the new brand of fund activity that our paper celebrates and calls for more of. 

In recent years, increasingly ambitious efforts in a number of states have featured engagement on at least three major fronts somewhat different from the initial fund focus: (1) cleantech innovation support through research, development, and demonstration (RD&D) funding; (2) financial support for early-stage cleantech companies and emerging technologies, including working capital for companies; and (3) industry development support through business incubator programs, regional cluster promotion, manufacturing and export promotion, supply chain analysis and enhancement, and workforce training programs.

These new economic development efforts—on display in California, Massachusetts, New York, and elsewhere—show the next era of state clean energy fund leadership coming into focus. States are now poised to jumpstart a new, creative period of expanded clean energy economic development and industry creation, to complement and build upon individualistic project financing. 

Such work could not be more timely at this moment of federal gridlock and market uncertainty.

Along these lines, then, our paper advances several recommendations for moving states more aggressively into this new period of clean energy economic development. We suggest that:

• States should reorient a significant portion (at least 10 percent of the total portfolio) of state CEF money to clean energy-related economic development

• States, as they reorient portions of their CEFS to economic development, should better understand the market dynamics in their metropolitan regions.  They need to lead by making available quality data on the number of jobs in their regions, the fastest-growing companies, the critical industry clusters, gaps in the supply chain for those industries, their export potential, and a whole range of economic development and market indicators

• States also should better link their clean energy funds with economic development entities, community development finance institutions (CDFIs), development finance organizations and other stakeholders who could be ideal partners to develop decentralized funding and effective economic development programs

In addition, we think that Washington needs to recognize the strength and utility of the CEFs and actively partner with them:

• The federal government should consider redirecting a portion of federal funds (for instance, from federal technology support programs administered by the Department of Energy and other programs meant for federal-state cooperation) to provide joint funding of cluster development, export programs, workforce training, and other economic development programs  through matching dollars to state funds that now have active economic development programs, and to provide incentives to states without such programs to create them

• The federal government should create joint technology partnerships with states to advance each state’s targeted clean energy technology industries, by matching federal deployment funding with state funding.

• The states and the federal government, more generally, should look to “decentralize” financing decisions to local entities with street knowledge of their industries, relying on more “development finance” authorities that have financed traditional infrastructure and now could finance new clean energy projects and programs

In sum, our new paper proposes a much greater focus in U.S. clean energy finance on “bottom up,” decentralized clean initiatives that rely on the states to catalyze regional economic development in regions. Such an approach—which reflects the emergence of an emerging “pragmatic caucus” in U.S. economic life—is currently demanded by federal inaction. However, it might also be the smartest, most durable way to develop the clean energy industries of the future without the partisan rancor and obtuseness that has stymied federal energy policy. State clean energy funds—having funded thousands of individual projects—bring significant knowledge to bear as they focus now on building whole industries. For that reason, the funds’ transition from project development to industry creation should be nurtured and supported.

       

       

Analysis of dozens of publicly created redistricting plans shows that map-making technology can improve political representation and detect a gerrymander.  In 2012, President Obama won the vote in Ohio by three percentage points, while Republicans held a 13-to-5 majority in Ohio’s delegation to the U.S. House. After redistricting in 2013, Republicans held 12 of Ohio’s House seats while Democrats held four. As is typical in these races, few were competitive; the average margin of victory was 32 points. Is this simply a result of demography, the need to create a majority-minority district, and the constraints traditional redistricting principles impose on election lines—or did the legislature intend to create a gerrymander?

Crowd-Sourced Redistricting Maps

In the Ohio elections, we have a new source of information that opens a window into the legislature’s choice: Large numbers of publicly created redistricting plans.

During the last round of redistricting, across the country thousands of people in over a dozen states created hundreds of legal redistricting plans. Advances in information technology and the engagement of grassroots reform groups made these changes possible. To promote these efforts we created the DistrictBuilder open redistricting platform and many of these groups used this tool to create their plans.

