SUMMARY

Replacing inefficient kerosene lighting with electric lighting or other clean alternatives can rapidly achieve development and energy access goals, save money and reduce climate warming. Many of the 250 million households that lack reliable access to electricity rely on inefficient and dangerous simple wick lamps and other kerosene-fueled light sources, using 4 to 25 billion liters of kerosene annually to meet basic lighting needs. Kerosene costs can be a significant household expense and subsidies are expensive. New information on kerosene lamp emissions reveals that their climate impacts are substantial. Eliminating current annual black carbon emissions would provide a climate benefit equivalent to 5 gigatons of carbon dioxide reductions over the next 20 years. Robust and low-cost technologies for supplanting simple wick and other kerosene-fueled lamps exist and are easily distributed and scalable. Improving household lighting offers a low-cost opportunity to improve development, cool the climate and reduce costs.

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INTRODUCTION

If you are one of those government officials, finance experts, development professionals or NGO members whose eyes glaze over when you see an article on procurement, you are the audience I want to address. Procurement is the purchase of works, goods and services by individuals or firms, or government entities in the case of public procurement. We all make procurement decisions in our everyday lives. We pride ourselves on making good decisions and being able to apply discretion and judgment. Now imagine if you were improving your home and were constrained by pages and pages of legal and technical regulations that take away that discretion. You would soon question whether those regulations were relevant and whether they provide any value or simply delayed and jeopardized good decision-making. Worse yet, imagine if you had to follow rules that someone else outside your family, your community or your country set for you. While public procurement requires a higher standard of governance than personal procurement, developing countries and other stakeholders are raising these questions regarding the policies set by multilateral aid institutions.

In November 2013, the World Bank released the report of its first stage efforts in reforming its procurement policy as it relates to the projects it finances. As the World Bank enters the second stage in designing the actual reforms, the “development community” faces a crucial moment and opportunity to refine and reform a fundamental instrument in the development toolbox—one that has been treated for too long as a “plumbing and wiring” issue that ignores the broader public policy implications and the growing burden of conflicting objectives, regulations, incentives and political polemics. The purpose of this paper is to examine concerns regarding reform of multilateral agencies’ public procurement policies, enhance awareness of what is at stake and lay the groundwork for the reform discussions at development institutions that will take place over the next year.

I should alert you, however, that I am neither a procurement specialist, nor am I a lawyer or an engineer. I would describe myself as a development practitioner. After decades of working on infrastructure projects and on multilateral operational policy, I have maintained a deep respect for my procurement colleagues who have protected my proverbial “backside.” One quickly learns in this business that a mistake in procurement can result in serious consequences as one sits in the middle of the converging, and often conflicting, interests of governments, donors, private sector and, of course, affected communities. The procurement policies applied by the multilateral finance institutions have been responsible for enhancing competition, deepening transparency and raising the integrity of investment in developing countries, as well as opening markets for developed and developing countries’ businesses. As the world of public procurement has evolved, however, one also learns that procurement is becoming more than just getting the “plumbing and wiring” right. Indeed, the role and application of public procurement policies and practices is an essential element of design and implementation with crucial consequences for the quality of outcomes. The case set forth in this paper lays out the factors driving the need for major reform of multilateral banks’ procurement policies—rather than simply adapting existing policies. This paper also presents the major challenges to be addressed in designing the reforms and the tensions to be resolved or balanced as the World Bank enters the more detailed design stage of its reform effort.

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In the developing world, more than 200 million children under the age of five years are at risk of not reaching their full development potential because they suffer from the negative consequences of poverty, nutritional deficiencies and inadequate learning opportunities. Overall, 165 million children (one in four) are stunted, and 90 percent of these children live in Africa and Asia. And though some progress has been made globally, child malnutrition remains a serious public health problem with enormous human and economic costs. Worldwide, only about 50 percent of children are enrolled in preprimary education, and in low-income countries a mere 17 percent. And though more and more children are going to school, millions have little to show for it. By some accounts, 250 million children of primary school age cannot read even part of a sentence. Some of these children have never been to school (58 million); but more often, they perform poorly despite having spent several years in school, which reflects not only the poor quality of many schools but also the multiple disadvantages that characterize their early life.

Ensuring that all children—regardless of their place of birth and parental income or education level—have access to opportunities that will allow them to reach their full potential requires investing early in their development. To develop their cognitive, linguistic, socioemotional and physical skills and abilities, children need good nutrition and health, opportunities for play, nurture and learning with caregivers, early stimulation and protection from violence and neglect.

The Case for Early Interventions 

The arguments for investing in children early are simple and convincing. Early investment makes sense scientifically. The brain is almost fully developed by age three, providing a prime opportunity to achieve high gains. We know that the rapid rate of development of the brain’s neural pathways is responsible for an individual’s cognitive, social and emotional development, and there is solid evidence that nutrition and stimulation during the first 1,000 days of life are linked to brain development. 

Early investment makes sense in terms of equity. The playing field has the highest chances of being leveled early on, and we know that programs have a higher impact for young children from poorer families. In the United States, for example, increasing preschool enrollment to 100 percent for low-income children would reduce disparities in school readiness by 24 percent between black and white children and by 35 percent between Hispanic and white children. We also know that equalizing initial endowments through early childhood development (ECD) programs is far more cost-effective than compensating for differences in outcomes later in life. 

Early investment makes sense economically. Investing early prevents higher costs down the road, and interventions yield a high return on investment. There is evidence of the benefits for the individual and for society more broadly. For instance, at the level of the individual, in Jamaica children participating in an early childhood stimulation program were found to have 25 percent higher earnings 20 years later compared with children who did not participate. At the economy-wide level, eliminating malnutrition is estimated to increase gross domestic product by 1 to 2 percentage points annually, while countries with school systems that have a 10-percentage-point advantage in the proportion of students

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The United Nations will convene a major international conference on Financing for Development (FfD) in Addis Ababa, Ethiopia from July 13 to 16, 2015, to discuss financing for the post-2015 agenda on sustainable development. This conference, the third of its kind, will hope to replicate the success of the Monterrey conference in 2002 that has been credited with providing the glue to bind countries to the pursuit of the Millennium Development Goals (MDGs).

The analogy is pertinent but should not be taken too far. The most visible part of the Monterrey Consensus was the commitment by rich countries to “make concrete efforts towards the target of 0.7 percent of gross national product” as official development assistance (ODA). This was anchored in a clear premise that “each country has primary responsibility for its own economic and social development,” which includes support for market-oriented policies that encourage the private sector. While not all of the Monterrey targets have been met, there has been a considerable increase in resources flowing to developing countries, as a central plank of efforts to achieve the MDGs.

Today, aid issues remain pivotal for a significant number of countries, but they are less relevant for an even larger number of countries. The core principles of Monterrey need to be reaffirmed again in 2015, but if the world is to follow-through on a universal sustainable development agenda, it must address the multi-layered financing priorities spanning all countries. A simple “30-30-130” mnemonic helps to illustrate the point. There are 193 U.N. member states. Of these, only around 30 are still low-income countries (33 at the latest count). These are the economies that are, and will continue to be, the most heavily dependent on aid as the world looks to how it should implement the sustainable development goals (SDGs). Conversely, there are only around 30 “donor” countries (including 28 members of the OECD Development Assistance Committee, or DAC) that have made international commitments to provide more aid. For the remaining 130 or so emerging middle-income economies that have achieved higher levels of average prosperity, aid discussions risk forming a sideshow to the real issues that constrain their pursuit of sustainable development. The bottom line is that for most countries, the Financing for Development conference should unlock finance from many different sources, including but not exclusively aid, to implement the SDGs.

Addis will take place in the context of sluggish global growth, an upsurge in conflict, considerable strains in multilateral 2 political cooperation, and challenging ODA prospects in many countries.

There are other differences between Addis and Monterrey. Monterrey took place after agreement had been reached on the MDGs, while Addis will precede formal agreement on the SDGs by a few months. Monterrey was focused on a government-to-government agreement, while Addis should be relevant to a far larger number of stakeholders—including businesses, academics, civil society, scientists, and local authorities. Monterrey was held against a backdrop of general optimism about the global economy and widespread desire for intensified international collaboration following the terrorist events of September 11, 2001. Meanwhile, Addis will take place in the context of sluggish global growth, an upsurge in conflict, considerable strains in multilateral political cooperation, and challenging ODA prospects in many countries. In addition, regulators are working to reduce risk-taking by large financial institutions, increasing the costs of providing long-term capital to developing countries.

Against this backdrop, an Intergovernmental Committee of Experts on Sustainable Development Finance (ICESDF) crafted a report for the United Nations on financing options for sustainable development. The report provides an excellent overview of issues and the current state of global financing, and presents over 100 recommendations. But it falls short on prescribing the most important priorities and action steps on which leaders should focus at Addis.

This paper seeks to identify such a priority list of actions, with emphasis on the near-term deliverables that could instigate critical changes in trajectories towards 2030. At the same time, the paper does not aim to describe the full range of outcomes that need to be in place by roughly 2025 in order to achieve the SDGs by their likely deadline of 2030. Addis will be a critical forum to provide political momentum to a few of the many useful efforts already underway on improving global development finance. Time is short, so there is limited ability to introduce new topics or ideas or to build consensus where none already exists.

We identify three criteria for identifying top priorities for agreement in Addis:

• Priorities should draw from, and build on, on-going work—including the ICESDF report and the outputs „„of several other international workstreams on finance that are underway.
• Agreements should have significant consequences for successful implementation of the SDGs at the coun„„try, regional or global level.
• Recommendations should be clearly actionable, with next steps in implementation that are easy to under„„stand and easy to confirm when completed.

It is not necessary (or desirable) that every important topic be resolved in Addis. In practical terms, negotiators face two groups of issues. First are those on which solutions can be negotiated in time for the July conference. Second are those for which the problems are too complex to be solved by July, but which are still crucial to be resolved over the coming year or two if the SDGs are to be achieved. For this second group of issues, the intergovernmental agreement can set specific timetables for resolving each problem at hand. There is some precedent for this, including in the 2005 U.N. World Summit, which included timetables for some commitments. What is most critical is that the moment be used to anchor and advance processes that will shift toward creating a global financing system for achieving sustainable development across all countries. Committing to timetables for action and building on reforms already undertaken could be important ways of enhancing the credibility of new agreements.

In this paper, we lay out nine areas where we believe important progress can be made. In each area, we start from identifying a gap or issue that could present an obstacle to the successful implementation of the SDGs if left unattended. In some cases the gaps will affect all countries, in other cases only a subset of countries. But we believe that the package of actions, taken as a whole, reflects a balance of opportunities, responsibilities and benefits for all countries. We also believe that by making the discussion issue-focused, the needs for financing can be balanced with policy actions that will be required to make sure financing is effectively and efficiently deployed.

In addition to the nine areas listed below, there are other commitments already made which have not yet been met. We urge renewed efforts to meet these commitments, but also recognize that political and financial realities must be managed to make progress. Such commitments include meeting the Monterrey Consensus target to provide 0.7 percent of GNI in official development assistance (ODA), the May 2005 agreement of all EC-15 countries to reach that target by 2015, and bringing the Doha Development Round of trade talks to a successful conclusion. These remain important and relevant, but in this paper we choose to focus on new areas and fresh ideas so as to avoid treading over well-worn territory again.

Most sub-Saharan African countries have long had to rely on foreign assistance or loans from international financial institutions to supply part of their foreign currency needs and finance part of their domestic investment, given their low levels of domestic saving. But now many of them, for the first time, are able to borrow in international financial markets, selling so-called eurobonds, which are usually denominated in dollars or euros. 

