China has provided foreign assistance since the 1950s, and is now the largest developing country to provide aid outside of the Development Assistance Committee (DAC), a forum of the world’s major donor countries under the Organization for Economic Cooperation and Development (OECD). Like its foreign policy more broadly, Chinese foreign assistance has adhered to the “Five Principles of Peaceful Coexistence” and emphasized the virtue of national self-reliance. At the same time, it has served a strategic purpose alongside other foreign policy priorities.

A slow start but a steady increase

Compared to top DAC donor countries, the scale of China’s foreign assistance is still relatively small. According to some estimates and OECD International Development Statistics, China’s gross foreign aid in 2001 was extremely limited, amounting to only about 1.8 percent of the total contribution by DAC donors. However, since launching its “Go Global” strategy in 2005, China has deepened its financial engagement with the world, and its foreign aid totals have grown at an average rate of 21.8 percent annually. In 2013, China contributed about 3.9 percent to total global development assistance, which is 6.6 percent of the total contribution by DAC countries and over 26 percent of total U.S. foreign aid. 

Millions of USD (Current)

Gross foreign aid provided by China versus major DAC donors

And the lion’s share goes to: Africa

Africa is one of China’s most emphasized areas of strategic engagement. Particularly since the establishment of the Forum on China-Africa Cooperation (FOCAC) in 2000, the relationship between China and Africa has gotten closer and closer. In 2009, African countries received 47 percent of China’s total foreign assistance. Between 2000 and 2012, China funded 1,666 official assistance projects in 51 African countries (the four countries that don’t have diplomatic relations with China—Gambia, Swaziland, Burkina Faso, and São Tomé and Príncipe—were left out), which accounted for 69 percent of all Chinese public and private projects. Among the 1,666 official projects, 1,110 qualified as Official Development Assistance (ODA)—defined by the OECD as flows of concessional, official financing administered to promote the economic development and welfare of developing countries. The remaining 556 projects could be categorized, also according to the OECD, as Other Official Flow (OOF)—transactions by the state sector that are not “development-motivated” or concessional (such as export credits, official sector equity and portfolio investment, and debt reorganization). (Note: in terms of dollar amounts, not included in the statistics here, most Chinese lending to Africa and other parts of the developing world is not concessional and is therefore not foreign aid.)

Zeroing in on infrastructure

About 61 percent of Chinese concessional loans to Africa are used for infrastructure construction, and 16 percent are for industrial development. The three areas that receive the largest allocations of Chinese concessional loans are transport and storage; energy generation and supply; and industry, mining, and construction. A small portion of the remaining allocations go to health, general budget support, and education. 

Some have interpreted these trends to mean that China is making an effort to export domestic excess capacity in manufacturing and infrastructure, especially considering the uncertainties of China’s economic transition. But the motivations are broader than that. China’s “Africa Policy”—issued in December 2015, in Johannesburg—clearly expresses the Chinese government’s belief that infrastructure construction is a crucial channel for African development. This notion could be connected to the domestic Chinese experience of having benefited from the technological diffusion of foreign aid and foreign direct investment in the construction sector. Moreover, in practice, China’s more than 20 years of experience in implementing international contract projects, as well as advanced engineering technologies and relatively low labor costs, have proved to be a comparative advantage in Chinese foreign assistance. In addition, by prioritizing the principles of non-interference and mutual benefit, China is more comfortable providing infrastructure packages (e.g., turn-key projects) than many other countries. 

Doing assistance better

Legitimate concerns have been raised about China’s tendency to facilitate authoritarianism and corruption, as well that its assistance does not always trickle down to the poor. As such, the state-to-state Chinese approach to providing assistance should be reformed. Globalization scholar Faranak Miraftab indicates that on-the-ground partnerships between communities and the private sector—mediated by the public sector—could achieve synergies to overcome certain shortcomings, creating a win-win situation. With deeper involvement by domestic assistance providers, Chinese foreign assistance could touch more people’s lives by tackling both the short- and long-term needs of the most under-resourced parts of civil society. Domestic assistance providers should exploring public-private partnerships, which among other benefits could yield increased foreign assistance services. By focusing on its comparative advantage in contributing to infrastructure projects that benefit the general public while also facilitating participation from civil society, Chinese foreign assistance could bring more concrete benefits to more individuals. 

China has already begun tackling these and other weaknesses. Although infrastructure and industry still account for the largest share of total official projects in Africa, China has intentionally strengthened its official development finance efforts in areas related to civil society. Projects have surged in the areas of social infrastructure and services, developmental food aid and food security, support to non-governmental organizations, and women in development, to name a few. Moreover, following President Xi Jinping’s promise at the United Nations summit in September 2015, an initial $2 billion has been committed as a down payment toward the China South-South Cooperation and Assistance Fund. The funding is primarily designed to improve the livelihoods of residents of recipient countries and diversify domestic aid providers (e.g., NGOs) qualified to participate or initiate assistance projects in the least-developed countries. 

In order to achieve positive results, it is critical for the Chinese government to carry out detailed management initiatives to engage civil society: for example, establishing a complete system for information reporting and disclosure (actions have already been taken in several ministries and bureaus), publishing guidelines for the private sector to develop assistance services overseas, and improving coordination and accountability among ministries and within the Ministry of Commerce. Although challenges still remain, Chinese foreign assistance is moving in a positive direction without abandoning its defining characteristics. 

       

       

       

       

       

       

       

       

      

       

       

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In a world where borders matter less and where seemingly faraway threats can become immediate problems, the fight against poverty is no longer a matter of just doing the right thing – it is a matter of doing the smart thing to ensure security at home and abroad. As seen across the globe, by exhausting institutions, depleting resources, weakening leaders and crushing hope, extreme poverty fuels instability that often leads to armed conflict and can be a breeding ground for terrorists. The reverse is also true: insecurity stemming from conflict and demographic and environmental challenges makes it harder for leaders, institutions and other stakeholders to address poverty. Simply put, poverty is both a cause of insecurity and a product of it.

To explore this tangled web, in August 2006 the Brookings Blum roundtable discussed the challenges and possible solutions with a diverse group of leaders, including policymakers, business executives and academics, and developed recommendations for change.

2006 Brookings Blum Roundtable: Related Materials
	Read the roundtable report - Ending Poverty, Promoting Peace: The Quest for Global Security »  View related conference book »  Download the participant list » (PDF)  Download the scene setter » (PDF)

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2006 Brookings Blum Roundtable Agenda:

1. Global Poverty, Conflict and Insecurity

• Susan Rice, The Brookings Institution, "Global Poverty, Weak States and Insecurity"
• Edward Miguel, University of California, Berkeley, "Global Poverty, Conflict and Insecurity"

2. Operating in Insecure Environments

• Jane Nelson, Harvard University, "Operating in Insecure Environments"

3. Keynote Address: "Achieving Peace in an Inequitable World"

• James D. Wolfensohn, Chairman of Citigroup International Advisory Board and Former President of the World Bank

4. The Role of Leadership in Overcoming Poverty & Security in Africa
   Chaired by: Mary Robinson, Realizing Rights: The Ethical Globalization Initiative

• Robert Rotberg, Harvard University, "The Role of Leadership in Overcoming Poverty & Insecurity in Africa"

Leadership Presentations:

• Mohammed Ibrahim, Chairman, Celtel International
• John Kachamila, Former Minister, Mozambique
• Ketumile Masire, Former President of Botswana

5. Resource and Environmental Insecurity

• Colin Kahl, University of Minnesota, "Demography, Environment and Civil Strife"
• Anthony Nyong, University of Jos, Nigeria, "Resource and Environmental Security"

6. Keynote Address

• Kemal Dervis, Administrator, United Nations Development Programme

7. Youth and Conflict

• Henrik Urdal, The International Peace Research Institute, "The Demographics of Political Violence: Youth Bulges, Insecurity and Conflict"
• Marc Sommers, Tufts University, "Embracing The Margins: Working with Youth Amidst War and Insecurity"
• Jane Nelson, Harvard University, "Operating in Insecure Environments: The Youth Demographic"

8. Transformational Diplomacy and the Route to Security

• Jennifer Windsor, Freedom House, "Breaking the Poverty-Insecurity Nexus: Is Democracy the Answer?"