Over the last several years, we have used the trove of information produced by public redistricting to gain insight into the politics of representation. In previous work that analyzed public redistricting in Virginia^[1], and in Florida^[2], we discovered that members of the public are capable of creating legal redistricting plans that outperform those maps created by legislatures in a number of ways.

Public redistricting in Ohio shows something new—the likely motives of the legislature. This can be seen through using information visualization methods to show the ways in which redistricting goals can be balanced (or traded-off) in Ohio , revealing the particular trade-offs made by the legislature.

The figure below, from our new research paper^[3], shows 21 plots—each of which compares legislative and publicly-created plans using a pair of scores—altogether covering seven different traditional and representational criteria. A tiny ‘A’ shows the adopted plan. The top-right corner of each mini-plot shows the best theoretically possible score. When examined by itself, the legislative plan meets a few criteria: it minimizes population deviation, creates an expected majority-minority seat, and creates a substantial majority of districts that would theoretically be competitive in an open-seat race in which the statewide vote was evenly split.

Figure 1: Pairwise Congressional Score Comparisons (Scatterplots) - Standardized Scores

In previous rounds of redistricting, empirical analysis would stop here—unless experts were called in to draw alternative plans in litigation. However, the large number of public plans now available allows us to see other options, plans the legislature could readily have created had it desired to do so. Comparison of the adopted plans and public plans reveal the weakness of the legislature’s choice. Members of the public were able to find plans that soundly beat the legislative plan on almost every pair of criteria, including competitive districts.

So why was the adopted plan chosen? Information visualization can help here, as well, but we need to add another criterion—partisan advantage:

Pareto Frontier: Standard Criteria vs. Democratic Surplus

When we visualize the number of expected Democratic seats that was likely to result from each plan, and compare this to the other score, we can see that the adopted plan is the best at something— producing Republican seats.

Was Ohio gerrymandered? Applying our proposed gerrymandering detection method, the adopted plans stands in high contrast to the public sample of plans, even if the overall competition scoring formula is slightly biased towards the Democrats, as strongly biased towards the Republicans on any measure of partisan fairness. Moreover analyzing the tradeoffs among redistricting criteria illuminate empirically demonstrates what is often suspected, but is typically impossible to demonstrate—that had the legislature desired to improve any good-government criterion—it could have done so, simply by sacrificing some partisan advantage. In light of this new body of evidence, the political intent of the legislature is clearly displayed.

However, when politics and technology mix, beware of Kranzberg’s first law: “Technology is neither good nor bad; nor is it neutral.”^[4] Indeed there is an unexpected and hopeful lesson on reform revealed by the public participation that was enabled by new technology. The public plans show that, in Ohio, it is possible to improve the expected competitiveness, and to improve compliance with traditional districting principles such as county integrity, without threatening majority-minority districts simply by reducing partisan advantage—this is a tradeoff we should gladly accept.

       

       

       

       

       

I had been mulling a rebuttal to my colleague and friend Jon Rauch’s interesting—but wrong—new Brookings paper praising the role of “hacks, machines, big money, and back room deals” in democracy. I thought the indictments of Chris Christie’s associates last week provided a perfect example of the dangers of all of that, and so of why Jon was incorrect. But in yesterday’s L.A. Times, he beat me to it, himself defending the political morality (if not the efficacy) of their actions, and in the process delivering a knockout blow to his own position.

Bridgegate is a perfect example of why we need fewer "hacks, machines, big money, and back room deals" in our politics, not more. There is no justification whatsoever for government officials abusing their powers, stopping emergency vehicles and risking lives, making kids late for school and parents late for their jobs to retaliate against a mayor who withholds an election endorsement. We vote in our democracy to make government work, not break. We expect that officials will serve the public, not their personal interests. This conduct weakens our democracy, not strengthens it.