The sudden surge in the demand for international sovereign bonds issued by countries in a region that contains some of the world’s poorest countries is due to a variety of factors—including rapid growth and better economic policies in the region, high commodity prices, and low global interest rates. Increased global liquidity as well as investors’ diversification needs, at a time when the correlation between many global assets has increased, has also helped increase the attractiveness of the so-called “frontier” markets, including those in sub-Saharan Africa. At the same time, the issuance of international sovereign bonds is part of a number of African countries’ strategies to restructure their debt, finance infrastructure investments, and establish sovereign benchmarks to help develop the sub-sovereign and corporate bond market. The development of the domestic sovereign bond market in many countries has also help strengthen the technical capacity of finance ministries and debt management offices to issue international debt.

Whether the rash of borrowing by sub-Saharan governments (as well as a handful of corporate entities in the region) is sustainable over the medium to long term, however, is open to question. The low interest rate environment is set to change at some point—both raising borrowing costs for the countries and reducing investor interest. In addition, oil prices are falling, which makes it harder for oil-producing countries to service or refinance their loans. In the medium term, heady economic growth may not continue if debt proceeds are only mostly used for current spending, and debt is not adequately managed.

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Strong Growth and Changing Composition 

External financial flows to sub-Saharan Africa (defined as the sum of gross private capital flows, official development assistance (ODA), and remittances to the region) have not only grown rapidly since 1990, but their composition has also changed significantly. The volume of external flows to the region increased from $20 billion in 1990 to above $120 billion in 2012. Most of this increase in external flows to sub-Saharan Africa can be attributed to the increase in private capital flows and the growth of remittances, especially since 2005 (see Figure 1).

Figure 1. Sub-Saharan Africa: External Flows (1990-2012, in USD billions)

As also displayed in Figure 1, in 1990 the composition of external flows to sub-Saharan Africa was about 62 percent ODA, 31 percent gross inflows from the private sector, and about 7 percent remittances. However, by 2012, ODA accounted for about 22 percent of external flows to Africa, a share comparable to that of remittances (24 percent) and less than half the share of gross private capital flows (54 percent). Also notably, in 1990, FDI flows were greater than ODA flows in only two countries (Liberia and Nigeria) in sub-Saharan Africa excluding South Africa, but 22 years later, 17 countries received more FDI than ODA in 2012—suggesting that sub-Saharan African countries are increasingly becoming less aid dependent (see Figure 2).

Figure 2. Sub-Saharan Africa: Number of Countries Where FDI is Greater than ODA (1990-2012)

But to what extent have these changes in the scale and composition of external flows to sub-Saharan Africa equally benefited countries in the region? Did the rising tide lift all boats? Is aid really dying? Are all countries attracting private capital flows and benefiting from remittances to the same degree? Finally, how does external finance compare with domestic finance? 

The False Demise of ODA

A closer look at the data indicates that, clearly, ODA is not dead, though its role is changing. For instance, middle-income countries (MICs) are experiencing the sharpest decline in ODA as a share of total external flows to the region, while aid flows account for more than half of external flows in fragile as well as low-income countries (LICs) and resource-poor landlocked countries (see Figure 3 and Appendix).

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Editor’s Note: In the report “Think Tank 20: Growth, Convergence and Income Distribution: The Road from the Brisbane G-20 Summit” experts from Brookings and around the world address interrelated debates about growth, convergence and income distribution, three key elements that are likely to shape policy debates beyond the ninth G-20 summit that was held on November 15-16 in Brisbane, Australia. The content of this blog is based on the chapter on Latin America. Read the full brief on Latin America's growth trends here.

A figure says a thousand words. And, looking at Figure 1, which shows the population-weighted average income per capita in emerging economies relative to the U.S., there could be no doubt in anybody’s mind that since the late 1990s something rather extraordinary happened—a phenomenon with no antecedents in the post-WWII period—that propelled emerging economies into an exponential process of convergence.

Needless to say, this phenomenon had enormous consequences for the welfare of millions of citizens in emerging economies. It lifted more than 500 million people out from poverty and extreme poverty, and gave rise to the so-called emerging middle class that grew at a rate of 150 million per year.

So, it seems that something rather extraordinary happened in emerging economies. Or did it? Let’s look again. When China and India are removed from the emerging markets sample, Figure 1 becomes Figure 2a.

In Figure 2a, one can still discern a period of convergence starting in the late 1990s. But convergence here was not nearly as strong—relative income is still far below its previous heights—and it occurred after a period of divergence that started in the mid-1970s after the first oil shock, in the early 1980s with the debt crisis, and in the late 1980s with post-Berlin Wall meltdown in Eastern European economies.

This pattern is actually characteristic of every emerging region including Latin America (see Figure 2b). Only Asia differs markedly from this pattern—with China and India displaying exponential convergence since the late 1990s, while the rest of emerging Asia experienced a sustained but much slower convergence since the mid-1960s. 

From a Latin American perspective, the relevant question we need to ask is whether the recent bout of convergence that started in 2004 after a quarter of a century of relative income decline is a break with the past or just a short-lived phenomenon?

In order to address this question from a Latin American perspective, we study the arithmetic of convergence (i.e., whether mechanical projections are consistent with the convergence hypothesis) and the economics of convergence (i.e., whether income convergence was associated with a comparable convergence in the drivers of growth).

According to our definition of convergence,[1] since 1950, growth-convergence-development miracles represent a tiny fraction of emerging countries. Only five countries managed to achieve this: Japan, South Korea, Taiwan, Hong Kong and Singapore. In other words, convergence towards income per capita levels of rich countries is an extremely rare event.

But where does Latin America stand? Based on growth projections for the period 2014-2018, not a single Latin American country will converge to two-thirds of U.S. income per capita in two generations. Unfortunately, the arithmetic does not seem to be on the side of the region.

What about the economics? To answer this question, we analyze whether Latin America’s process of income convergence in the last decade was also associated with a similar convergence in the key drivers of growth: trade integration, physical and technological infrastructure, human capital, innovation, and the quality of public services. Figure 3 illustrates the results.

In contrast to relative income, during the last decade, LAC-7 [2] countries failed to converge towards advanced country levels in every growth driver. The overall index of growth drivers—the simple average of the five sub-indexes—remained unchanged in the last decade relative to the equivalent index for advanced economies. By and large, the latter holds true for every LAC-7 country with exceptions like Colombia (the only country that improved in every single growth driver in the last decade) and Chile (the country in the region where the levels of growth drivers are closer to those of advanced economies). 

Latin America had a decade of uninterrupted high growth rates—with the sole exception of 2009 in the aftermath of the Lehman crisis—that put an end to a quarter of a century of relative decline in income per capita levels vis-à-vis advanced economies. However, high growth and income convergence were largely the result of an unusually favorable external environment, rather than the result of convergence to advanced-country levels in the key drivers of growth. Fundamentally, the last was a decade of “development-less growth” in Latin America.

With the extremely favorable external conditions already behind us, the region is expected to grow at mediocre rates of around 2 percent in per capita terms for the foreseeable future. With this level of growth, the dream of convergence and development is unlikely to be realized any time soon.

To avoid such a fate the region must make a renewed effort of economic transformation. Although the challenges ahead appear to be huge, there is plenty of room for optimism. First, Latin America has built a sound platform to launch a process of development. Democracy has by-and-large consolidated across the region, and an entire generation has now grown up to see an election as the only legitimate way to select national leaders. Moreover, it is for the most part a relatively stable region with no armed conflicts and few insurgency movements threatening the authority of the state. Second, a sizeable group of major countries in Latin America have a long track record of sound macroeconomic performance by now. Third, the region could be just steps away from major economic integration. Most Latin American countries in the Pacific Coast have bilateral free trade agreements with their North American neighbors (11 countries with the U.S. and seven countries with Canada). Were these countries to harmonize current bilateral trade agreements among themselves—in the way Pacific Alliance members have been doing—a huge economic space would be born: a Trans-American Partnership that would comprise 620 million consumers, and have a combined GDP of more than $22 trillion (larger than the EU’s, and more than double that of China). Were such a partnership on the Pacific side of the Americas to gain traction, it could eventually be extended to Atlantic partners, in particular Brazil and other Mercosur countries.

In the last quarter of a century democracy, sound macroeconomic management and an outward-looking development strategy made substantial strides in the region. If these conquests are consolidated and the same kind of progress is achieved in key development drivers in the next 25 years, many countries in the region could be on the road to convergence.

[1] We define convergence as a process whereby a country’s income per capita starts at or below one-third of U.S. income per capita at any point in time since 1950, and rises to or above two-thirds of U.S. income per capita.

[2] LAC-7 is the simple average of Argentina, Brazil, Chile, Colombia, Mexico, Peru and Venezuela, which account for 93 percent of Latin America’s GDP.

Event Information

On August 1-3, 2007, the Brookings Blum Roundtable gathered representatives reflective of this dynamic landscape to discuss these trends. Through robust discussion and continuing cross-sector partnerships, the conference hopes to foster lasting and widespread improvements in this new field of development.

2007 Brookings Blum Roundtable Agenda:

1. Fighting Global Poverty: Who'll Be Relevant In 2020?
   • Matthew Bishop, The Economist, "Fighting Global Poverty: Who'll Be Relevant In 2020?"
   • Homi Kharas, The Brookings Institution, "The New Reality Of Aid"
   • Jane Nelson, Harvard University, "New Development Players And Models"
2. Angelina, Bono, And Me: New Vehicles To Engage The Public
   • Darrell M. West, Brown University, "Angelina, Mia, And Bono: Celebrities And International Development"
   • Joshua Busby, University of Texas, Austin, "Is There A Constituency For Global Poverty? Jubilee 2000 And The Future Of Development Advocacy"
   • Ngozi Okonjo-Iweala, The Brookings Institution, "Nigeria's Fight For Debt Relief: Tracing The Path"
3. Leveraging Knowledge For Development
   • Ashok Khosla, Development Alternatives Group, "Leveraging Knowledge To End Poverty"
   • Eric Brewer, University of California, Berkeley, "Development And Engineering"
4. Social Enterprise And Private Enterprise
   Chaired by: Mary Robinson, Realizing Rights: The Ethical Globalization Initiative
   • J. Gregory Dees, Duke University, "Philanthropy And Enterprise: Harnessing The Power Of Business And Entrepreneurship For Social Change"
5. Africa's Economic Successes: What's Worked And What's Next
   Moderated by: Paul Martin, former Prime Minister of Canada
   Panelists
   • Donald Kaberuka, African Development Bank
   • Ngozi Okonjo-Iweala, The Brookings Institution
6. Effecting Change Through Accountable Channels
   • Jane Nelson, Harvard University, "Effecting Change Through Accountable Channels"
   • Simon Zadek, AccountAbility, "Accountability Compacts: Collaborative Governance For The 21^stCentury"
7. Global Impact: Philanthropy Changing Development
   • Mark R. Kramer, FSG Social Impact Advisors, "Philanthropy, Aid, And Investment: Creating A Common Language"
   • Joseph O'Keefe, The Brookings Institution, "Aid - From Consensus To Competition?"
8. Keynote Address
   • Former Vice President Al Gore, Generation Investment Management

Event Information

Global poverty and climate change are two of the most pressing challenges for global policymakers today, and require policy prescriptions that address their interrelated issues. Effective climate solutions must empower development by improving livelihoods, health and economic prospects while poverty alleviation must become a central strategy for both mitigating emissions and reducing the poor’s vulnerability to climate change.