Presentations:

• Philip Zelikow, United States Department of State
• Madeleine Albright, 64th Secretary of State
• Mary K. Bush, Chairman, HELP Commission
• Lael Brainard, The Global Economy and Development Program, The Brookings Institution

       

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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.

2010 Brookings Blum Roundtable: Related Materials
	Read the roundtable report - Aiding Development: Assistance Reform in the 21st Century »  Read the conference policy briefs »  Download the participant list » (PDF) Download the scene setter » (PDF) Download the full roundtable agenda » (PDF)

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.

       

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

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.

Did the Highway Increase Human Mobility?

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.

The Success of Big Data

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.

      

About 12,000 troops will parade through Tiananmen Square in Beijing tomorrow to celebrate the 70th anniversary of Japan’s surrender to the allies in World War II. China’s leadership is ostensibly using the anniversary as an opportunity, to use the Chinese phrasing, to celebrate “victory in the World Anti-fascist War and the Chinese people’s War of Resistance against Japanese Aggression.”

But really, the purpose is to display its modernized weaponry ahead of several key international visits by President Xi Jinping. For Western leaders, the parade has proven a diplomatic nightmare: The Chinese have pressured them to attend, but they realize that the event is aimed at celebrating the country’s new international assertiveness (and perhaps to sideline a rather bloody summer on the Chinese stock markets). 

Students pose with Chinese national flags and red stars in preparation for the parade on August 31, 2015. Photo credit: Reuters/China Daily.

It’s the present, stupid

Sixty-six years after the end of the war, the world has been learning how to deal with a new China—now a powerful country with a strong economy and an increasingly well-equipped military. China’s defense budget has seen a double-digit increase for the past 25 years, and the country now has J-15 fighter jets, Z-19 attack helicopters, and a truck-mounted version of the DF-41 intercontinental missile. There is little doubt the parade will be impressive both in precision and display. 

In spite of how the Chinese leadership spins it, the parade is not just about history—it’s also about the present and the future. China is using it as a moment to show off its strengths and assert a stronger role in the Asia-Pacific region (as tensions in the South China Sea remain high), if not the world.

The red carpet

One interesting sight will be the VIP box: Which heads of state will actually attend? Confirmed leaders include Russian President Vladimir Putin (who himself hosted Xi Jinping last May for a huge victory parade in Moscow); South African President Jacob Zuma; Venezuelan President Nicolas Maduro; Sudanese President Omar Hassan al-Bashir (who has an international arrest warrant against him); and—somewhat unexpectedly considering World War II sensitivities in the region—South Korean President Park Geun-hye. Park will attend ceremonies, but not the parade. North Korean leader Kim Jong Un will not be present, nor will Japanese Prime Minister Shinzo Abe. 

Fellow leading industrial nations countries don’t want to put Japan in a bind, but no one is willing to offend China. Hence, state leaders have responded to the standing Chinese invitation with an array of contortions. In the end, no Western leader will attend: President Barack Obama—who will be hosting Xi Jinping in the United States in a few weeks—will be represented by U.S. Ambassador to China Max Baucus. Unlike for the launch of the Asian Infrastructure Investment Bank (AIIB) earlier this year, Washington didn’t pressure other Western leaders to avoid Beijing. This wasn’t necessary, as those governments all had their own reasons for staying away. Even the German president—a largely ceremonial figure—has declined. So has his French counterpart François Hollande, who will travel to China in October to discuss climate issues; French Foreign Minister Laurent Fabius will attend instead. Italy will also be represented by its foreign minister. As for the United Kingdom, Prime Minister David Cameron chose to wait for the Chinese state visit to London in October to meet Xi in person. Britain is represented by a former Conservative cabinet minister, Kenneth Clarke. Even more surprising is the list of retired statesmen: former German Chancellor Gerhard Schroeder, who is known to have engaged with Russia’s Putin after leaving office in 2005, will be in there, like his friend and former U.K. counterpart Tony Blair. 

Aircraft perform during a rehearsal on August 23, 2015 for the September 3 military parade in Beijing. Photo credit: Reuters.

Enough troubles

The U.S.-China relationship is already complicated enough and needs no further upsets. While China flexes its muscles with a parade, America is in the middle of a presidential campaign during which candidates—such as Republican Wisconsin Governor Scott Walker, who recently called on President Obama to cancel Xi's visit—are openly criticizing China. For his part, Donald Trump claimed that “China would be in trouble” should he become president, adding: “The poor Chinese.” Although these kinds of comments cannot be taken too seriously, they will require even more diplomatic skills on the part of the current administration, and its successor, to fully restore fully the U.S.-China dialogue.

In these circumstances, it is no surprise that Washington has shown little interest in attending the Beijing events. Nor does the Obama administration want to be part of a demonstration of assertiveness weeks before a state visit to Washington by President Xi. History tells us that U.S.-China relations are going to get even more interesting than a parade.

       

       

       

       

       

       

       

       

       

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On April 30, 2007, the Brookings Center on the United States and Europe held its fourth annual conference. As in previous years, the annual conference brought together scholars, officials, and policymakers from both sides of the Atlantic to examine the evolving roles of the United States and Europe in the global arena. Panel discussions covered some critical issues about Europe and the U.S.-Europe relationship: "The French Elections", "NATO and Afghanistan" and "Islam in Europe". Panelists included, among others, Lt. General Karl Eikenberry, Deputy Chairman of the NATO Military Committee; Ashraf Ghani, former Finance Minister of Afghanistan; Tufyal Choudhury of Durham University; Philip Gordon of the Brookings Institution; and Corine Lesnes from Le Monde.

8:30 a.m.		Continental breakfast available
8:50 a.m.		Welcome and Introduction Strobe Talbott, President, The Brookings Institution
9:00 - 10:30 a.m.		"The French Elections" Chair: Jim Hoagland, The Washington Post Panelists: Laurent Cohen-Tanugi, Skadden Arps; Notre Europe Corine Lesnes, Le Monde Philip Gordon, The Brookings Institution
10:30 - 10:45 p.m.		Break
10:45 a.m. - 12:15 p.m.		"NATO in Afghanistan" Chair: Carlos Pascual, The Brookings Institution Panelists: Lt. General Karl Eikenberry, Deputy Chairman of the NATO Military Committee Ashraf Ghani, former Finance Minister of Afghanistan Marvin Weinbaum, Middle East Institute
12:15 - 1:30 p.m.		Buffet Lunch (Saul/Zilkha)
1:30 - 3:00 p.m.		"Islam in Europe" Chair: Jeremy Shapiro, The Brookings Institution Panelists: Daniel Benjamin, The Brookings Institution Tufyal Choudhury, Durham University Jonathan Laurence, Boston College

The Center on the United States and Europe Annual Conference is made possible by the generous support of the German Marshall Fund of the United States

Transcript

• Transcript (.pdf)

Event Materials

• 20070430

       

       

Gary Burtless, a senior fellow in Economic Studies, explains new research on the growing longevity gap between high-income and low-income Americans, especially among the aged.

“Life expectancy difference of low income workers, middle income workers, and high income workers has been increasing over time,” Burtless says. “For people born in 1920 their life expectancy was not as long typically as the life expectancy of people who were born in 1940. But those gains between those two birth years were very unequally distributed if we compare people with low mid-career earnings and people with high mid-career earnings.” Burtless also discusses retirement trends among the educated and non-educated, income inequality among different age groups, and how these trends affect early or late retirement rates.