It is also incorrect that, as Jon suggests, reformers and transparency advocates are, in part, to blame for the gridlock that sometimes afflicts our American government at every level. As my co-authors and I demonstrated at some length in our recent Brookings paper, “Why Critics of Transparency Are Wrong,” and in our follow-up Op-Ed in the Washington Post, reform and transparency efforts are no more responsible for the current dysfunction in our democracy than they were for the gridlock in Fort Lee. Indeed, in both cases, “hacks, machines, big money, and back room deals” are a major cause of the dysfunction. The vicious cycle of special interests, campaign contributions and secrecy too often freeze our system into stasis, both on a grand scale, when special interests block needed legislation, and on a petty scale, as in Fort Lee. The power of megadonors has, for example, made dysfunction within the House Republican Caucus worse, not better.

Others will undoubtedly address Jon’s new paper at length. But one other point is worth noting now. As in foreign policy discussions, I don’t think Jon’s position merits the mantle of political “realism,” as if those who want democracy to be more democratic and less corrupt are fluffy-headed dreamers. It is the reformers who are the true realists. My co-authors and I in our paper stressed the importance of striking realistic, hard-headed balances, e.g. in discussing our non-absolutist approach to transparency; alas, Jon gives that the back of his hand, acknowledging our approach but discarding the substance to criticize our rhetoric as “radiat[ing] uncompromising moralism.” As Bridgegate shows, the reform movement’s “moralism" correctly recognizes the corrupting nature of power, and accordingly advocates reasonable checks and balances. That is what I call realism. So I will race Jon to the trademark office for who really deserves the title of realist!

      

       

SUMMARY:
With the U.S. poverty rate stuck at around 15 percent for years, it’s clear that something needs to change, and candidates need to focus on three pillars of economic advancement-- education, work, family -- to increase economic mobility, according to Brookings Senior Fellow Isabel Sawhill and Senior Research Assistant Edward Rodrigue.

“Economic success requires people’s initiative, but it also requires us, as a society, to untangle the web of disadvantages that make following the sequence difficult for some Americans. There are no silver bullets. Government cannot do this alone. But government has a role to play in motivating individuals and facilitating their climb up the economic ladder,” they write.

The pillar of work is the most urgent, they assert, with every candidate needing to have concrete jobs proposals. Closing the jobs gap (the difference in work rates between lower and higher income households) has a huge effect on the number of people in poverty, even if the new workers hold low-wage jobs. Work connects people to mainstream institutions, helps them learn new skills, provides structure to their lives, and provides a sense of self-sufficiency and self-respect, while at the aggregate level, it is one of the most important engines of economic growth. Specifically, the authors advocate for making work pay (EITC), a second-earner deduction, childcare assistance and paid leave, and transitional job programs. On the education front, they suggest investment in children at all stages of life: home visiting, early childhood education, new efforts in the primary grades, new kinds of high schools, and fresh policies aimed at helping students from poor families attend and graduate from post-secondary institutions. And for the third prong, stable families, Sawhill and Rodrique suggest changing social norms around the importance of responsible, two-person parenthood, as well as making the most effective forms of birth control (IUDs and implants) more widely available at no cost to women.

“Many of our proposals would not only improve the life prospects of less advantaged children; they would pay for themselves in higher taxes and less social spending. The candidates may have their own blend of responses, but we need to hear less rhetoric and more substantive proposals from all of them,” they conclude.

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We can be sure that the 2016 presidential candidates, whoever they are, will be in favor of promoting opportunity and cutting poverty. The question is: how? In our contribution to a new volume published today, “Campaign 2016: Eight big issues the presidential candidates should address,” we show that people who clear three hurdles—graduating high school, working full-time, and delaying parenthood until they in a stable, two-parent family—are very much more likely to climb to middle class than fall into poverty:

But what specific policies would help people achieve these three benchmarks of success?  Our paper contains a number of ideas that candidates might want to adopt. Here are a few examples: 

1. To improve high school graduation rates, expand “Small Schools of Choice,” a program in New York City, which replaced large, existing schools with more numerous, smaller schools that had a theme or focus (like STEM or the arts). The program increased graduation rates by about 10 percentage points and also led to higher college enrollment with no increase in costs.