In its fifth annual gathering, led by Lael Brainard and co-chaired by Strobe Talbott and Richard C. Blum, the Brookings Blum Roundtable addressed the challenges of climate change and development and convened leaders from both the development and climate change communities from August 1-3, 2008, to discuss and debate policy ideas that could benefit both fronts. By examining common challenges—accountability, effective deployment of resources, agenda-setting, mobilizing the public and financial resources, and achieving scale and sustainability—the Roundtable established a solid foundation for collaboration among the climate change and development communities and fostered ideas for policy action.

Keynote Sessions

Keynote Panel: “Noble Nobels: Solutions to Save the Planet”

• Steven Chu, University of California, Berkeley
• Al Gore, Generation Investment Management; 45^th Vice President of the United States

Keynote Panel: Legal Empowerment of the Poor

• Mary Robinson, Realizing Rights: The Ethical Globalization Initiative
• Madeline Albright, The Albright Group; Former U.S. Secretary of State

Keynote Panel: “How Do We Achieve Climate Justice?”

• Kumi Naidoo, CIVICUS and the Global Call to Action Against Poverty
• Mary Robinson, Realizing Rights: The Ethical Globalization Initiative
  
  

Event Information

From high-profile stabilization contexts like Afghanistan to global public health campaigns to a renewed focus on sustainable food security and the looming impacts of climate change, development effectiveness is a central and hotly debated issue. As traditional donors make progress in the international aid effectiveness dialogue, they must increasingly take into account the changing global development landscape and the slew of new actors, including emerging donors, multinational corporations, mega philanthropists, high-profile advocates, and a vocal and energized global public.

The seventh annual Brookings Blum Roundtable, led by Kemal Derviş and co-chaired by Richard C. Blum and Strobe Talbott, convened over 40 exceptional international thought leaders, entrepreneurs and practitioners to explore the relationship between efforts to promote aid effectiveness and the anticipated shape of the global development agenda over the next decade. The roundtable discussions provided an opportunity to look beyond questions of increased resources for anti-poverty services to the effectiveness of different approaches and to systemic issues associated with the delivery of development outcomes. The high-level group of participants explored opportunities for new commitment in engaging the private sector and multilateral actors, as well as the increasingly important role of climate assistance and operations in instable arenas. Over separate meal conversations, Dr. Donald Kaberuka, president of the African Development Bank, and Dr. Rajiv Shah, administrator of the U.S. Agency for International Development (USAID), reflected on the current and future roles of their organizations, and how they could each act on the suggestions put forward at the roundtable.

Event Information

The context for aid is changing. Globalization has spurred economic convergence, upending the twentieth century economic balance and creating a smaller world where both problems and solutions spill across national borders more readily. This has given rise to a legion of new development actors, including emerging economies, NGOs, private businesses, and coordinating networks, who have brought fresh energy and resources to the field while rendering the prospect of genuine donor coordination ever more difficult. Global integration and competition for resources has raised the prominence of global public goods, whose equitable and sustainable provision requires international collective action. Meanwhile, poor countries are demanding a new form of partnership with the international community, built upon the principles of country ownership and mutual accountability.

From G-20 meetings and the upcoming High Level Forum on Aid Effectiveness in Korea to unfolding events in the Middle East and North Africa, leadership from the United States is crucial, placing pressure on the Obama administration to deliver on its promise of far-reaching reforms to U.S. global development efforts. And amidst this shifting global landscape is the issue of effectively communicating the importance of global development cooperation to both a national and global public, at a time when budget pressures are being felt across many of the world’s major economies

At the eighth annual Brookings Blum Roundtable, co-chaired by Kemal Derviş and Richard C. Blum, 50 thought-leaders in international development came together to discuss a new role for global development cooperation, one that employs inclusive and innovative approaches for tackling contemporary development problems and that leverages the resources of a large field of actors.

Roundtable Agenda

Wednesday, August 3, 2011

Welcome: 8:40 a.m. – 9:00 a.m.
Open Remarks
• Richard C. Blum, Blum Capital Partners, LP and Founder of the Blum Center for 
Developing Economies at Berkeley
• Mark Suzman, Global Development Program, Bill & Melinda Gates Foundation
• Kemal Derviş, Global Economy and Development, Brookings

Statement of Purpose, Scene Setter, Comments on the Agenda
• Homi Kharas, Brookings

Session I: 9:00AM - 10:30AM
Reframing Development Cooperation
In almost any discussion of international development, foreign aid takes center stage. But while 
aid can certainly be a catalyst for development, it does not work in isolation. Participants will 
discuss the key objectives of development cooperation, consider what measures of development 
cooperation are most valuable for recipients, and explore an effective balance of roles and 
responsibilities - including both public and private players - in today’s evolving development 
landscape.

Moderator
• Walter Isaacson, Aspen Institute

Introductory Remarks
• Owen Barder, Center for Global Development
• Donald Kaberuka, African Development Bank Group
• Ananya Roy, University of California, Berkeley
• Elizabeth Littlefield, Overseas Private Investment Corporation

Session II: 10:50AM - 12:20PM
The G-20's Development Agenda
Last year’s G-20 meeting in Seoul marked the first time the group formally took up the issue of development. There they announced the Seoul Development Consensus for Shared Growth and the Multi-Year Action Plan for Development: two far-reaching policies which are expected to guide the G20’s future agenda. What is the G-20’s comparative advantage vis-à-vis development, and how can the group’s development efforts be strengthened and supported?

Moderator
• Mark Suzman, Bill and Melinda Gates Foundation

Introductory Remarks
• Alan Hirsch, The Presidency, South Africa
• Suman Bery, International Growth Centre
• Homi Kharas, Brookings

Dinner Program: 6:00PM - 9:00PM
A Conversation with Al Gore and Mary Robinson
Topic: "Energy Security and Climate Justice"

Moderator
• Kemal Derviş, Global Economy and Development, Brookings

Thursday, August 4, 2012 

Session III: 9:00AM - 10:30AM 
The Road to Buscan
In November, participants from over 150 countries, including ministers of developing and developed countries, heads of bilateral and multilateral development institutions, and civil society representatives, will take part in the fourth High Level Forum on Aid Effectiveness in Busan, South Korea. The forum is intended to take account of the development community’s progress in achieving greater impact through aid and to redefine the aid effectiveness agenda to adjust to a changing global landscape. What would constitute success or failure at Busan?

Moderator
• Raymond Offenheiser, Oxfam America

Introductory Remarks
• J. Brian Atwood, Organisation of Economic Co-operation and Development, 
Development Assistance Committee 
• Wonhyuk Lim, Korean Development Institute
• Ngozi Okonjo-Iweala, World Bank 
• Steven Radelet, U.S. Agency for International Development 

Session IV: 10:50AM - 12:20PM 
Lessons from the Middle East on Governance and Aid
Popular protests across the Middle East against authoritarian regimes have prompted reflection 
on the role of aid to non-democratic and poorly governed countries. Some critics believe that aid 
should only be given to relatively well-governed countries where it is more likely to be effective, 
but for others, this amounts to collective punishment for the people who suffer under such 
governments. Do aid allocation models need to change and what role can the development 
community now play in supporting peaceful, democratic reform in the Middle East?

Moderator
• Madeleine K. Albright, Albright Stonebridge Group

Introductory Remarks
• Ragui Assaad, University of Minnesota
• Sheila Herrling, Millennium Challenge Corporation
• Tarik Yousef, Silatech

Lunch Program: 12:30PM - 2:00PM
A Conversation with Thomas R. Nides, U.S. Deputy Secretary of State for Management and Resources

Moderator
• Richard C. Blum, Blum Capital Partners, LP and Founder of the Blum Center for Developing Economies at Berkeley

Session V: 9:00AM - 10:30AM
Implementing U.S. Development Reforms 
The end of 2010 saw the completion of two major policy reviews in Washington concerned with 
international development: the Presidential Policy Directive on Global Development and the 
Quadrennial Diplomacy and Development Review. Progress on implementation has been 
significant in many respects and meager in others. Additionally, despite directives to deliver on 
many valuable priorities for improvement, essential components of fundamental reform are still 
in need of address. Casting a shadow across the exercise, or alternatively serving as a spur to 
focus, the budget environment has soured.

Moderator
• Jim Kolbe, German Marshall Fund of the United States

Introductory Remarks
• Rajiv Shah, U.S. Agency for International Development
• Samina Ahmed, International Crisis Group
• Robert Mosbacher, Jr., Mosbacher Energy Company

Session VI: 10:50AM - 12:20PM
Communicating Development Cooperation
Public interest in and support for aid matter. Yet in many aid giving countries, there is 
widespread cynicism as to what end aid programs serve and ignorance as to what activities they 
actually involve. What are the best examples of development efforts which have been 
communicated successfully and what can we learn from this to shore up support for 
development cooperation now and in the future?

Moderator 
• Liz Schrayer, U.S. Global Leadership Coalition

Introductory Remarks 
• Steven Kull, Program on International Policy Attitudes
• Joshua Bolten, ONE
• S. Shankar Sastry, University of California, Berkeley
• Jack Leslie, Weber Shandwick

Closing Remarks: 12:20PM- 12:30PM
• Richard C. Blum, Blum Capital Partners, LP and Founder of the Blum Center for 
Developing Economies at Berkeley
• Kemal Derviş, Global Economy and Development, Brookings

Public Event: 4:00PM - 5:30PM
Brookings and the Aspen Institute present “Development as National Security?”: A Conversation with Rajiv Shah, U.S. Agency for International Development; Sylvia Mathews Burwell, Bill & Melinda Gates Foundation; Richard J. Danzig, Center for a New American Security; and Susan C. Schwab, University of Maryland.

Moderator
• Jessica Tuchman Mathews, Carnegie Endowment for International Peace

Welcome and Introductions
• Kemal Derviş, Brookings

Hosts
• Richard C. Blum and Senator Dianne Feinstein

Event Information

On August 1-3, 2012, Brookings Global Economy and Development hosted the ninth annual Brookings Blum Roundtable on Global Poverty in Aspen, Colorado. The year’s roundtable theme, "Innovation and Technology for Development", brought together global leaders, entrepreneurs and practioners to discuss how technology and innovation can be seized to help solve some of the world's most pressing global development challenges.

Global development challenges are of massive scale: 61 million children out of school and many more failing to learn basic literacy and numeracy skills; 850 million facing hunger; 1 billion living in slums and 1.3 billion without access to electricity. Yet remarkably little is understood about successful strategies for designing scalable solutions, the impediments to reaching scale, or the most appropriate pathways for getting there.

However, a batch of new technologies offers the promise of a breakthrough by encouraging innovative business models, pushing down transaction costs and disintermediating complex activities. Mobile money could realistically reach over 1 billion poor people in the next decade and directly connect millions of rich individuals with millions of poor people. Real-time data can allow resources to be better targeted and managed. New media can sharpen accountability and reduce waste and overlap.

Roundtable Agenda

Wednesday, August 1, 2012

Welcome: 8:40AM - 9:00AM
Brookings Welcome
• Strobe Talbott, Brookings

Opening Remarks
• Richard C. Blum, Blum Capital Partners, LP and Founder of the Blum Center for Developing Economies at Berkeley
• Mark Suzman, Bill and Melinda Gates Foundation
• Kemal Derviş, Global Economy and Development, Brookings

Session I: 9:00AM - 10:30AM
Framing Session: Translating Technological Innovations into Transformational Impact
In this opening discussion, participants will explore the overarching questions for the roundtable: If the poor can readily be identified and if they have access to financial services and participate in technology-driven communication networks, how does this change the development paradigm? How can effective partnerships be forged to combine the efforts of different international and local actors (businesses, governments, foundations, NGOs, and universities) in propagating solutions? Can scalable technologies raise the profile and potential of new business models, approaches and partnerships?