Also stay tuned for our regular economic update with David Wessel, who also looks at the new research and offers his thoughts on what it means for Social Security.

Show Notes

Later retirement, inequality and old age, and the growing gap in longevity between rich and poor

Disparity in Life Spans of the Rich and the Poor Is Growing

Subscribe to the Brookings Cafeteria on iTunes, listen on Stitcher, and send feedback email to BCP@Brookings.edu.

       

The mayoral election in Baltimore has brought local economic development strategies to the forefront. In a city in which inequality—by income, by race, and between neighborhoods—has increased in the past five years, the candidates have made it clear that more action must be taken to close disparities and improve economic outcomes for all residents. In a podcast segment, I commend the much-needed focus on equity but argue that the mayoral candidates should not lose sight of another critical piece of the equity equation: economic growth. Citing lessons from my recent paper, I outline strategies that Baltimore’s presumptive leaders should pursue—as well as several they should abandon—to place the city’s residents on the path to a more prosperous, equitable future.

Listen to the full podcast segment here: 

       

       

       

       

       

       

       

Nearly eight years after a U.S.-led invasion toppled the Taliban regime, Afghanistan remains far from stable. As President Barack Obama considers alternatives to increasing the number of U.S. troops in Afghanistan, his administration’s new counternarcotics strategy meshes well with counterinsurgency and state-building efforts in the country. It is a welcome break from previous ineffective and counterproductive policies. The effectiveness of the policy with respect to counternarcotics, counterinsurgency and state-building, however, will depend on the operationalization of the strategy. The details are not yet clear, but the strategy potentially faces many pitfalls.

Efforts to bankrupt the Taliban through eradication are futile and counterproductive since they cement the bonds between the population and the Taliban. But interdiction is very unlikely to bankrupt the Taliban either. Security needs to come first before any counternarcotics policy has a chance of being effective. Counterinsurgent forces can prevail against the Taliban, without shutting down the Taliban drug income, by adopting an appropriate strategy that provides security and rule of law to the population and by sufficiently beefing up their own resources vis-à-vis the Taliban. Rural development is a long term and multifaceted effort. Simplistic strategies that focus simply on price ratios or try to raise risk through “seed-burn-seed” approaches are ineffective. Wheat replacement strategy as a core of the alternative livelihoods effort is singularly inappropriate for Afghanistan. Shortcuts do not lead to sustainable policies that also mitigate conflict and enhance state-building.

The Obama administration will need to reduce expectations for quick fixes and present realistic timelines to Congress, the U.S. public and the international community for how long rural development and other counternarcotics policies in Afghanistan will take to show meaningful and sustainable progress that advances human security of the Afghan people, mitigates conflict and enhance state building. Unless this is conveyed, there is a real danger that even a well-designed counternarcotics policy will be prematurely and unfortunately discarded as ineffective.

The New Strategy in Afghanistan’s Context

In summer 2009, the Obama administration unveiled the outlines of a new counternarcotics policy in Afghanistan. The new policy represents a courageous break with previous misguided efforts there and thirty years of U.S. counternarcotics policies around the world. Instead of emphasizing premature eradication of poppy crops, the new policy centers on increased interdiction and rural development. This approach strongly enhances the new counterinsurgency policy focus on providing security to the rural population, instead of being preoccupied with the numbers of incapacitated Taliban and al Qaeda.

In Afghanistan, somewhere between a third and a half of its GDP comes from poppy cultivation and processing and much of the rest from foreign aid, so the illicit poppy economy determines the economic survival of a large segment of the population. This is true not only of the farmers who cultivate opium poppy frequently in the absence of viable legal and illegal economic alternatives. But, as a result of micro- and macro-economic spillovers and the acute paucity of legal economic activity, much of the economic life in large cities is also underpinned by the poppy economy. After a quarter century of intense poppy cultivation, the opium poppy economy is deeply entrenched in the socio-economic fabric of the society. Islamic prohibitions against opiates notwithstanding, the poppy economy inevitably underlies Afghanistan’s political arrangements and power relations. Profits from taxing poppy cultivation and protecting smuggling rings bring substantial income to the Taliban. A recent CRS report (August 2009) estimates the income at $70-$100 million per year, which accounts for perhaps as much as half of Taliban income. But many other actors in Afghanistan profit from the opium poppy economy in a similar way: former warlords cum government officials; members of Afghanistan’s police; tribal chiefs; and independent traffickers.

Moreover, the Taliban and many others who protect the opium poppy economy from efforts to suppress it derive much more than financial profits. Crucially, they also obtain political capital from populations dependent on poppy cultivation. Such political capital is a critical determinant of the success and sustainability of the insurgency since public support or at least acceptance are crucial enablers of an insurgency. Indeed, as I detail in my forthcoming book, Shooting Up: Counterinsurgency and the War on Drugs, along with providing order that the Afghan government is systematically unable to provide and capitalizing on Ghilzai Pashtun sentiments of being marginalized, protection of the poppy fields is at the core of the Taliban support. By not targeting the farmers, the new counternarcotics strategy is thus synchronized with the counterinsurgency efforts because it can deprive the Taliban of a key source of support. Its overall design also promises to lay the necessary groundwork for substantial reductions in the size and impacts of the illicit economy in Afghanistan.

However, while appropriate in its overall conception, the new strategy has pitfalls. Specifically how to operationalize interdiction and rural development will to a great extent determine the effectiveness of the strategy—not only with respect to the narrow goal of narcotics suppression, but also with respect to counterinsurgency and state-building. While many of the details still remain to be developed, some of those that have trickled out give reasons for concern.

Effects of Previous Eradication-Centered Policy

During the 2008-09 growing season, the area of cultivation in Afghanistan fell by 22% to 123,000 hectares and opium production fell by 10 percent to 6,900 metric tons (mt). Much of this decline in cultivation was driven by market forces largely unrelated to policy: After several years of massive overproduction in Afghanistan that surpassed the estimated global market for opiates by almost three times, opium prices were bound to decline. Even at 6,900 mt, production still remains twice as high as world demand, leading to speculation that someone somewhere is stockpiling opiates.

More significant, the persistence of high production betrays the ineffectiveness of simplistic policies, such as premature forced eradication before alternative livelihoods are in place, which since 2004 (until the new Obama strategy) was the core of the counternarcotics policy in Afghanistan. Policies that fail to address the complex and multiple structural drivers of cultivation and ignore the security and economic needs of the populations dependent on poppy cultivation generate vastly counterproductive effects with respect to not only counternarcotics efforts, but also counterinsurgency, stabilization and state building.

The eastern Afghan province of Nangarhar provides a telling example. For decades, Nangarhar has been one of the dominant sources of opium poppy. But over the past two years, as a result of governor Gul Agha Shirzai’s suppression efforts—including bans on cultivation, forced eradication, imprisonment of violators and claims that NATO would bomb the houses of those who cultivate poppy or keep opium—cultivation declined to very low numbers. This has been hailed as a major success to be emulated throughout Afghanistan.

In fact, the economic and security consequences were highly undesirable. The ban greatly impoverished many, causing household incomes to fall 90% for many and driving many into debt. As legal economic alternatives failed to materialize, many coped by resorting to crime, such as kidnapping and robberies. Others sought employment in the poppy fields of Helmand, yet others migrated to Pakistan where they frequently ended up recruited by the Taliban. The population became deeply alienated from the government, resorting to strikes and attacks on government forces. Districts that were economically hit especially severely, such as Khogiani, Achin and Shinwar, have become no-go zones for the Afghan government and NGOs. Although those tribal areas have historically been opposed to the Taliban, the Taliban mobilization there has taken off to an unprecedented degree. The populations began allowing the Taliban to cross over from Pakistan, and U.S. military personnel operating in that region indicate that intelligence provision to Afghan forces and NATO has almost dried up. Tribal elders who supported the ban became discredited, and the collapse of their legitimacy is providing an opportunity for the Taliban to insert itself into the decision-making structures of those areas. And all such previous bans in the province, including in 2005, turned out to be unsustainable in the absence of legal economic alternatives. Thus, after the 2005 ban, for example, poppy cultivation inevitably swung back.