2. To support work, make the Child and Dependent Care Tax Credit (CDCTC) refundable and cap it at $100,000 in household income. Because the credit is currently non-refundable, low-income families receive little or no benefit, while those with incomes above $100,000 receive generous tax deductions. This proposal would make the program more equitable and facilitate low-income parents’ labor force participation, at no additional cost.

3. To strengthen families, make the most effective forms of birth control (IUDs and implants) more widely available at no cost to women, along with good counselling and a choice of all FDA-approved methods. Programs that have done this in selected cities and states have reduced unplanned pregnancies, saved money, and given women better ability to delay parenthood until they and their partners are ready to be parents. Delayed childbearing reduces poverty rates and leads to better prospects for the children in these families.

These are just a few examples of good ideas, based on the evidence, of what a candidate might want to propose and implement if elected. Additional ideas and analysis will be found in our longer paper on this topic.

      

The issue of paid leave is heating up in 2016. At least two presidential candidates — Democrat Hillary Clinton and Republican Sen. Marco Rubio (Fla.) — have proposed new federal policies. Several states and large cities have begun providing paid leave to workers when they are ill or have to care for a newborn child or other family member.

This forward movement on paid-leave policy makes sense. The United States is the only advanced country without a paid-leave policy. While some private and public employers already provide paid leave to their workers, the workers least likely to get paid leave are low-wage and low-income workers who need it most. They also cannot afford to take unpaid leave, which the federal government mandates for larger companies.

Paid leave is good for the health and development of children; it supports work, enabling employees to remain attached to the labor force when they must take leave; and it can lower costly worker turnover for employers. Given the economic and social benefits it provides and given that the private market will not generate as much as needed, public policies should ensure that such leave is available to all.

But it is important to do so efficiently, so as not to burden employers with high costs that could lead them to substantially lower wages or create fewer jobs.

States and cities that require employers to provide paid sick days mandate just a small number, usually three to seven days. Family or temporary disability leaves that must be longer are usually financed through small increases in payroll taxes paid by workers and employers, rather than by employer mandates or general revenue.

Policy choices could limit costs while expanding benefits. For instance, states should limit eligibility to workers with experience, such as a year, and it might make sense to increase the benefit with years of accrued service to encourage labor force attachment. Some states provide four to six weeks of family leave, though somewhat larger amounts of time may be warranted, especially for the care of newborns, where three months seems reasonable.

Paid leave need not mean full replacement of existing wages. Replacing two-thirds of weekly earnings up to a set limit is reasonable. The caps and partial wage replacement give workers some incentive to limit their use of paid leave without imposing large financial burdens on those who need it most.

While many states and localities have made sensible choices in these areas, some have not. For instance, the D.C. Council has proposed paid-leave legislation for all but federal workers that violates virtually all of these rules. It would require up to 16 weeks of temporary disability leave and up to 16 weeks of paid family leave; almost all workers would be eligible for coverage, without major experience requirements; and the proposed law would require 100 percent replacement of wages up to $1,000 per week, and 50 percent coverage up to $3,000. It would be financed through a progressive payroll tax on employers only, which would increase to 1 percent for higher-paid employees.

Our analysis suggests that this level of leave would be badly underfunded by the proposed tax, perhaps by as much as two-thirds. Economists believe that payroll taxes on employers are mostly paid through lower worker wages, so the higher taxes needed to fully fund such generous leave would burden workers. The costly policy might cause employers to discriminate against women.

The disruptions and burdens of such lengthy leaves could cause employers to hire fewer workers or shift operations elsewhere over time. This is particularly true here, considering that the D.C. Council already has imposed costly burdens on employers, such as high minimum wages (rising to $11.50 per hour this year), paid sick leave (although smaller amounts than now proposed) and restrictions on screening candidates. The minimum wage in Arlington is $7.25 with no other mandates. Employers will be tempted to move operations across the river or to replace workers with technology wherever possible.