Moderator
• Homi Kharas, Brookings

Introductory Remarks
• Thomas A. Kalil, White House Office of Science and Technology
• Michael Kubzansky, Monitor Group 
• Lalitesh Katragadda, Google India
• Smita Singh, Independent

Session II: 10:50AM - 12:20PM
Mobile Money and Mass Payments
Participants will explore the following questions for the rountable: Is the rapid uptake of mobile money/payment technology throughout the developing world assured and if not, what (or whom) are the impediments? What is required to enable successful mass payments systems that employ mobile money technology? What is the optimal role of government, non-profits and private actors in supporting mobile money services? How can mass payments systems be used to implement national safety nets?

Moderator
• Gillian Tett, Financial Times

Introductory Remarks
• Neal Keny-Guyer, Mercy Corps
• Mwangi Kimenyi, Brookings
• Mung Ki Woo, MasterCard Worldwide Group Executive Mobile

Dinner Program: 7:30PM - 9:15PM
Aspen Institute Madeleine K. Albright Global Development Lecture

Featuring
• Rajiv Shah, Administrator, United States Agency for International Development

Click here to read Rajiv Shah's remarks »

Thursday, August 2, 2012 

Session III: 9:00AM - 10:30AM 
Mass Networks: Leveraging Information from the Crowd
Participants will explore the following questions for the rountable: What are the most promising examples of using social media, crowdsourcing and “big data” to advance development and humanitarian outcomes? How can traditional foreign assistance make use of virtual networks to support transparency, democratic governance and improved service delivery? How can technologies be used to understand clients, promote beneficiary feedback and learning to fine tune business models in base of the pyramid markets?

Moderator
• Walter Isaacson, Aspen Institute

Introductory Remarks
• Anne-Marie Slaughter, Princeton University
• Juliana Rotich, Ushahidi
• Robert Kirkpatrick, UN Global Pulse Initiative
• Rakesh Rajani, Twaweza

Session IV: 10:50AM - 12:20PM
Innovation and Technology for Green Growth
Participants will explore the following questions for the rountable: How advanced is green growth technology vis-à-vis the scale and urgency of the global climate challenge? What is the role of pricing and intellectual property and push and pull mechanisms in speeding up propagation within developed and developing markets? How can the goal of “sustainable energy for all” be achieved, and is it feasible in all countries?

Moderator
• Al Gore, The Climate Reality Project

Introductory Remarks
• Mary Robinson, Mary Robinson Foundation - Climate Justice
• Helen Clark, United Nations Development Programme
• Arthur Njagi, International Finance Corporation
• Viswanathan Shankar, Standard Chartered Bank

Lunch Program: 12:30PM - 2:00PM
Partnering with Academic Research Institutions
This discussion will explore partnerships between public sector development institutions and academic research institutions to support global development goals. Topics will include the constraints to research; how to make research more relevant to developing country problems; issues around incentives for scientists and universities; and relationships between universities, financiers and implementers.

Moderator
• Javier Solana, ESADE

Panel
• Richard C. Blum, Blum Capital Partners, LP and Founder of the Blum Center for Developing Economies at Berkeley
• Luis Alberto Moreno, Inter-American Development Bank
• Shankar Sastry, University of California, Berkeley
• Alex Deghan, United States Agency for International Development

Friday, August 3, 2012 

Session V: 9:00AM - 10:30AM
Business Solutions and Private Sector Development
Participants will explore the following questions for the rountable: What role can the new breed of socially conscious private actors (e.g., social enterprises and impact investors) play in overcoming finance and delivery constraints and scaling up development impact? Where is the need for investment finance most acute, and who or what can fill these gaps? How are management approaches evolving to suit base of the pyramid markets? What are the impediments to the adoption or adaptation of scalable technologies by developing country enterprises, and are southern innovations being efficiently spread? What is constraining private sector development in Africa, and is technology a key bottleneck?

Moderator
• Laura Tyson, University of California, Berkeley

Introductory Remarks
• Rob Mosbacher, Mosbacher Energy Company
• Mathews Chikaonda, Press Corporation Limited
• Elizabeth Littlefield, Overseas Private Investment Corporation
• Amy Klement, Omidyar Network

Session VI: 10:50AM - 12:20PM
Delivering U.S. Leadership: Role for the Public Sector
Participants will explore the following questions for the rountable: What is an appropriate role for the U.S. government in promoting technological solutions for development and scaling these up? How should the government leverage new private sector players? What are the best examples of, and lessons learned from, earlier and on-going public private partnerships? How can the U.S. government work more effectively to support local innovation and technology in developing countries?

Moderator
• Sylvia Burwell, Walmart Foundation

Introductory Remarks
• Rajiv Shah, Administrator, United States Agency for International Development
• Sam Worthington, InterAction
• Henrietta Fore, Holsman International

Closing Remarks: 12:20PM - 12:30PM

• Richard C. Blum, Blum Capital Partners, LP and Founder of the Blum Center for Developing Economies at Berkeley
• Kemal Derviş, Global Economy and Development, Brookings

Lunch Program: 12:30PM - 2:00PM
A Conversation with Michael Froman and Thomas Nides
This conversation will focus on the politics and finance of the US government’s efforts on global development, including its specific initiatives regarding technology and innovation for development.

Moderator
• Madeleine K. Albright, Albright Stronebridge Group

Live Webcast Event: 4:00PM - 5:30PM
Brookings and the Aspen Institute Present: "A Conversation with Former World Bank President Robert Zoellick"

Global Economy and Development at Brookings and the Aspen Strategy Group will host Robert Zoellick, who recently stepped down as president of the World Bank after serving in that office for the past five years. Mr. Zoellick has held several senior positions in the U.S. Government, including deputy secretary of state and U.S. trade representative under President George W. Bush. This event will be webcast live on the Brookings website. Click here for more details.

Introduction
• R. Nicholas Burns, Director, Aspen Strategy Group and Professor of the Practice of Diplomacy and International Politics, Harvard Kennedy School of Government

Moderator
• Strobe Talbott, President, Brookings

Event Information

Lifting an estimated 1.2 billion people from extreme poverty over the next generation will require robust and broadly-shared economic growth throughout the developing world that is sufficient to generate decent jobs for an ever-expanding global labor force. Innovative but affordable solutions must also be found to meet people’s demand for basic needs like food, housing, a quality education and access to energy resources. And major investments will still be required to effectively address global development challenges, such as climate change and child and maternal health.  On all these fronts, the private sector, from small- and medium-sized enterprises to major global corporations, must play a significant and expanded role.

On August 4-6, 2013, Brookings Global Economy and Development is hosting the tenth annual Brookings Blum Roundtable on Global Poverty in Aspen, Colorado. This year’s roundtable theme, “The Private Sector in the New Global Development Agenda,” brings together global leaders, entrepreneurs, practitioners and public intellectuals to discuss how the contribution of the private sector be enhanced in the push to end poverty over the next generation and how government work more effectively with the private sector to leverage its investments in developing countries. 

Tweets about "#Blum2013"

Roundtable Agenda

Sunday, August 4, 2013

Welcome: 8:40AM - 9:00AM MST
Brookings Welcome
• Strobe Talbott, Brookings

Opening Remarks
• Richard C. Blum, Blum Capital Partners, LP and Founder of 
the Blum Center for Developing Economies at UC Berkeley
• Julie Sunderland, Bill and Melinda Gates Foundation
• Kemal Derviş, Global Economy and Development, Brookings

Session I: 9:00AM - 10:30AM MST
Framing Session: Reimagining the Role of the Private Sector
In this opening discussion, participants will explore the overarching questions for the roundtable: How can the contribution of the private sector be enhanced in the push to end poverty over the next generation? What are the most effective mechanisms for strengthening private sector accountability? How can business practices and norms be encouraged that support sustainable development and job creation? How can business build trust in its contributions to sustainable development?

Moderator
• Nancy Birdsall, Center for Global Development

Introductory Remarks
• Homi Kharas, Brookings Institution
• Viswanathan Shankar, Standard Chartered Bank
• Shannon May, Bridge International Academies


Session II: 10:50AM - 12:20PM MST
Private Equity
Participants will explore the following questions for the roundtable: What are the constraints to higher levels of private equity in the developing world, including in non-traditional sectors? How can early-stage investments be promoted to improve deal flow? How can transaction costs and technical assistance costs be lowered?

Moderator
• Laura Tyson, University of California, Berkeley

Introductory Remarks
• Robert van Zwieten, Emerging Markets Private Equity Association
• Runa Alam, Development Partners International
• Vineet Rai, Aavishkaar

Dinner Program: 6:45PM - 9:15PM MST
Aspen Institute Madeleine K. Albright Global Development Lecture

Featuring
• Dr. Paul Farmer, Chief Strategist and Co-Founder, Partners in Health

Monday, August 5, 2013

Session III: 9:00AM - 10:30AM MST
Goods, Services and Jobs for the Poor
Participants will explore the following questions for the roundtable: In what areas are the most promising emerging business models that serve the poor arising? What are the major obstacles in creating and selling profitable, quality, and beneficial products to the poor and how can they be overcome? What common features distinguish successful and replicable solutions?

Moderator
• Mary Robinson, Mary Robinson Foundation

Introductory Remarks
• Ashish Karamchandani, Monitor Deloitte
• Chris Locke, GSMA
• Ajaita Shah, Frontier Markets
• Hubertus van der Vaart, SEAF

Tuesday, August 6, 2013 

Session V: 9:00AM - 10:30AM MST
Unlocking Female Entrepreneurship
Participants will explore the following questions for the roundtable: How is the global landscape for female entrepreneurship changing? What types of interventions have the greatest ability to overturn barriers to female entrepreneurship in the developing world? Who, or what institutions, should lead efforts to advance this agenda? Can progress be made without a broader effort to end economic discrimination against women?

Moderator
• Smita Singh, Independent

Introductory Remarks
• Dina Powell, Goldman Sachs
• Carmen Niethammer, IFC
• Randall Kempner, ANDE

Session VI: 10:50AM - 12:20PM MST
U.S. Leadership and Resources to Engage The Private Sector
Participants will explore the following questions for the roundtable: How can U.S. foreign assistance be strengthened to more effectively promote the role of the private sector? How can U.S. diplomacy support private sector development in the emerging economies and multinational enterprises investing in the developing world? What can the US do to promote open innovation platforms?

Moderator
• George Ingram, Brookings

Introductory Remarks
• Sam Worthington, InterAction
• John Podesta, Center for American Progress
• Rajiv Shah, USAID

Closing Remarks
• Richard C. Blum, Blum Capital Partners, LP and Founder of the Blum Center for Developing Economies at Berkeley
• Kemal Derviş, Global Economy and Development, Brookings

Public Event: 4:30PM - 6:00PM MST
Brookings and the Aspen Institute Present: "America's Fiscal Health and its Implications for International Engagement"
Global Economy and Development at Brookings and the Aspen Institute will host the 66th U.S. Secretary of State Condoleezza Rice and Administrator of the U.S. Agency for International Development Rajiv Shah for a discussion on the current state of the U.S.'s fiscal health and its impact on American diplomatic and development priorities. Moderated by Ambassador Nicholas Burns, Director, Aspen Strategy Group.

Moderator
• Nicholas Burns, Director, Aspen Strategy Group

Panelists
• Condoleezza Rice, 66th United States Secretary of State
• Rajiv Shah, Administrator of the United States Agency for International Development

Event Materials

• BBR Participant List 2013_FINAL

Event Information

The emergence of a new digital economy is changing the ways in which businesses and development organizations engage in emerging and developing countries. Transaction costs have been radically driven down, enabling greater inclusion. And technology is driving efficiency improvements, and permitting rapid scaling-up and transformational change.