The Ingredients of Success

Security
The prerequisite for success with respect to narcotics is security, i.e. sustained state control of territory. Without it, Afghanistan cannot be stabilized and the state strengthened; nor can counternarcotics policies be effective. Whether one adopts iron-fisted eradication or sustainable rural development as the core of a counternarcotics policy, security is essential. Without security first, counternarcotics efforts have not yet succeeded anywhere. Suppression without alternative livelihoods in place requires firm control of the entire territory to prevent illicit crop displacement and harsh suppression of the population dependent on illicit crops. Apart from being problematic with respect to human rights, this harsh approach is also very costly politically. Rural development requires security, otherwise investment will not come in, the population will not make risky long-term investments in legal crops and structural drivers of cultivation will not be effectively addressed. Development under a hail of bullets simply does not work, and in the context of insecurity, illicit economies persist and dominate.

Nor have counternarcotics policies, such as eradication or interdiction, succeeded in bankrupting or severely weakening any belligerent groups profiting from drugs anywhere in the world. Not in China, Thailand, Burma, Peru, Lebanon or even Colombia. Instead, they cement the bonds between marginalized populations dependent on illicit crops and belligerents plus severely reduce human intelligence flows to the counterinsurgent forces.

But counterinsurgent forces can prevail against insurgents and terrorists without stopping or reducing the terrorists’ drug-based financial inflows—either by increasing their own forces and resources vis-à-vis the belligerents or by adopting a smarter strategy that is either militarily more effective or wins the hearts and minds. This was the case in China, Thailand, Burma, and Peru where counterinsurgents succeeded without eradication. Evidence that counterinsurgent forces can prevail without bankrupting the belligerents through eradication also holds in the case of Colombia where the FARC has been weakened militarily not because of the aerial spraying of coca fields, but in spite of it. Today, more coca is grown there than at the beginning of Plan Colombia; but as a result of U.S. resources and training, Colombian forces were capable of greatly weakening the FARC even though forced eradication virtually eliminated human intelligence from the population to the government.

Interdiction with the Right Focus
The broad focus of the new counternarcotics strategy on interdiction is well placed, but interdiction’s effectiveness will depend on its objectives and execution. Just like eradication, interdiction will not succeed in bankrupting the Taliban. The Taliban has many other sources of income, including donations from Pakistan and the Middle East, taxation of legal economic activity, smuggling with legal goods, wildlife and illicit logging. In fact, it rebuilt itself in Pakistan between 2002 and 2004 without access to the poppy economy. Overall, drug interdiction has a very poor record in substantially curtailing belligerents’ income, with only a few successes registered in, for example, highly localized settings in Colombia and Peru.

Instead, the objective of the policy should be to reduce the coercive and corrupting power of organized crime groups. But achieving that requires a well-designed policy and a great deal of intelligence. Previous interdiction efforts in Afghanistan have in fact had the opposite effect: they eliminated small traders and consolidated the power of big traffickers, giving rise to the vertical integration of the industry. They also strengthened the bonds between some traffickers and the Taliban (although many traffickers continue to operate independently or are linked to the government).

Large-scale interdiction that targets entire networks and seeks to eliminate local demand for opium from local traders, which some are arguing for, is extraordinarily resource-intensive given the structure of the Afghan opium industry. Prioritization will need to be given to devoting scarce resources to drug interdiction or directly to counterinsurgency. The odds of success are not high. But even if such an interdiction strategy did succeed in shutting down local demand, the policy would become counterproductive since in local settings its effects would approximate the effects of eradication, thus once again alienating the population. Such large-scale interdiction is thus not currently appropriate for Afghanistan.

But even the NATO-led selective interdiction of targeting designated Taliban-linked traffickers (the United States has identified fifty such traffickers) is not free from pitfalls. First, selective interdiction can actually provide opportunities for the Taliban to directly take over the trafficking role or strengthen the alliance between the remaining traffickers and the Taliban, thus achieving the opposite of what it aims for. In fact, interdiction measures in Peru and Colombia frequently resulted in tightening the belligerents-traffickers nexus and belligerents’ takeover of trafficking.

Second, uncalibrated interdiction can provoke intense turf wars among the remaining traffickers, thus intensifying violence in the country and muddling the battlefield picture by introducing a new form of conflict. Mexico provides a vivid example of such an undesirable outcome. In the Afghan tribal context, such turf wars can easily become tribal or ethnic warfare.

Third, such selective interdiction can also send the message that the best way to be a trafficker is to be a member of the Afghan government, thus perpetuating a sense of impunity and corruption and undermining long-term state building and legitimacy.

Finally, the effectiveness of interdiction is to a great extent dependent on the quality of rule of law in Afghanistan plus the capacity and quality of the justice and corrections systems, all of which are woefully lacking in Afghanistan and are deeply corrupt.

Comprehensive Rural Development
Rural development appropriately lies at the core of the new strategy because, despite the enormous challenges, it has the best chance to effectively and sustainably strengthen the Afghan state and reduce the narcotics economy. But for rural development to do that, it needs to be conceived as broad-based social and economic development that focuses on improvements in human capital—including health care and education—and addresses all of the structural drivers of opium poppy cultivation. In Afghanistan, these drivers include insecurity; lack of physical infrastructure (such as roads), electrification and irrigations systems; lack of microcredit; lack of processing facilities; and the absence of value-added chains and assured markets. They also include lack of land titles and, increasingly, the fact that land rent by sharecroppers has become dependent on opium poppy cultivation as land concentration has increased over the past eight years. Poppy cultivation and harvesting are also very labor-intensive, thus offering employment opportunities unparalleled in the context of Afghanistan’s economy.

The price-profitability of poppy in comparison to other crops is only one of the drivers and frequently not the most important one. Without other structural drivers being addressed, farmers will not switch to licit crops even if they fetch more money than the illicit ones. By the same token, however, farmers are frequently willing to sacrifice some profit and forgo illicit crop cultivation as long as the licit alternatives bring them sufficient income and address all of the structural drivers, including the insecurity to which farmers are exposed in illicit economies.

Unfortunately, the wheat distribution program that was the core of rural development in Afghanistan last year (and that is slated to be its key component this year) is likely to be woefully ineffective for several reasons. First, in 2008, the program was based solely on an unusually high price ratio of wheat to poppy, driven by poppy overproduction and a global shortage of wheat. However, this price ratio is unlikely to hold; Afghanistan’s wheat prices are dictated anyway by surrounding markets, such as Pakistan and Kazakhstan. Second, the program did nothing to address the structural drivers. In fact, it had counterproductive effects because the free distribution of wheat undermined local markets in seeds. Afghan farmers can obtain seeds; their challenge lies in how to obtain profit afterwards. Thus, some sold the wheat seed instead of cultivating it. Third, those who actually cultivated wheat frequently did so not for profit, but for subsistence to minimize costs of buying cereals on the market. In fact, because of land distribution issues, many Afghan farmers do not have access to enough land to cover even their subsistence needs with wheat monocropping. A key lesson from alternative development over the past thirty years is that monocropping substitution strategies are particularly ineffective. Fourth, if all of current poppy farmers switched to wheat cultivation, Afghanistan would experience a great increase in unemployment since wheat cultivation employs 88% less labor than poppy cultivation and harvesting do.

Instead of wheat, rural development in Afghanistan needs to emphasize diversified high-value, high-labor-intensive crops, such as fruits, vegetables and specialty items like saffron. Generating lasting off-farm income opportunities will also be important, but even more challenging than jump-starting legal agromarkets.