Cities, states and the federal government should provide paid sick and family leave for all workers. But it can and should be done in a fiscally responsible manner that does not place undue burdens on the workers themselves or on their employers.

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Editor's note: this piece originally appeared in The Washington Post. 

      

On April 2, 2011, Ethiopia embarked upon the construction of what is expected to be the biggest hydroelectric power plant in Africa.  Called the Grand Ethiopian Renaissance Dam (GERD), it will be located on the Blue Nile, 40 kilometers (25 miles) from the border with the Republic of Sudan and will have the capacity to produce 6,000 megawatts of electricity.  The GERD, once completed and made operational, is expected to ameliorate chronic domestic energy shortages, help the country’s households (especially those located in the rural areas) switch to cleaner forms of energy and allow the government to earn foreign exchange through the exportation of electricity to other countries in the region.  Although authorities in Addis Ababa believe that the dam will contribute  significantly to economic growth and development—not just in Ethiopia, but also in neighboring countries, such as Sudan—its construction has been very controversial.  The major controversies revolve around Ethiopia’s decision to fund the building of the dam from its own sources and the potential impacts of the dam on downstream countries, especially Egypt.  

Ethiopia opted to source funds for the construction of the GERD through selling bonds to citizens at home and abroad.  Government employees have been encouraged to devote as much as one or two months of their salaries to the purchasing of the GERD bonds.  Most public workers in Ethiopia earn relatively low wages and face a significantly high cost of living.  Hence, they are not likely to be able to sacrifice that much of their salaries to invest in this national project.  Nevertheless, many of them have been observed purchasing the GERD bonds, primarily because of pressure from the government and the belief that participation in this national project is a show of one’s patriotism.

The government of Ethiopia has also encouraged the private sector to invest in the GERD project.  Specifically, private domestic banks and other business enterprises are expected to purchase millions of Birr worth of these bonds.  The government also hopes that Ethiopians in the diaspora will contribute significantly to this massive effort to develop the country’s hydroelectric power resources.  However, many Ethiopians in the diaspora have not been willing to invest in the GERD project, citing pervasive corruption in the public sector and dictatorial government policies as reasons why they would not commit the resources necessary to move the project forward.  Additionally, Ethiopians living outside the country have argued that the present government in Addis Ababa continues to impede the country’s transition to democracy by making it virtually impossible for opposition parties to operate, using draconian laws (e.g., anti-terrorism laws) to silence legitimate protests and generally denying citizens the right to express themselves.  For these reasons, many of them have refused to invest in the GERD project.  Finally, Ethiopia’s traditional development partners, including such international organizations as the World Bank and the International Monetary Fund, appear to be unwilling to lend the country the necessary funds for the construction of the dam given the controversies surrounding the dam and their policies on the building of megadams.

Egypt has registered its opposition to the construction of the GERD.  In fact, before he was ousted, former Egyptian president Mohamed Morsi made it known to authorities in Addis Ababa that Egypt would not support the project.  The Egyptians, as they have done before, have invoked the Anglo-Egyptian Treaty of 1929, which granted Egypt veto power over all construction projects on the Nile River and its tributaries.  According to Cairo, then, Ethiopia was supposed to obtain permission from Egypt before embarking on the GERD project.

In May 2010, five upstream riparian states (Ethiopia, Kenya, Uganda, Rwanda and Tanzania) signed the Nile Basin Cooperative Framework Agreement (CFA), which, they argue, would provide the mechanism for the equitable and fair use of Nile River waters.  On June 13, 2013, the Ethiopian Parliament ratified the CFA and incorporated it into domestic law.  The other four signatories have not yet ratified the treaty but plan to do so eventually.  Egypt and Sudan, however, have refused to sign the CFA and continue to argue that the 1929 Anglo-Egyptian Treaty, as well as the 1959 bilateral agreement between Egypt and Sudan, represent the only legal mechanisms for Nile River governance.  Recently, however, the government of Sudan has indicated its support for the GERD, and South Sudan, which gained its independence from Khartoum on July 9, 2011, does not oppose the project either.