On August 5-7, 2015, Brookings Global Economy and Development is hosting the twelfth annual Brookings Blum Roundtable on Global Poverty in Aspen, Colorado. This year’s roundtable theme, “Disrupting development with digital technologies,” brings together global leaders, entrepreneurs, practitioners, and public intellectuals to discuss three trends in particular have the potential to redefine how global development occurs and how efforts will support it over the next 10 years: (1) the growing adoption of digital payments serving people everywhere with near-frictionless transactions; (2) the spread of internet connectivity and digital literacy; and (3) the harnessing of data to better serve the poor and to generate new knowledge.

This event is closed, but you can follow along on Twitter using #Blum2015.

Roundtable Agenda

Wednesday, August 5, 2015

Welcome and opening remarks - 8:40-9:00 a.m.:

• Richard C. Blum, Blum Capital Partners
• Mike Kubzansky, Omidyar Network
• Kemal Derviş, Brookings Institution

Session I - 9:00-10:30 a.m.: Realizing the potential of the digital economy

The digital revolution presents profound opportunities for global development. By integrating poor people into digital networks, the revolution can redefine what it means to be poor, and forge new pathways to prosperity for both individuals and countries.

What are the challenges in making the digital revolution fully inclusive and scalable—and how can they be lifted? In a full-fledged digital economy, which constraints facing the poor will diminish and which will remain? What risks does the digital economy pose?

Moderator:

• Kemal Derviş, Brookings Institution

Introductory remarks:

• Michael Faye, GiveDirectly, Segovia Technology
• Tunde Kehinde, African Courier Express
• Christina Sass, Andela
• Tariq Malik, National Database and Registration Authority

Session II - 10:50 - 12:20 p.m.: Global money

Between 2011 and 2014, 700 million people started a bank account for the first time, representing a giant step toward the World Bank goal of universal financial inclusion by 2020. Meanwhile, the digitalization of payments, spurred in part by 255 mobile money services across the developing world, is pushing the cost of basic financial transactions down toward zero.

How will an era of global money transform formal and informal business? Which sectors, product markets, and government services have the most to gain and lose from increased market efficiency? What are the consequences for financial regulation?

Moderator:

• Henrietta Fore, Holsman International

Introductory remarks:

• Ruth Goodwin-Groen, Better than Cash Alliance
• Luis Buenaventura, Rebit.ph, Satoshi Citadel Industries
• Tayo Oviosu, Paga
• Loretta Michaels, U.S. Department of the Treasury

Lunch - 12:30-2:00 p.m.

Cocktail reception and interview - 5:00-7:00 p.m.:

During the reception, Richard Blum will lead a short discussion with Walter Isaacson and Ann Mei Chang on the topic “Silicon Valley and Innovation for the Developing World,” followed by questions. Remarks begin at 5:30 and will end at 6:15 p.m.

Thursday, August 6, 2015

Session III - 9:00-10:30 a.m.: Global connections

Numerous ventures are competing today to bring internet connectivity to the furthest corners of the planet, while low-cost, user-centered-designed platforms are expanding the spread of digital literacy. Social media and crowdsourcing offer efficient ways for people to share information, solve problems, and act collectively.

To what extent can internet connectivity overcome isolation and empower poor communities that are socially, economically, and politically disenfranchised? Do the benefits of global connectivity for the world’s poor rely on issues like net neutrality, and what has been learned from recent battles to uphold this paradigm?

Moderator:

• Anne-Marie Slaughter, New America Foundation

Introductory remarks:

• Ross LaJeunesse, Google
• Andy O’Connell, Facebook
• Maria Ressa, Rappler
• Chris Locke, Caribou Digital

Session IV - 10:50-12:20 p.m.: Global knowledge

The creation of a universal digital network will provide the poor with greater access to the information they need, and generate new knowledge that can be used to serve poor people more effectively. Digital inclusion can expand possibilities for targeting, verification, and analysis, while big data from biometric registries, satellites, phones, payments, and the internet can unlock insights on individual needs and preferences. In addition, open source platforms and MOOCs have the potential to be powerful accelerators for technology and skill transfer.

What kinds of new personalized services can be developed using improved capacity for targeting and tailoring? How might the reduction of barriers to information affect social mobility and economic convergence? How should big data be regulated?

Moderator:

• Smita Singh, President’s Global Development Council

Introductory remarks:

• David Soloff, Premise
• Rebecca Taber, Coursera
• Jonathan Hakim, Cignifi
• Deepak Mishra, World Bank

Friday, August 7, 2015

Session V - 9:00-10:30 a.m.: Opportunities and challenges for business

The digital economy promises to disrupt many existing markets and generate new business opportunities that employ and serve the poor.

How can businesses employ digital technologies to expand their presence in poor and emerging countries? According to businesses, what is an effective regulatory framework for the digital economy? To what extent can strong digital infrastructure compensate for deficiencies in physical infrastructure or governance?

Moderator:

• Laura Tyson, Blum Center for Developing Economies

Introductory Remarks:

• Jesse Moore, M-KOPA Solar
• Anup Akkihal, Logistimo
• V. Shankar, formerly Standard Chartered Bank
• Barbara Span, Western Union

Session VI - 10:50-12:20 p.m.: Opportunities and challenges for development cooperation

The U.S. government sees itself as a leader in harnessing technology for global development. Meanwhile, aid agencies have been identified as a possible target for disintermediation by the digital revolution.

How can development organizations, both government and non-government, accelerate the digital revolution? How might traditional aid programs be enhanced by employing digital knowledge and technologies? Does U.S. regulatory policy on the digital economy cohere with its global development agenda?

Moderator:

• Mary Robinson, Mary Robinson Foundation - Climate Justice

• Neal Keny-Guyer, Mercy Corps
• Michael Anderson, Children's Investment Fund Foundation
• Helen Clark, United Nations Development Program
• Ann Mei Chang, USAID

Closing remarks:

• Richard C. Blum, Blum Capital
• Mike Kubzansky, Omidyar Network
• Kemal Derviş, Brookings Institution

Event Materials

• Participant List 731

There is a lot of hope around the potential of Big Data—massive volumes of data (such as cell phone GPS signals, social media posts, online digital pictures and videos, and transaction records of online purchases) that are large and difficult to process with traditional database and software techniques—to help achieve the sustainable development goals. The United Nations even calls for using the ongoing Data Revolution –the explosion in quantity and diversity of Big Data—to make more and better data usable to inform development analysis, monitoring and policymaking: In fact, the United Nations believes that that “Data are the lifeblood of decision-making and the raw material for accountability. Without high-quality data providing the right information on the right things at the right time; designing, monitoring and evaluating effective policies becomes almost impossible.” The U.N. even held a “Data Innovation for Policy Makers” conference in Jakarta, Indonesia in November 2014 to promote use of Big Data in solving development challenges.

Big Data has already played a role in development: Early uses of it include the detection of influenza epidemics using search engine query data or the estimation of a country’s GDP by using satellite data on night lights. Work is also under way by the World Bank to use Big Data for transport planning in Brazil.

During the Data for Development session at the recent NetMob conference at MIT, we presented a paper in which we jump on the Big Data bandwagon. In the paper, we use mobile phone data to assess how the opening of a new toll highway in Dakar, Senegal is changing how people commute to work (human mobility) in this metropolitan area. The new toll road is one of the largest investments by the government of Senegal and expectations for its developmental impact are high. In particular, the new infrastructure is expected to increase the flow of goods and people into and out of Dakar, spur urban and rural development outside congested areas, and boost land valuation outside Dakar. Our study is a first step in helping policymakers and other stakeholders benchmark the impact of the toll road against many of these objectives.

Assessing how the impact of the new toll highway differs by area and how it changes over time can help policymakers benchmark the performance of their investment and better plan the development of urban areas.

The Dakar Diamniadio Toll Highway (in red in Figure 1), inaugurated on August 1, 2013 is the first section (32 km or 20 miles) of a broader project to connect the capital, Dakar, through a double three-lane highway to a new airport (Aeroport International Blaise Diagne, AIBD) and a special economic zone, the Dakar Integrated Special Economic Zone (DISEZ) and the rest of the country.

Note: The numbers indicate the incidence of increased inter cell mobility and were used to calculate the percentage increase in mobility.

The cost of this large project is estimated to be about $696 million (FCFA 380.2 billion or 22.7 percent of 2014 fiscal revenues, excluding grants) with the government of Senegal having already disbursed $353 million. The project is one of the first toll roads in sub-Saharan Africa (excluding South Africa) structured as a public-private partnership (PPP) and includes multilateral partners such as the World Bank, the French Development Agency, and the African Development Bank.

In our study, we ask whether the new toll road led to an increase in human mobility and, if so, whether particular geographical areas experienced higher or lower mobility relative to others following its opening.

Using mobile phone usage data (Big Data), we use statistical analysis in our paper to approximate where people live and where they work. We then estimate how the reduction in travel time following the opening of the toll road changes the way they commute to work.

As illustrated in the map of Figure 1, we find some interesting trends:

• Human mobility in the metropolitan Dakar area increased on average by 1.34 percent after the opening of the Dakar Diamniadio Toll Highway. However, this increase masks important disparities across the different sub-areas of the Dakar metropolitan areas. Areas in blue in Figure 1 are those for which mobility increased after the opening of the new road toll while those in red experienced decreased mobility.
• In particular, the Parcelles Assainies suburban area benefited the most from the toll road with an increase in mobility of 26 percent. The Centre Ville (downtown) area experienced a decrease in mobility of about 20 percent.

These trends are important and would have been difficult to discover without Big Data. Now, though, researchers need to parse through the various reasons these trends might have occurred. For instance, the Parcelles Assainies area may have benefited the most because of its closer location to the toll road whereas the feeder roads in the downtown area may not have been able to absorb the increase in traffic from the toll road. Or people may have moved from the downtown area to less expensive areas in the suburbs now that the new toll road makes commuting faster.

From these preliminary results (our study is work in progress, and we will be improving its methodology), we are encouraged by the fact that our method and use of Big Data has three areas of application for a project such as this:

Benchmarking: Our method can be used to track how the impact of the Dakar Diamniadio Toll Highway changes over time and for different areas of the Dakar metropolitan areas. This process could be used to study other highways in the future and inform highway development overall.

Zooming in: Our analysis is a first step towards a more granular study of the different geographic areas within the Dakar suburban metropolitan area, and perhaps inspire similar studies around the continent. In particular, it would be useful to study the socio-economic context within each area to better appreciate the impact of new infrastructure on people’s lives. For instance, in order to move from estimates of human mobility (traffic) to measures of “accessibility,” it will be useful to complement the current analysis with an analysis of land use, a study of job accessibility, and other labor markets information for specific areas. Regarding accessibility, questions of interest include: Who lives in the areas most/least affected? What kind of jobs do they have access to? What type of infrastructure do they have access to? What is their income level? Answers to these questions can be obtained using satellite information for land prices, survey data (including through mobile phones) and data available from the authorities. Regarding urban planning, questions include: Is the toll diverting the traffic to other areas? What happens in those areas? Do they have the appropriate infrastructure to absorb the increase in traffic?

Zooming out: So far, our analysis is focused on the Dakar metropolitan area, and it would be useful to assess the impact of new infrastructure on mobility between the rest of the country and Dakar. For instance, the analysis can help assess whether the benefits of the toll road spill over to the rest of the country and even differentiate the impact of the toll road on the different regions of the country.