After eight years of underresourcing and neglecting agriculture development, the new counternarcotics policy’s focus on the farm is appropriate. But the new strategy needs to take care not to throw away the baby with the bath water. The effort still needs to include developing value-added chains and assured internal and external markets plus enabling sustained access to them. Once again, thirty years of history of alternative livelihoods show that without value-added chains and accessible markets even productive legal farms become unsustainable and farmers revert back to illicit crops.

Finally, rural development requires time. Perhaps in no country in the world since Mao wiped out poppy cultivation in China in the 1950s did counternarcotics efforts face such enormous challenges as they do in Afghanistan—in terms of the scale of the illicit economy, its centrality to the overall economy of the country and hence its vast marco- and micro-economic and political effects, the underdevelopment of the country and its human capital and the paucity of viable economic alternatives. Even under much more auspicious circumstances along all the above dimensions, counternarcotics rural development in Thailand took thirty years.

Conclusion

Clearly, there is a need to quickly bring some economic, social and rule of law improvements to the lives of the Afghan people. Without such quick, visible and sustainable change, it will become impossible to rebuild the confidence of the Afghan people in the future, harness their remaining aspirations and to persuade them that the central state with support of the international community is preferable to the Taliban or local warlord- or tribal-based fiefdoms. But there is an equal need to urge strategic patience in the United States—both for counterinsurgency and for counternarcotics.

Eradication can be a part of the mix of counternarcotics policies, but should only be adopted in areas that are free of violent conflict and where sufficient legal economic alternatives are available to the population. Interdiction needs to focus on reducing the coercive and corrupting power of crime groups. Before interdiction measures are undertaken, an analysis of second and third- order effects needs to be conducted. It needs to be carefully calibrated with the strength of law enforcement in Afghanistan to avoid provoking dangerous turf wars, ethnic violence and cementing the relationship between the Taliban and the traffickers. It also needs to target top traffickers linked to the Afghan government. Interdiction needs to encompass building the justice and corrections system in Afghanistan and broad rule of law efforts. Rural development needs to address all structural drivers of poppy cultivation. It needs to focus not only on the farm, but also on value-added chains and assured markets. It needs to emphasize diversified high-value, high-labor intensive crops, and not center on wheat.

Evaluations of counternarcotics policies need to back away from simplistic and inappropriate measures, such as the numbers of hectares eradicated or traffickers caught. Instead, the measures need to encompass the complexity of the issue, including, size of areas cultivated with licit as well as illicit crops, human development indexes, levels of education, the number of resource-poor farmers dependent on illicit crops for basic subsistence or vulnerable to poverty-driven participation in illicit economies, food security, availability of legal microcredit, prevalence of land titles and accessibility of land, infrastructure density and cost of infrastructure use (such as road tolls), availability of non-belligerent dispute resolution and arbitrage mechanisms, quality of property rights, prevalence of value-added chains, and accessibility of markets. The United States and its allies must reduce public expectations for quick fixes and dedicate increased resources to rural development for a long time. Although U.S. forces do not need to stay in Afghanistan for decades, economic development will take that long.

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Executive Summary

Tax increment finance (TIF) is a popular and potentially powerful tool for places that need economic development the most yet have the least to spend. By allowing jurisdictions to use portions of their tax base to secure public-sector bonds, the mechanism allows fiscally strapped localities to finance site improvements or other investments so as to "level the playing field" in economic development.

However, poorly designed TIF programs can cause problems. Not only can they increase the incentives for localities to engage in inefficient, zero-sum competition for tax base with their neighbors. Also, lax TIF rules may promote sprawl by reducing the costs of greenfield development at the urban fringe. It is therefore critical that state legislatures design TIF rules well.

In view of this, an analysis of the way TIF is designed and utilized in Missouri shows that:

• Missouri law creates the potential for overuse and abuse of TIF. Vague definitions of the allowable use of TIF permit almost any municipality, including those market forces already favor, to use it. Weak limits on its use for inefficient inter-local competition for tax base touch off struggles between localities. And the inclusion of sales tax base in the program tilts it toward lower-wage jobs and retail projects, which rarely bring new economic activity into a region.
  
  
• Thanks to these flaws, TIF is used extensively in high-tax-base Missouri suburban areas with little need for assistance in the competition for tax base. This is especially true in the St. Louis metropolitan area. There, TIF money very frequently flows to purposes other than combating "blight" in disadvantaged communities' its classic purpose. In fact, less than half of the 21 St. Louis-area cities that were using TIF in 2001 were disadvantaged or "at-risk" when evaluated on four indicaters of distress. On another measure, just seven of the 20 suburban areas using TIF fell into the "at-risk" category.
  
  
• TIF is also frequently being used in the outer parts of regions' particularly in the St. Louis area. Most notably, only nine of the St. Louis region's 33 TIF districts lie in the region's core. Conversely, 14 of the region's 38 TIF districts lie west of the region's major ring road (I-270). These districts, moreover, contain 57 percent of the TIF-captured property tax base in the region. By contrast, the Kansas City region shows a pattern more consistent with the revitalization goals of TIF. The vast majority of the districts lie in the region's center city, though the huge size of the city means many are still geographically far-flung.

In sum, poorly designed TIF laws are being misused at a time when state and local fiscal pressures require every dollar be spent prudently. As a result, a potentially dynamic tool for reinvestment in Missouri's most disadvantaged communities threatens to become an engine of sprawl as it is abused by high-tax-base suburban areas that do not need public subsidies.

For these reasons, Missouri would be well-served by significant reforms in the laws governing TIF:

• The allowable purposes for TIF should be more strictly defined to target its use to places with the most need for economic development.
  
  
• Higher level review of local determinations that TIF subsidies will support net contributions to the regional or state economy (the "but-for" requirement) should be implemented.
  
  
• Local TIF administrators should be required to show that TIF subsidies are consistent with land-use and economic development needs both locally and in nearby areas.

If such reforms were put in place, TIF could be returned to its attractive main purpose: that of providing resources that would not otherwise be available to localities that badly need them to promote needed economic development and redevelopment.

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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.

Fundamental Approaches to Slowing Resistance

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.

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.

       

Antimicrobial resistance is one of the most significant threats to public health globally. It will worsen in the coming decades without concerted efforts to spur the development of new antibiotics, while ensuring the appropriate use of existing antibiotics. Antimicrobial therapy is essential for treating and preventing bacterial infections, some of which can be life-threatening and acquired as a result of
critical medical interventions, including surgery, chemotherapy and dialysis. However, the international rise in antimicrobial resistance has weakened our antibiotic armamentarium and multi-resistant bacteria now cause over 150,000 deaths annually in hospitals around the world (WHO, 2013). Unfortunately, the evolution of drug-resistant pathogens is unavoidable due to random genetic changes in the pathogens that can render antibiotics ineffective. While antibiotic therapy can succeed in killing susceptible pathogens, it also inadvertently selects for organisms that are resistant. Because each exposure to antibiotics contributes to this process, efforts to restrict antibiotic usage only slow the development of resistance. Ultimately, innovative antimicrobial drugs with diverse mechanisms of action will be needed to treat emerging resistant pathogens.

Combating resistance

Inappropriate use of antibiotics contributes significantly to the acceleration of resistance. Needlessly exposing patients to antibiotics (for example, for viral or mild infections likely to resolve on their own), the use of overly broad-spectrum antibiotics and suboptimal doses of appropriate therapy hasten the evolution of resistant pathogens. While affordable, rapid and accurate point-of-care diagnostics are essential for determining appropriate therapy for many bacterial diseases, routine clinical use will be limited if the tests are too expensive or not accessible during routine clinical encounters. In the absence of a clear diagnostic result, many health care providers prescribe empiric broadspectrum therapy without knowing exactly what they are treating. Although inappropriate use is widespread in many parts of the world, where antibiotics are available without a prescription or oversight by a health care provider or stewardship team, overuse abounds even where antibiotic prescribing is more tightly regulated.