Significant increases in population in Egypt, the need for the country to expand its irrigated agricultural base, as well as other industrial needs have significantly increased the country’s demand for water.  Unfortunately for Egyptians, the only viable source of water in the country is the Nile River.  Thus, Egyptians, as made clear by their leaders, are not willing to relinquish even one drop of water.  The country’s bitter opposition to the GERD stems from the fact that it will reduce the flow of water into the Nile River and force Egyptians to live with less water than now.  Egyptian leaders are not willing to accept the assertion made by the Ethiopian government that the construction of the dam will not significantly reduce the flow of water from the Blue Nile into Egypt.  Thus, Cairo has hinted that it would employ all means available to stop the construction of the GERD.

The site of the GERD was identified during geological surveys conducted between 1956 and 1964 by the United States Bureau of Reclamation.  Although studies determining the feasibility of a dam on the Blue Nile were completed almost half a century ago, previous Ethiopian governments did not make any attempt to build such a structure on the Blue Nile.  This inaction may have been due to Egypt’s ability to lobby the international donor community and prevent it from providing Addis Ababa with the necessary financial resources to complete the project, Ethiopia’s chronic internal political instability, or Egypt’s military strength and its strong ties with neighboring Sudan (the latter shares the same interests as Egypt regarding the waters of the Nile River).  In fact, the 1929 Anglo-Egyptian Treaty and the 1959 bilateral agreement between Sudan and Egypt granted both countries complete control of all the waters of the Nile River.

Since the ouster of Hosni Mubarak, Egypt has been weakened significantly, politically, economically and militarily.  The struggle between the military and civil society for control of the government has been a major distraction to the Egyptian military, and it is unlikely that it can effectively face a relatively strong and more assertive Ethiopian military.  Hence, it appears that this might be the most opportune time for Ethiopia to initiate such a construction project.  Perhaps more important is the fact that virtually all of the upstream riparian states are no longer willing to allow both Egypt and Sudan to continue to monopolize the waters of the Nile River.  In addition, Ethiopia is relatively at peace and maintains good relations with its neighbors, particularly the Republic of Sudan, which would be critical in any successful attack on Ethiopia by Egypt.  Of course, Addis Ababa has also invoked and relied on the Cooperative Framework Agreement which, besides Ethiopia, has been signed by four other upstream riparian States—the CFA favors the equitable and fair use of the waters of the Nile River.  Authorities in Addis Ababa believe that the GERD will contribute to such fair and equitable use; after all, the Blue Nile (which is located in Ethiopia) provides 86 percent of the water that flows into the Nile River.  Up to this point, Ethiopia has made virtually no use of that water, allowing Egypt and Sudan alone to dictate its usage.

Critics of the GERD, including some Ethiopians within and outside the country, argue that Addis Ababa initiated the building of the dam just to divert public attention away from internal political tensions associated with lack of religious freedom, human rights violations, suppression of the press, and the economic and political polarization that has become pervasive throughout the country during the last several decades. 

Given the economic significance of the Blue Nile for the source country (Ethiopia) and downstream countries (Egypt and Sudan), it is critical that these countries engage in constructive dialogue to find a mutually beneficial solution for the project.  Such negotiations should take into consideration the fact that the status quo, characterized by Egyptian monopolization of the waters of the Nile River and the exclusion of Ethiopia from exploiting its own water resources for its development, cannot be maintained.  Thus, the construction of the GERD should be taken as a given and the three countries—Egypt, Sudan and Ethiopia—should find ways to maximize the benefits of the dam and minimize its negative impacts on the downstream countries.  As part of that negotiation, both Egypt and Sudan should abandon their opposition to the CFA, sign it and encourage their legislatures to ratify it.  The Nile River and its tributaries should be considered common property belonging to all Nile River Basin communities and should be managed from that perspective.