This experience tells us that there are major opportunities in converting Big Data into actionable information, but the impact of Big Data still remains limited. In our case, the use of mobile phone data helped generate timely and relatively inexpensive information on the impact of a large transport infrastructure on human mobility. On the other hand, it is clear that more analysis using socioeconomic data is needed to get to concrete and impactful policy actions. Thus, we think that making such information available to all stakeholders has the potential not only to guide policy action but also to spur it. 

References

Atkin, D. and D. Donaldson (2014). Who ’ s Getting Globalized ? The Size and Implications of Intranational Trade Costs . (February).

Clark, X., D. Dollar, and A. Micco (2004). Port efficiency, maritime transport costs, and bilateral trade. Journal of Development Economics 75(2), 417–450, December.

Donaldson, D. (2013). Railroads of the Raj: Estimating the Impact of Transportation Infrastructure. forthcoming, American Economic Review.

Fetzer Thiemo (2014) “Urban Road Construction and Human Commuting: Evidence from Dakar, Senegal.” Mimeo

Ji, Y. (2011). Understanding Human Mobility Patterns Through Mobile Phone Records : A cross-cultural Study.

Simini, F., M. C. Gonzalez, A. Maritan, and A.-L. Barab´asi (2012). A universal model for mobility and migration patterns. Nature 484(7392), 96–100, April.

Tinbergen, J. (1962). Shaping the World Economy; Suggestions for an International Economic Policy.

Yuan, Y. and M. Raubal (2013). Extracting dynamic urban mobility patterns from mobile phone data.

The 2015 Brookings Blum Roundtable was convened to explore how digital technologies might disrupt global development.

Our intention was to imagine a world 10 years from now where digital technologies have become ubiquitous. In this world, how would we expect digital trends and innovations to affect the work of business and development organizations? What policy challenges and risks will the new digital economy pose? And what are the constraints on making digital innovations fully inclusive and scalable?

In 10 years, the world will look very different from today. The number of people worldwide who own a telephone, have access to the Internet, have registered their biometric identity, and own a bank account is rising by between 200 million and 300 million a year. These technologies are spreading at such a high speed that an era of digital inclusion beckons, characterized by universal connectivity and the frictionless movement of money and information.

History attests to the transformative effects of technology. And there is every reason to believe that the impact of digital technologies will be especially profound. The spread of mobile telephones already represents perhaps the most conspicuous change for life in the developing world over the past generation. However, the impact of digital technologies on people’s well-being can be both positive and negative. The onus is on developing countries and the broader global development community to maximize the upside of digital inclusion, while managing its downside, in navigating this exciting future.

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Missouri's population is spreading out, adding to the costs of providing services and infrastructure across the state, according to a new study released today by the Brookings Institution Center on Urban and Metropolitan Policy.

The 84-page study, Growth in the Heartland: Challenges and Opportunities for Missouri, reports that Missouri's population is quickly dispersing, with smaller metropolitan areas experiencing some of the state's fastest growth and residency in unincorporated areas on the rise. Though new residents and jobs fueled prosperity in the 1990s, the report finds that growth has slowed in the past year, and suggests that the state's highly decentralized development patterns could become troublesome as Missouri contends with a slowing economy and serious budget deficits.

Sponsored by the Ewing Marion Kauffman Foundation, Growth in the Heartland provides the most comprehensive and up-to-date body of research and statistics yet assembled analyzing the direction, scope, and implications of development in Missouri. In addition to assessing the consequences of those trends for the state's fiscal health, economic competitiveness, and quality of life, the report addresses the potential role of state and local policy in shaping those trends in the future. Specific findings of the report conclude that:

• Growth in the Columbia, Springfield, Joplin, and St. Joseph metropolitan areas strongly outpaced that of the Kansas City and St. Louis metropolitan areas in the 1990s. Altogether the four smaller areas captured fully one-quarter of the state's growth and doubled the growth rate of the Kansas City and St. Louis areas.
  
  
• Population and job growth also moved beyond the smaller metro areas and towns into the state's vast unincorporated areas. Overall, residency in these often-outlying areas grew by 12.3 percent in the 1990s—a rate 50 percent faster than the 8.1 percent growth of towns and cities.
  
  
• Most rural counties reversed decades of decline in the 1990s, with eight in ten rural counties experiencing population growth and nine in ten adding new jobs. By 2000, more rural citizens lived outside of cities and towns than in them, as more than 70 percent of new growth occurred in unincorporated areas.

"Missouri experienced tremendous gains during the last decade, but the decentralized nature of growth across the state poses significant fiscal challenges for the future," said Bruce Katz, vice president of Brookings and director of the policy center. "The challenge for Missouri is to give communities the tools, incentives, and opportunities to grow in more efficient and fiscally responsible ways."

The Brookings Institution Center on Urban and Metropolitan Policy is committed to shaping a new generation of policies that will help build strong neighborhoods, cities, and metropolitan regions. By informing the deliberations of state and federal policymakers with expert knowledge and practical experience, the center promotes integrated approaches and practical solutions to the challenges confronting metropolitan communities. Learn more at www.brookings.edu/urban.

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As the prevalence of drug-resistant bacteria continues to rise, there is a pressing need for new drugs to combat infections by these organisms. However, research and development in this area has slowed, creating a public health concern that we lack the drugs necessary to treat multi-drug resistant infections. Challenges to promoting antibacterial drug development may be scientific, methodological, regulatory, or economic in nature.

On Wednesday, May 9, 2012, the Engelberg Center for Health Care Reform convened an expert workshop, "Facilitating Antibacterial Drug Development,” that explored solutions to methodological and regulatory challenges that could make the development process more efficient. This meeting brought together diverse multi-stakeholder experts—including medical product developers, health care professionals, researchers, patient advocates, representatives of the U.S. Food and Drug Administration, and other groups—to explore the following issues:

• Existing paradigms for antibacterial drug development;
• Novel approaches to further antibacterial drug development, including use of pharmacokinetics and pharmacodynamics, Bayesian methods, innovative clinical trial designs, new data sources, alternate clinical endpoints, and new regulatory tools; and
• Short- and long-term opportunities to advance the antibacterial drug development enterprise through collaboration among stakeholders, improved regulatory science, and other means.

For more information on FDA’s Antibacterial Drug Development Task Force, click here.

Event Materials

• May 9 Event Summary
• Antibacterial Drug Development Participant List
• Facilitating Antibacterial Drug Development Agenda
• Facilitating Antibacterial Drug Development Discussion Guide
• Panel 1 Brad Spellberg Presentation
• Panel 1 George Talbot Presentation
• Panel 1 John Powers Presentation
• Panel 1 Thomas Fleming Presentation
• Panel 2 George Drusano Presentation
• Panel 2 Scott Emerson Presentation
• Panel 3 Daniel Benjamin Presentation
• Panel 3 Edward Cox Presentation
• Panel 3 John Rex examples
• Panel 3 John Rex Presentation
• Panel 4 Helen Boucher Presentation

Event Information

As part of ongoing cooperative work with the U.S. Food and Drug Administration, the Engelberg Center for Health Care Reform has formed a council to bring together expert perspectives on the challenges facing antibacterial drug development. Designed to include representatives from academia, patient advocacy groups, industry, providers, and government agencies, the Brookings Council on Antibacterial Drug Development (BCADD), will convene twice a year to discuss pressing issues in the treatment of infectious diseases and potential steps to address them.  

The first BCADD meeting, held on August 30, 2012, brought stakeholders together to discuss the following:

• Ongoing antibacterial initiatives at FDA and the Clinical Trials Transformation Initiative
• Statistical and methodological approaches that could be harnessed to improve the efficiency of antibacterial drug development
• Balancing benefit-risk and uncertainty considerations with public health needs
• Next steps for council action

For more information on FDA’s Antibacterial Drug Development Task Force, click here.

Event Materials

• 30 antibacterial drug development summary
• Presentation Slides
• FINAL BCADD Discussion Guide 20120828
• FINAL May 9 Summary 20120828
• Participant List_Final

Event Information

As part of an ongoing cooperative agreement with the U.S. Food and Drug Administration (FDA), the Engelberg Center for Health Care Reform at Brookings has formed the Brookings Council on Antibacterial Drug Development (BCADD) to identify steps to address the major technical, regulatory, and financial barriers impeding antibacterial drug development. At the first meeting of the BCADD, stakeholders emphasized the importance of concentrating on discrete policy and program areas to revitalize the antibacterial drug development enterprise.

BCADD convened a diverse group of stakeholders, including FDA officials, industry and biotech representatives, payers, providers, clinicians, and academic researchers Wednesday, February 27, 2013, to discuss two of the economic challenges facing antibacterial drug development:

• Better understanding the potential role of incentives in drug discovery and development; and
• Identifying potential reimbursement models that can support both stewardship and expanded investment for antibacterial drug products.

Event Materials

• meeting summary 20130925 FINAL
• Discussion Guide
• Participant List
• Presentation

The news Monday from the Centers for Disease Control and Prevention (CDC) on the incidence of resistant infections is disturbing but not surprising. CDC estimates that over two million Americans every year are affected by drug-resistant infections and of those, 23,000 die annually. The report notes that these figures are conservative and are likely an underestimate of the burden of resistant infections. While these numbers reflect domestic rates, antibiotic resistance is a global issue as well.

To further compound the issue, today’s antibiotic pipeline is nearly dry and has been for some time, with only a handful of large pharmaceutical companies and smaller biotech firms still engaged in antibiotic development. The threat of a so-called ‘post-antibiotic era’ – a time when there are no longer any effective antibiotic treatments – could become a reality without a concerted and comprehensive effort to combat this global threat. The evolution of drug resistance is an inherent risk of antibiotic use. The CDC report cited the development of new antibiotics and diagnostic tools, as well as programs and policies to support appropriate use of antibiotics, as being among the core strategies to combat resistance.

Clinical effectiveness and the relatively low cost of antibiotics have had the unintended consequence of contributing to overuse, accelerating the development of antibiotic resistance to all major classes of antibiotics. While there are some diagnostic tools available to support targeted treatment, it is often more time- and cost-effective for a physician to prescribe a relatively inexpensive, broad-spectrum antibiotic than to conduct a diagnostic test (if one exists at all). Antibiotic overuse can also be driven by patients who see antibiotics as safe and often low-cost cure-alls. Recognizing that these past patterns of overuse are dangerous, the clinical community is working diligently to curb inappropriate use and promote public health through stewardship and education programs. However, given the weakness of the current antibiotic development environment, it may be too little-too late; rates of resistance continue to rise globally while the number of effective therapies to treat many pathogens is dwindling. According to the CDC, resistance can be ”slowed but not stopped” – there will always be a need for novel antibiotics that can combat the evolution of these pathogens.

The current system for manufacturer return on investment for antibiotics, which are typically reimbursed at very low levels, is oriented towards volume sales. As a result, stewardship and educational programs geared toward limiting use of novel antibiotics create an ‘antibiotic development paradox.’ How can we incentivize investment in developing new effective antibiotics and also have successful programs that limit the use of these antibiotics in an effort to prevent or delay the development of resistance? Unless this fundamental conflict in the current business model is addressed, pharmaceutical firms are unlikely to expand development efforts.

How do we turn the tide?

There are several proposals that address aspects of the antibiotic development paradox with the goal of reinvigorating the antibiotic drug development ecosystem in a way that maximizes our ability to stay ahead of resistance. While none of these proposals alone will solve this problem, each could support the long-term goal of reinvigorating antibiotic discovery, development, and treatment.