Studies conducted in the USA indicate that around 258 million courses of antibiotics are dispensed annually for outpatient use (Hicks, 2013) and up to 75 per cent of ambulatory antibiotic prescriptions are for the treatment of common respiratory infections, which may or may not be bacterial in origin (McCaig,1995). Recent evidence suggests that over half of these prescriptions are not medically indicated. For example, 60 per cent of US adults with a sore throat receive an antibiotic prescription after visiting a primary care practice or emergency department, despite the fact that only ten per cent require treatment with antibiotics. This is particularly troubling given the availability of rapid tests that can detect Group A Streptococcus, the bacteria responsible for the ten per cent of cases that require antibiotic treatment.

The overuse of antibiotics has been driven largely by their low cost and clinical effectiveness, which has led many patients to view them as cure-alls with few risks. This perception is reinforced by the fact that antibiotics are curative in nature and used for short durations. However, the clinical effectiveness of these drugs decreases over time, as resistance naturally increases, and this process is accelerated with inappropriate use. Moreover, there are numerous consequences associated with the use of antibiotics, including over 140,000 emergency department visits yearly in the USA for adverse incidents (mostly allergic reactions; CDC, 2013a). In addition, antibiotics can eliminate protective bacteria in the gut,
leaving patients vulnerable to infection with Clostridium difficile, which causes diarrhoeal illness that results in 14,000 deaths every year in the USA (CDC, 2013b). It is estimated that antimicrobial resistance costs the US health care system over US$20 billion annually in excess care and an additional $35 billion in lost productivity (Roberts et al., 2009).

The inappropriate use of antimicrobial drugs is particularly concerning because highly resistant pathogens can easily cross national borders and rapidly spread around the globe. In recent years, strains of highly drug-resistant tuberculosis, carbapenem-resistant Enterobacteriaceae and other resistant pathogens have spread outside their countries of origin within several years of their detection. Because resistant bacteria are unlikely to stay isolated, stewardship efforts must be improved globally and international attention is needed to improve surveillance of emerging pathogens and resistance patterns.

A major challenge for clinicians and regulators will be to find stewardship interventions that can be scaled-up and involve multiple stakeholders, including providers, drug manufacturers, health care purchasers (insurers), governments and patients themselves. Such interventions should include practical and costeffective educational programmes targeted towards providers and patients that shift expectations for antibiotic prescriptions to a mutual understanding of the benefits and risks of these drugs.

Educational programmes alone, however, will not be sufficient to lower prescribing rates to recommended levels. Pushing down the inappropriate use of antibiotics also warrants stronger mechanisms that leverage the critical relationships between the stakeholders. For example, health care purchasers can play an important role by using financial disincentives to align prescribing habits with clinical guidelines that are developed by infectious disease specialists in the private and public sectors. This type of approach has the potential to be effective because it includes multiple stakeholders that share responsibility for the appropriate use of antibiotics and, ultimately, patient care.

Key obstacles to antibiotic development

The continual natural selection for resistant pathogens despite efforts to limit antibiotic use underscores the need for new antibiotics with novel mechanisms of action. To date, antimicrobial drug innovation and development have not kept pace with resistance. The number of approved new molecular entities (NME) to treat systemic infections has been steadily declining for decades (see Figure 1). Some infections are not susceptible to any antibiotic and in some cases the only effective drugs may cause serious side effects, or be contra-indicated due to a patient’s allergies or comorbidities (e.g. renal failure). There is significant unmet medical need for therapies that treat serious and life-threatening bacterial diseases caused by resistant pathogens, as well as some less serious infections where there are few treatment alternatives available (e.g. gonorrhoea).

Antibiotic development for these areas of unmet medical need has been sidelined by a number of scientific, regulatory and economic obstacles. While the costs and complexity of any clinical trial necessary for approval by drug regulators can be substantial, in part due to the large study samples needed to demonstrate safety and efficacy, the infectious disease space faces a number of unique clinical challenges. Patients with serious drug-resistant infections may be in need of urgent antibiotic therapy, which can preclude efficient consent and timely trial enrolment procedures; prior therapy can also confound treatment effects if the patient is later enrolled in a trial for an experimental drug. In addition, many patients with these pathogens are likely to have a history of longterm exposure to the health care setting and may have significant comorbidities that render them less likely to meet inclusion criteria for clinical trials.

Emerging infections for which there are few or no treatment options also tend to be relatively rare. This makes it difficult to conduct adequate and well-controlled trials, which typically enrol large numbers of patients. However, clinical drug development can take many years and waiting until such infections are more common is not feasible. Another issue is that it may also not be possible to conclusively identify the pathogen and its susceptibility at the point of enrolment due to the lack of rapid diagnostic technologies. Ultimately, uncertainty about the aetiology of an infection may necessitate trials with larger numbers of patients in order to achieve sufficient statistical power, further compounding the challenge of enrolling seriously ill infectious disease patients in the first place.

The need to conduct large trials involving acutely ill patients that are difficult to identify can make antibiotic development prohibitively expensive for drug developers, especially given that antibiotics are relatively inexpensive and offer limited opportunities to generate returns. Unlike treatments for chronic diseases, antibiotic therapy tends to last no longer than a few weeks, and these drugs lose efficacy over time as resistance develops, leading to diminishing returns. The decline in antimicrobial drug innovation is largely due to these economic obstacles, which have led developers to seek more durable and profitable markets (e.g. cancer or chronic disease) in recent decades. There are only a handful of companies currently in the market and the development pipeline is very thin. Changes to research infrastructure, drug reimbursement and regulation are all potentially needed to revitalise antibiotic innovation.

Opportunities to streamline innovative antibiotic development

In the USA, several proposals have been made to expedite the development and regulatory review of antibiotics while ensuring that safety and efficacy requirements are met. In 2012, the US President’s Council of Advisors on Science and Technology recommended that the US Food and Drug Administration (FDA) create a ‘special medical use’ (SMU) designation for the review of drugs for subpopulations of patients with unmet medical need. Drug sponsors would be required to demonstrate that clinical trials in a larger patient population would need much more time to complete or not be feasible. A drug approved under the SMU designation could be studied in subgroups of patients that are critically ill, as opposed to the broader population, under the condition that the drug’s indication would be limited to the narrow study population. The SMU designation was discussed at an expert workshop convened by the Brookings Institution in August 2013. Many participants at the meeting agreed that there is a pressing need to develop novel antibiotics and that such a limited-use pathway could support the appropriate use of newly approved drugs.

The Infectious Diseases Society of America developed a related drug development pathway called the Limited Population Antibacterial Drug (LPAD) approval mechanism. The LPAD approach calls for smaller, faster and less costly clinical trials to study antibiotics that treat resistant bacteria that cause serious infections. Both the SMU and LPAD approaches would allow drug developers to demonstrate product safety and efficacy in smaller patient subpopulations and provide regulatory clarity about acceptable benefit–risk profiles for antibiotics that treat serious bacterial diseases. The US House of Representatives is currently considering a bill¹ that incorporates these concepts.

A recent proposal from the drug manufacturer industry for streamlined antibiotic development is to establish a tiered regulatory framework to assess narrow-spectrum antibiotics (e.g. active versus a specific bacterial genus and species or a group of related bacteria) that target resistant pathogens that pose the greatest threat to public health (Rex, 2013: pp. 269–275). This is termed a ‘pathogen-focused’ approach because the level of clinical evidence required for approval would be correlated with the threat level and feasibility of studying a specific pathogen or group of pathogens. The pathogen-focused approach was also highlighted at a recent workshop at the Brookings Institution (Brookings Institution, 2014). Some experts felt that the approach is promising but emphasised that each pathogen and experimental drug is unique and that it could be challenging to place them in a particular tier of a regulatory framework. Given that pathogen-focused drugs would likely be marketed internationally, it will be important for drug sponsors to have regular interactions and multiple levels of discussion with regulators to find areas of agreement that would facilitate the approval of these drugs.

Antibiotics with very narrow indications could potentially support stewardship as well by limiting use to the most seriously ill patients. Safe use of these drugs would likely depend on diagnostics, significant provider education, labelling about the benefits and risks of the product, and the scope of clinical evidence behind its approval. Because these antibiotics would be used in a very limited manner, changes would potentially need to be made to how they are priced and reimbursed to ensure that companies are still able to generate returns on their investment. That said, a more focused drug development programme with regulatory clarity could greatly increase their odds of success and, combined with appropriate pricing and safe use provisions, could succeed in incentivising antimicrobial drug development for emerging infections.

Endnote
1 H.R. 3742 – Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013.

References
Barnett, M. L. and Linder, J. A., 2014. ‘Antibiotic prescribing to adults with sore throat in the United States, 1997–2010’. JAMA Internal Medicine, 174(1), pp. 138–140.

Brookings Institution, 2013. Special Medical Use: Limited Use for Drugs Developed in an Expedited Manner to Meet an UnmetMedical Need. Brookings Institution. Available at: www.brookings.edu/events/2013/08/01-special-medical-use

Brookings Institution, 2014. Modernizing Antibacterial Drug Development and Promoting Stewardship. Available at: www.brookings.edu/events/2014/02/07-modernizing-antibacterialdrug-development [Accessed 11 March 2014].

CDC, 2013a. Antibiotic resistance threats in the United States,2013 [PDF] CDC. Available at: www.cdc.gov/drugresistance/threatreport-2013/pdf/ar-threats-2013-508.pdf#page=25 [Accessed 16 January 2014].

CDC, 2013b. Clostridium difficile. Antibiotic resistance threats in the United States, 2013 [PDF] CDC. Available at: www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=50 [Accessed 16 January 2014].

Hicks, L. A. et al., 2013. ‘US Outpatient Antibiotic Prescribing, 2010’. New England Journal of Medicine, 368(15), pp. 1461–1463.
Infectious Disease Society of America, 2012.

Limited Population Antibacterial Drug (LPAD) Approval Mechanism. Available at: www.idsociety.org/uploadedFiles/IDSA/News_and_Publications/IDSA_News_Releases/2012/LPAD%20one%20pager.pdf [Accessed 5 March 2014].

Infectious Disease Society of America, 2012. Limited Population Antibacterial Drug (LPAD) Approval Mechanism [PDF] Infectious
Disease Society of America. Available at: www.idsociety.org/uploadedFiles/IDSA/News_and_Publications/IDSA_News_Releases/2012/LPAD%20one%20pager.pdf  [Accessed 18 January 2013].

Kumarasamy, K. K., Toleman, M. A., Walsh, T. R. et al.,2010. ‘Emergence of a new antibiotic resistance mechanism in India,
Pakistan, and the UK: A molecular, biological, and epidemiological study’. Lancet Infectious Diseases, 10(9), pp. 597–602.

McCaig, L. F. and Hughes, J. M., 1995. ‘Trends in antimicrobial drug prescribing among office-based physicians in the United
States’. Journal of the American Medical Association, 273(3), pp. 214–219.

President’s Council of Advisors on Science and Technology, 2012. Report to the President on Propelling Innovation in Drug
Discovery, Development and Evaluation. Available at:www.whitehouse.gov/sites/default/files/microsites/ostp/pcast-fdafinal.pdf    [Accessed 5 March 2014].

Rex, J. H. et al., 2013. ‘A comprehensive regulatory framework to address the unmet need for new antibacterial treatments’. Lancet Infectious Diseases, 13(3), pp. 269–275.

Roberts, R. R., Hota, B., Ahmad, I. et al., 2009. ‘Hospital and societal costs of antimicrobial – Resistant infections in a Chicago
teaching hospital: Implications for antibiotic stewardship’. Clinical Infectious Diseases, 49(8), pp. 1175–1184.

WHO (World Health Organization), 2010. Fact Sheet: Rational Use of Medicines [webpage] WHO. Available at:
www.who.int/mediacentre/factsheets/fs338/en [Accessed 28 February 2014].

WHO (World Health Organization), 2013. Antimicrobial Drug Resistance [PDF] WHO. Available at: http://apps.who.int/gb/ebwha/pdf_files/EB134/B134_37-en.pdf [Accessed 6 March 2014].

WHO (World Health Organization), 2013. Notified MDR-TB cases (number per 100,000 population), 2005–12. WHO. Available at:
https://extranet.who.int/sree/Reports?op=vs&path=/WHO_HQ_Reports/G2/PROD/EXT/MDRTB_Indicators_map [Accessed 28 February 2014].

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After years of warnings from the public health community about the growing threat of antibiotic resistance, yesterday the White House announced a national strategy to combat the growing problem of antibiotic resistance within the U.S. and abroad. The administration’s commitment represents an important step forward, as antibiotic-resistant infections are responsible for 23,000 deaths annually, and cost over $50 billion in excess health spending and lost productivity.  The administration’s National Strategy on Combating Antibiotic-Resistant Bacteria includes incentives for developing new drugs, more rigorous stewardship of existing drugs, and better surveillance of antibiotic use and the pathogens that are resistant to them.  President Obama also issued an Executive Order that establishes an interagency Task Force and a non-governmental Presidential Advisory Council that will focus on broad-based strategies for slowing the emergence and spread of resistant infections. 

While antibiotics are 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 promote growth 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.

The administration’s announcement included a report from the President’s Council of Advisors on Science and Technology (PCAST) titled “Combatting Antibiotic Resistance,” which includes recommendations developed by a range of experts to help control antibiotic resistance. In addition, they outline a $20 million prize to reward the development of a new rapid, point-of-care diagnostic test. Such tests help health care providers choose the right antibiotics for their patients and streamline drug development by making it easier to identify and treat patients in clinical trials.  

The Need for Financial Incentives and Better Reimbursement

A highlight of the PCAST report is its recommendations on economic incentives to bring drug manufacturers back into the antibiotics market. Innovative changes to pharmaceutical regulation and research and development (R&D) will be welcomed by many in the health care community, but financial incentives and better 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. Further, legislative proposals under consideration by Congress to reinvigorate the antibiotic pipeline, including the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, could complement the White House’s efforts and help turn the tide on antibiotic resistance. Spurring the development of new antibiotics is critical because resistance will continue to develop even if health care providers and health systems can find ways to prevent the misuse of these drugs.

       

For more than a decade, government assistance to Afghanistan, Iraq, and Pakistan (the so-called AIP countries) has dominated United States aid efforts. And as the examples below illustrate, American institutions and mindsets found it extraordinarily difficult to adjust to aid in unsafe places. Cameron Munter draws on his experience as the head of the Provincial Reconstruction Team (PRT) in Mosul, Iraq in 2006 and as ambassador of the United States to Pakistan in Islamabad in 2011, with a description of U.S. reconstruction and state-building from which we may find lessons to consider in the future.

In 2006, when he went to Mosul as the first leader of the first PRT, the American civilian and military authorities in Baghdad painfully learned that the post-conflict situation would not correct itself. The undergrowth of our own bureaucratic structure prevented us from gaining a sophisticated understanding of our surroundings. Members of the PRT came and left after a few months, without passing on their hard-obtained knowledge. Local authorities quickly realized that the PRT had neither the money nor the firepower of the brigade commanders. And most of all, the guiding principles in place were still the creation of a kind of constitutional framework where political leaders, police, courts, businesspeople, and citizens would have institutions familiar to Americans, institutions that would work as we knew how to make them work.