Creating incentives for drug development

Antibiotic drug development has been a losing prospect for drug developers and has driven many of them to exit the antibiotic innovation space in the last few decades in favor of other therapeutic areas that have much larger markets and are easier areas to study. In order to make antibiotic development more attractive, various mechanisms have been proposed to stimulate or better reward successful clinical development. Incentives that can lower the financial risks associated with development include grants, tax credits, public-private partnerships, and intellectual property protections. Post-approval, prizes, advanced market commitments, and value-based pricing could all potentially provide additional incentives to invest in this research. Some potential incentives were discussed at the Incentives for Change: Addressing the Challenges in Antibacterial Drug Development workshop convened by Brookings in February 2013.

Balancing benefit and risk for severely-ill patients

Other incentives are related to the drug approval process. Novel mechanisms for expedited development and approval can speed time to market while still meeting traditional evidentiary requirements for safety and efficacy. In the last several years, a number of proposals – including from the Infectious Diseases Society of America and the President’s Council of Advisors on Science and Technology – have sought to reduce development time and cost and increase regulatory clarity through a more targeted clinical trial process directed at the highest-risk patients. A narrower study population would allow the U.S. Food and Drug Administration to make a more targeted assessment of the product’s safety, efficacy, and benefit-risk profile that could accelerate innovation for patients with serious drug-resistant infections. The need to steward these antibiotics, which was noted as a core action in the CDC report, would be especially important to both prevent the growth of resistance and to reduce the risk of adverse effects in less seriously-ill populations. Additional information on the proposed limited-use pathway and appropriate use is available on the Brookings website.

De-link reimbursement from return on investment

In order to attract investment for new antibiotic research, we must develop a business model that can support ongoing and expanding development without compromising the effectiveness of new therapies. Recognizing the need to “de-link” return on investment from the volume of antibiotics sold, efforts to move away from the volume-based reimbursement system could become an attractive path forward. Promising models, which were discussed at the Brookings workshop in February, included several guaranteed payment schemes supported by public funding. Taken to an extreme, such a system could even allow new antibiotics to be reserved indefinitely until needed, removing the developer’s incentive to sell any drugs in the years following approval. While such a program would likely be expensive (with sufficient returns estimated on the order of $1.75-2.5 billion over five years), government intervention is needed to fix this public health crisis and dangerous market failure. Its societal value in curtailing resistance and providing critical drugs would outweigh the cost to taxpayers.

The antibiotic development paradox will require a multi-pronged strategy that includes incentives to support front-end drug discovery and development, and new reimbursement policies that de-link unit volume sales from return on investment. However, this is by no means a quick fix. Even if this approach is successful, it will take decades for manufacturers to rebuild lost antibiotic development infrastructure and expertise, and to successfully develop and market new treatments. For the few drugs currently in development, even with expedited development and review pathways, they are still years from reaching the market.

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Antibacterial drug resistance is a global public health threat poised to worsen due to the combination of the inappropriate use of existing drugs and a marked decline in innovative antibacterial drug development. In order to tackle this problem, stakeholders must consider comprehensive strategies that address both drug development and stewardship.

On February 7, the Engelberg Center for Health Care Reform convened an expert workshop, “Modernizing Antibacterial Drug Development and Promoting Stewardship” to explore a two-pronged approach to combating antibacterial drug resistance that includes: 1) the development of pathogen-focused antibacterial drugs that target the most serious public health threats; and 2) stewardship efforts for all antibacterial products in order to preserve their utility. Participating stakeholders included experts from the drug development and health care industries, the clinical community, government, and academia. These stakeholders shared their insights on potential frameworks and evidentiary considerations for pathogen-focused drug development, and efforts underway to promote the appropriate use of commonly used antibacterial drugs in the ambulatory care setting.

Event Materials

• Antibiotic Development Slides
• 07 antibacterial expert workshop discussion guide
• 07 antibacterial expert workshop public agenda
• 07 antibacterial expert workshop meeting summary

Event Information

Antibacterial drugs are a critical component of the nation’s public health armamentarium, and have saved millions of lives by preventing and treating a range of bacterial infections. However, antibacterial drug development has been hampered by challenges unique to the antibacterial drug market, which have stifled innovation and left patients and providers with fewer options to treat increasingly resistant infections. One consequence of the dwindling antibacterial drug pipeline has been a reduction in effective oral antibacterial drug treatment options, which are particularly important in the ambulatory and transitional care contexts. Recent proposals to re-invigorate the antibacterial pipeline are geared towards serious infections treated in the inpatient setting, which may lead to a greater focus on intravenous therapies. However, addressing both current and future needs in the infectious diseases space will require a balanced mix of both oral and parenteral antibacterial drugs.

In cooperation with the U.S. Food and Drug Administration (FDA), the Engelberg Center for Health Care Reform at Brookings held an expert workshop on November 20, 2014, to identify the most promising strategies to support oral antibacterial drug development. Participating stakeholders included experts from the drug development and health care industries, the clinical community, government, and academia. These stakeholders shared their insights on potential regulatory, scientific, and economic strategies to reinvigorate the oral antibacterial drug pipeline. 

Event Materials

• Reinvigorating the Oral Antibacterial Drug Development Pipeline Agenda
• Reinvigorating the Oral Antibacterial Drug Development Pipeline Discussion Guide
• Biographies 20141118
• Reinvigorating the Oral Antibacterial Drug Development Pipeline Slide Deck

While antibiotics are necessary and crucial for treating bacterial infections, their misuse over time has contributed to a rather alarming rate of antibiotic resistance, including the development of multidrug-resistance bacteria or “super bugs.” Misuse manifests throughout all corners of public and private life; from the doctor’s office when prescribed to treat viruses; to industrial agriculture, where they are used in abundance to prevent disease in livestock. New data from the World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) confirm that rising overuse of antibiotics has already become a major public health threat worldwide.

As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies. In fact, recent estimates suggest that every year more than 23,000 people die due to drug-resistant infections in the U.S., and many more suffer from complications caused by resistant pathogens. Further, infections will be harder to control. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.

Incentivize appropriate use of antibiotics. Many patients and providers underestimate the risks of using antibiotics when they are not warranted, in part because these drugs often have rapid beneficial effects for those who truly need them.  In many parts of the world the perception that antibiotics carry few risks has been bolstered by their low costs and availability without a prescription or contact with a trained health care provider. Education efforts, stewardship programs, and the development of new clinical guidelines have shown some success in limiting antibiotic use, but these fixes are limited in scope and generally not perceived as cost-effective or sustainable. Broader efforts to incentivize appropriate use, coupled with economic incentives, may be more effective in changing the culture of antibiotic use. These options might include physician or hospital report cards that help impact patient provider selection, or bonuses based on standardized performance measures that can be used to report on success of promoting appropriate use.  While these might create additional costs, they would likely help control rates of drug resistant infections and outweigh the costs of treating them.

Reinvigorate the drug development pipeline with novel antibiotics. There has not been a new class of antibiotics discovered in almost three decades, and companies have largely left the infectious disease space for more stable and lucrative product lines, such as cancer and chronic disease. Antibiotics have historically been inexpensive and are typically used only for short periods of time, creating limited opportunities for return on investment. In addition, unlike cancer or heart disease treatments, antibiotics lose effectiveness over time, making them unattractive for investment. Once they are on the market, the push to limit use of certain antibiotics to the most severe infections can further constrict an already weak market.

Late last year, H.R. 3742, the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, was introduced and referred to the House Energy and Commerce Subcommittee on Health. If enacted, the ADAPT Act would create a streamlined development pathway to expedite the approval of antibiotics that treat limited patient populations with serious unmet medical needs. This could potentially reduce costs and development time for companies, thereby encouraging investment in this space. Regulators have indicated that they would also welcome the opportunity to evaluate benefits and risk for a more selective patient subpopulation if they could be confident the product would be used appropriately. The bill has received a great deal of support and would help address a critical public health need (I cover this topic in more detail with my colleagues Kevin Outterson, John Powers, and Mark McClellan in a recent Health Affairs paper).

Advance new economic incentives to remedy market failure. Innovative changes to pharmaceutical regulation, research and development (R&D), and reimbursement are necessary to alleviate the market failure for antibacterial drugs. A major challenge, particularly within a fee-for-service or volume-based reimbursement system, is providing economic incentives that promote investment in drug development without encouraging overuse.  A number of public and private stakeholders, including the Engelberg Center for Health Care Reform and Chatham House’s Centre on Global Health Security Working Group on Antimicrobial Resistance, are exploring alternative reimbursement mechanisms that  “de-link” revenue from the volume of antibiotics sold. Such a mechanism, combined with further measures to stimulate innovation, could create a stable incentive structure to support R&D.

Improve tracking and monitoring of resistance in the outpatient setting. There is increasing concern about much less rigorous surveillance capabilities in the outpatient setting, where drug-resistant infections are also on the rise. Policymakers should consider new incentives for providers and insurers to encourage a coordinated approach for tracking inpatient and outpatient resistance data. The ADAPT Act, mentioned above, also seeks to enhance monitoring of antibiotic utilization and resistance patterns. Health insurance companies can leverage resistance-related data linked to health care claims, while providers can capture lab results in electronic health records. Ultimately, this data could be linked to health and economic outcomes at the state, federal, and international levels, and provide a more comprehensive population-based understanding of the impact and spread of resistance. Current examples include the Food and Drug Administration’s (FDA) Sentinel Initiative and the Patient-Centered Outcomes Research Institute’s PCORnet initiative. 

Antibiotic resistance is an urgent and persistent threat. As such, patients and providers will continue to require new antibiotics as older drugs are forced into retirement by resistant pathogens. Stewardship efforts will remain critical in the absence of game-changing therapies that parry resistance mechanisms. Lastly, a coordinated surveillance approach that involves diverse stakeholder groups is needed to understand the health and economic consequences of drug resistance, and to inform antibiotic development and stewardship efforts.

Editor's note: This blog was originally posted in May 2014 on Brookings UpFront.

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Barack Obama’s presidency has witnessed widespread change throughout Africa. His four trips there, spanning seven countries, reflect his belief in the continent’s potential and importance. African countries face many challenges that span issues of trade, investment, and development, as well as security and stability. With President Obama’s second term coming to an end, it is important to begin to reflect on his legacy and how his administration has helped frame the future of Africa.

On July 19, the Center for 21st Century Security and Intelligence at Brookings hosted a discussion on Africa policy. Matthew Carotenuto, professor at St. Lawrence University and author of “Obama and Kenya: Contested Histories and the Politics of Belonging” (Ohio University Press, 2016) discussed his research in the region. He was joined by Sarah Margon, the Washington director of Human Rights Watch. Brookings Senior Fellow Michael O'Hanlon partook in and moderated the discussion.

Video

• President Obama’s role in African security and development

Audio

• President Obama’s role in African security and development

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160719_us_africa_transcript

While antibiotics are necessary and crucial for treating bacterial infections, their misuse over time has contributed to a rather alarming rate of antibiotic resistance, including the development of multidrug-resistance bacteria or “super bugs.” Misuse manifests throughout all corners of public and private life; from the doctor’s office when prescribed to treat viruses; to industrial agriculture, where they are used in abundance to prevent disease in livestock. New data from the World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) confirm that rising overuse of antibiotics has already become a major public health threat worldwide.

As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies. In fact, recent estimates suggest that every year more than 23,000 people die due to drug-resistant infections in the U.S., and many more suffer from complications caused by resistant pathogens. Further, infections will be harder to control. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.

Incentivize appropriate use of antibiotics. Many patients and providers underestimate the risks of using antibiotics when they are not warranted, in part because these drugs often have rapid beneficial effects for those who truly need them.  In many parts of the world the perception that antibiotics carry few risks has been bolstered by their low costs and availability without a prescription or contact with a trained health care provider. Education efforts, stewardship programs, and the development of new clinical guidelines have shown some success in limiting antibiotic use, but these fixes are limited in scope and generally not perceived as cost-effective or sustainable. Broader efforts to incentivize appropriate use, coupled with economic incentives, may be more effective in changing the culture of antibiotic use. These options might include physician or hospital report cards that help impact patient provider selection, or bonuses based on standardized performance measures that can be used to report on success of promoting appropriate use.  While these might create additional costs, they would likely help control rates of drug resistant infections and outweigh the costs of treating them.

Reinvigorate the drug development pipeline with novel antibiotics. There has not been a new class of antibiotics discovered in almost three decades, and companies have largely left the infectious disease space for more stable and lucrative product lines, such as cancer and chronic disease. Antibiotics have historically been inexpensive and are typically used only for short periods of time, creating limited opportunities for return on investment. In addition, unlike cancer or heart disease treatments, antibiotics lose effectiveness over time, making them unattractive for investment. Once they are on the market, the push to limit use of certain antibiotics to the most severe infections can further constrict an already weak market.

Late last year, H.R. 3742, the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, was introduced and referred to the House Energy and Commerce Subcommittee on Health. If enacted, the ADAPT Act would create a streamlined development pathway to expedite the approval of antibiotics that treat limited patient populations with serious unmet medical needs. This could potentially reduce costs and development time for companies, thereby encouraging investment in this space. Regulators have indicated that they would also welcome the opportunity to evaluate benefits and risk for a more selective patient subpopulation if they could be confident the product would be used appropriately. The bill has received a great deal of support and would help address a critical public health need (I cover this topic in more detail with my colleagues Kevin Outterson, John Powers, and Mark McClellan in a recent Health Affairs paper).

Advance new economic incentives to remedy market failure. Innovative changes to pharmaceutical regulation, research and development (R&D), and reimbursement are necessary to alleviate the market failure for antibacterial drugs. A major challenge, particularly within a fee-for-service or volume-based reimbursement system, is providing economic incentives that promote investment in drug development without encouraging overuse.  A number of public and private stakeholders, including the Engelberg Center for Health Care Reform and Chatham House’s Centre on Global Health Security Working Group on Antimicrobial Resistance, are exploring alternative reimbursement mechanisms that  “de-link” revenue from the volume of antibiotics sold. Such a mechanism, combined with further measures to stimulate innovation, could create a stable incentive structure to support R&D.

Improve tracking and monitoring of resistance in the outpatient setting. There is increasing concern about much less rigorous surveillance capabilities in the outpatient setting, where drug-resistant infections are also on the rise. Policymakers should consider new incentives for providers and insurers to encourage a coordinated approach for tracking inpatient and outpatient resistance data. The ADAPT Act, mentioned above, also seeks to enhance monitoring of antibiotic utilization and resistance patterns. Health insurance companies can leverage resistance-related data linked to health care claims, while providers can capture lab results in electronic health records. Ultimately, this data could be linked to health and economic outcomes at the state, federal, and international levels, and provide a more comprehensive population-based understanding of the impact and spread of resistance. Current examples include the Food and Drug Administration’s (FDA) Sentinel Initiative and the Patient-Centered Outcomes Research Institute’s PCORnet initiative. 

Antibiotic resistance is an urgent and persistent threat. As such, patients and providers will continue to require new antibiotics as older drugs are forced into retirement by resistant pathogens. Stewardship efforts will remain critical in the absence of game-changing therapies that parry resistance mechanisms. Lastly, a coordinated surveillance approach that involves diverse stakeholder groups is needed to understand the health and economic consequences of drug resistance, and to inform antibiotic development and stewardship efforts.

Editor's note: This blog was originally posted in May 2014 on Brookings UpFront.

Quickly following on the heels of the midterm elections, Senate Majority Leader Mitch McConnell (R-KY) indicated that the medical device tax was a key target for repeal in the 114th Congress. Today, the Senate Finance Health Care Subcommittee will hold a hearing about the effects of the 2.3 percent tax that was included in the Affordable Care Act. Many believe that a repeal is, in fact, possible. Below is a basic primer about the tax and its contentious history.

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.

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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

Event Information

The emerging field of precision medicine continues to offer hope for improving patient outcomes and accelerating the development of innovative and effective therapies that are tailored to the unique characteristics of each patient. To date, however, progress in the development of precision medicines has been limited due to a lack of reliable biomarkers for many diseases. Biomarkers include any defined characteristic—ranging from blood pressure to gene mutations—that can be used to measure normal biological processes, disease processes, or responses to an exposure or intervention. They can be extremely powerful tools for guiding decision-making in both drug development and clinical practice, but developing enough scientific evidence to support their use requires substantial time and resources, and there are many scientific, regulatory, and logistical challenges that impede progress in this area.

On October 27th, 2015, the Center for Health Policy at The Brookings Institution convened an expert workshop that included leaders from government, industry, academia, and patient advocacy groups to identify and discuss strategies for addressing these challenges. Discussion focused on several key areas: the development of a universal language for biomarker development, strategies for increasing clarity on the various pathways for biomarker development and regulatory acceptance, and approaches to improving collaboration and alignment among the various groups involved in biomarker development, including strategies for increasing data standardization and sharing. The workshop generated numerous policy recommendations for a more cohesive national plan of action to advance precision medicine.  

Event Materials

• 1027 Brookings biomarkers workshop agenda
• 1027 Biomarkers workshop backgrounderfinal
• 1027 Biomarkers workshop slide deckfinal
• 1027 Biomarkers workshop participant listfinal

Summary

Global education plays an important role in contributing to U.S. foreign policy objectives. In a recent speech, Secretary of State Hillary Clinton highlighted education, along with health, agriculture, security, and local governance as the core areas for U.S. international development investment. She emphasized the importance of education, particularly of girls and youth, in improving global stability, speeding economic growth, and helping global health, all of which advance U.S. interests in the world.

But how effective has the U.S. government been in supporting global education? Unfortunately, its many good education activities and programs are not leveraged for maximum impact on the ground, especially in situations of armed conflict and state fragility. Challenges of U.S. foreign assistance—for example, fragmentation across multiple agencies, lack of policy coherence, diminished multilateral engagement—generally affects its work in education. Luckily some of the core strengths of U.S. assistance have an impact as well, specifically the large amount of resources (in total terms, if not relative terms) devoted to education and the vast breadth and depth of American academic, philanthropic and NGO partners engaged in pioneering work on education in the developing world.

This report analyzes the effectiveness of U.S. government education work specifically in relation to conflict-affected and fragile states. Findings across five domains—global reach, resources, technical expertise, policy and multilateral partnerships—show that U.S. education aid falls critically short of what it is capable of achieving. The U.S. government has substantial strengths in this area, especially in global reach, resources, and technical expertise, demonstrating a real comparative advantage in the field of education in situations of conflict and fragility. However, its fragmented policy across agencies and its limited multilateral engagement prevent it from maximizing its strengths, leaving it punching below its weight on this important issue. In this sense, the U.S. government is a classic underachiever, failing to efficiently deploy its many capabilities and potential for maximum impact.

There has never been a better time for looking at the aid-effectiveness of U.S. government education work. The Obama administration is bringing increased focus on the Paris Principles for Aid Effectiveness to its development initiatives. The U.S. Congress is actively engaged with pending legislative action to modernize foreign assistance and improve U.S. support for universal education. Two major reviews of foreign assistance are underway: the Quadrennial Diplomacy and Development Review led by the Department of State and USAID, and the Presidential Study Directive on U.S. Global Development Policy led by the White House.

Questions about foreign assistance reform asked in these two reviews can be applied to the education sector. For example, how can the U.S. government improve its education assistance by using a “whole-of-government” approach, by focusing on comparative advantages and strengths, and by improving coordination and by increasing multilateral engagement?

Careful analysis and answers to these questions can help propel the U.S. from its current position as an underachiever to being a leader in global education, specifically in contexts of conflict and state fragility.

This report makes nine specific recommendations, many of which could be achieved without any substantial increase in funding, that would enable the U.S. government to greatly increase the effectiveness of its education aid to populations living in contexts of conflict and state fragility.

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INTRODUCTION

With fewer than three years until the planned end-date of the United Nations Millennium Development Goals (MDGs), attention is rapidly turning to what will follow. The elaboration of the next global development agenda is a complex, multi-pronged process that is academic, political and practical, involving experts from a myriad of social and economic sectors and representing a cross-section of constituencies. While the formal U.N. process is still in the early stages, the ongoing discourse (predominantly occurring in the global north, but not exclusively) has introduced several potential frameworks for this agenda. This paper describes the leading frameworks proposed for the post-2015 global development agenda and discusses how education and learning fit within each of those frameworks. While many within the education community are working to develop a cohesive movement to advance an “access plus learning” agenda, it remains equally important to engage proactively with the broader development community to ensure that education fits within the agreed upon overarching organizing framework.

The frameworks described below represent a snapshot of current thinking in 2012. On the road to 2015, the education community will need to refine and sharpen its thinking with respect to how learning is incorporated into the prevailing framework. The seven frameworks that will be addressed in this paper are:

1. Ending Absolute Poverty
2. Equity and Inclusion
3. Economic Growth and Jobs
4. Getting to Zero
5. Global Minimum Entitlements
6. Sustainable Development
7. Well-Being and Quality of Life

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Demand for more walkable, mixed use neighborhoods is growing across the United States. However, the challenges associated with fi nancing these developments are allowing much of this demand to go unmet. This paper discusses how more, and more upfront, patient equity in walkable projects—from various sources and providers—would facilitate their development, and yield high returns over the long term. The paper also examines how patient equity contributed to the success of several such developments built over the past 15 years, illustrating untapped potential. Finally, it notes the role the public sector can play in providing patient equity investments.

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It is hard to find good news these days, especially coming from Sacramento, the capital of one of the most hard-pressed states in the country. Yet an evolving model of development is emanating from the metropolitan area that is being watched carefully around the country.

This model could inspire sweeping national transportation, energy and climate change legislation and future infrastructure investment and real estate development.

The model started with the much-admired Blueprint Project, led by the Sacramento Area Council of Governments. Next came Senate Bill 375, calling for regional transportation and development plans that minimize auto dependency, reduce climate change gas emissions and encourage walkable urban development. The next steps are the Sacramento Regional Transit Master Plan and Transit-Oriented Guidelines, to be released in May. Taken together, they offer a bold effort to give the market what it wants: the choice of the well-known drivable suburban or walkable urban development, the basis of the next American Dream.

For the past half-century, American households demanded and got only one way of living and working, the suburban way that meant driving. Basically, California invented this way of life and exported it across the country and around the world. We all reveled in it. The songs of the Beach Boys and Jan and Dean still echo through my mind, reminding me of a way of life and a way of developing our communities that was seductive at the time.

Little did we know of the unintended consequences of drivable suburban development pattern, including:

• Land consumption eight to 12 times that of population growth.
• Significant increase in car-miles driven and foreign oil consumed, mostly from hostile countries.
• The onset of the obesity, diabetes and asthma epidemics related to a car-dependent lifestyle, especially among our children who cannot even walk to school anymore.
• Household income diverted from wealth building to paying for a fleet of depreciating cars, taking at least 25 percent of income vs. less than 5 percent a century ago.
• The quality of life for the community goes down when more drivable suburban development occurs, such as the next strip mall. This leads to not-in-my-backyard opposition. According to a soon-to-be-released Brookings Institution study, car-dependent households emit three times the climate change gases, such as carbon dioxide, as a walkable urban household.