Munter arrived in Pakistan at a time of great hope for U.S.-Pakistani relations. In 2011, in a series of meetings with the U.S. deputy secretary of state for resources and the head of USAID, Kerry-Lugar-Berman priorities took center stage: education, energy efficiency, job creation, special projects in the tribal areas, and public health. It is one thing to define a task and quite another to apply it to the specific context of a country in which security considerations prevent most USAID workers from even laying eyes on their projects. Overall, it seems the United States was much better at measuring its commitment to a prosperous, democratic Pakistan at peace with its neighbors by counting how much it spent and how fast rather than creating the proper relationship with those on the ground with whom it might have partnered.

Under these circumstances, what are lessons learned? When security is shaky, assistance is difficult. It may be that in situations like the AIP countries, we only have the capacity to engage in humanitarian aid and immediate reconstruction. If that is so, then the whole question of engagement in dangerous places is reopened: In a military setting, with military tasks, and thus a military system of organization, can civilian assistance succeed? Money spent is the way we measure commitment in such a setting, and that doesn’t bring the results we need.

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• Imagining assistance: Tales from the American aid experience in Iraq in 2006 and Pakistan in 2011

      

       

Overview

Increasing educational attainment is likely to reduce conflict risk, especially in countries like Pakistan that have very low levels of primary and secondary school enrollment. Education quality, relevance and content also have a role to play in mitigating violence. Education reform must therefore be a higher priority for all stakeholders interested in a more peaceful and stable Pakistan. Debate within the country about education reform should not be left only to education policymakers and experts, but ought to figure front and center in national dialogues about how to foster security. The price of ignoring Pakistan’s education challenges is simply too great in a country where half the population is under the age of 17.

There has been much debate concerning the roots of militancy in Pakistan, and multiple factors clearly come into play. One risk factor that has attracted much attention both inside Pakistan and abroad is the dismal state of the national education sector. Despite recent progress, current school attainment and literacy levels remain strikingly low, as does education spending. The Pakistani education sector, like much of the country’s public infrastructure, has been in decline over recent decades. The question of how limited access to quality education may contribute to militancy in Pakistan is more salient now than ever, given the rising national and international security implications of continued violence.

The second half of 2009 witnessed not only the Pakistani government stepping up action against insurgents but also the release of a new Pakistan National Education Policy that aspires to far-reaching and important reforms, including a commitment to increase investment in education—from 2 to 7 percent of gross domestic product. Hundreds of millions of dollars in international education aid have been newly pledged by donor countries. This renewed emphasis on education represents a substantial opportunity to seek to improve security in Pakistan and potentially also globally over the medium to long term. Policymakers both inside and outside Pakistan should give careful consideration to whether and how education investments can promote peace and stability, taking into account what we now know about the state of the education sector and the roots of militancy.

This report takes a fresh look at the connection between schools, including but not limited to Pakistan’s religious seminaries, known as “madrasas,” and the rising militancy across the country. Poor school performance across Pakistan would seem an obvious area of inquiry as a risk factor for conflict. Yet to date, the focus has been almost exclusively on madrasas and their role in the mounting violence. Outside Pakistan, relatively little attention has been given to whether and how the education sector as a whole may be fueling violence, over and above the role of the minority of militant madrasas.

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INTRODUCTION

In recent years, there has been a resurgence of interest in the issue of inequality. Part of this resurgence can be traced to new evidence of persistent and widening wealth gaps. Average incomes may be converging globally as a result of high growth in emerging markets, stronger growth in many poor countries, and slow growth in rich countries. However, the evidence also shows that within countries a parallel process of income divergence, marginalization and rising inequality is also taking place. Put differently, the rising tide of global prosperity is not lifting all boats.

Much of the international debate on inequality focuses on the distribution of income across and within countries. Other dimensions of inequality have received less attention. This is unfortunate. Amartya Sen has described development as “a process of expanding the real freedoms that people enjoy” by building human capabilities or their capacity to lead the kind of life they value. Income is a means to that end but it is a limited indicator of well-being. Moreover, a person’s income reflects not just personal choice but also their opportunities for improving health, literacy, political participation and other areas. Education is one of the most basic building blocks for the “real freedoms” that Sen describes. People denied the chance to develop their potential through education face diminished prospects and more limited opportunities in areas ranging from health and nutrition, to employment, and participation in political processes. In other words, disparities in education are powerfully connected to wider disparities, including international and intra-country income inequalities. This is why education has been identified as one of the most critical factors in breaking down the disadvantages and social inequalities that are limiting progress toward the United Nations’ Millennium Development Goals (MDGs)—development targets adopted by the international community for 2015.

Understanding patterns of educational inequality is critical at many levels. Ethical considerations are of paramount importance. Most people would accept that children’s educational achievements should not be dictated by the wealth of their parents, their gender, their race or their ethnicity. Disparities in educational opportunities are not just inequalities in a technical sense, they are also fundamental in equities—they are unjust and unfair. In an influential paper, John Roemer differentiated between inequalities that reflect factors such as luck, effort and reasonable reward, and those attributable to circumstances that limit opportunity (Roemer 1988).1 While the dividing line may often be blurred, that distinction has an intuitive appeal. Most people have a high level of aversion to the restrictions on what people—especially children—are able to achieve as a result of disparities and inherited disadvantages that limit access to education, nutrition or health care (Wagstaff, 2002). There is a wide body of opinion across political science, philosophy and economics that equal opportunity—as distinct from equality of outcomes—is a benchmark of egalitarian social justice. The theories of distributive justice associated with thinkers such as Amartya Sen, John Rawls, Ronald Dworkin and John Roemer argue, admittedly from very different perspectives, that public policy should aim at equalizing opportunity to counteract disadvantages associated with exogenous circumstances over which individuals or social groups have no control. Given the role of education as a potential leveler of opportunity, it is a national focal point for redistributive social justice.

Considerations of economic efficiency reinforce the ethical case for equalizing educational opportunities. Education is a powerful driver of productivity, economic growth, and innovation. Econometric modeling for both rich and poor countries suggests that an increase in learning achievement (as measured by test score data) of one standard deviation is associated on average with an increase in the long-run growth rate of around 2 percent per capita annually (Hanushek and Wößmann, 2010; Hanushek, 2009; Hanushek and Wößmann, 2008). Such evidence points to the critical role of education and learning in developing a skilled workforce. Countries in which large sections of the population are denied a quality education because of factors linked to potential wealth, gender, ethnicity, language and other markers for disadvantage are not just limiting a fundamental human right. They are also wasting a productive resource and undermining or weakening the human capital of the economy.

International development commitments provide another rationale for equalizing educational opportunities. This is for two reasons. First, the commitments envisage education for all and achievement of universal primary education by 2015. Second, there is mounting evidence that inequality is acting as a brake on progress toward the 2015 goals. Since around 2005, the rate of decline in the out-of-school population has slowed dramatically. Based on current trends, there may be more children out of school in 2015 than there were in 2009. Caution has to be exercised in interpreting short-run trends, especially given the weakness of data. However, the past three editions of the UNESCO Education for All Global Monitoring Report (GMR) have highlighted the role of inequality in contributing to the slowdown with governments struggling to reach populations that face deeply entrenched disadvantages (UNESCO, 2008, 2010, 2011). Therefore, picking up the pace toward the 2015 goals requires a strengthened focus on equity and strategies that target the most marginalized groups and regions of the world (Sumner and Tiwari, 2010; UN-DESA, 2009; UNESCO, 2010). It should be added that disparities in education relate not just to access, but also to learning achievement levels.

Accelerated progress in education would generate wider benefits for the MDGs. Most of the world’s poorest countries are off-track for the 2015 MDG target of halving income poverty and a long way from reaching the targets on child survival, maternal health and nutrition. Changing this picture will require policy interventions at many levels. However, there is overwhelming evidence showing that education—especially of young girls and women—can act as a potent catalyst for change. On one estimate, if all of sub-Saharan Africa’s mothers attained at least some secondary education, there would be 1.8 million fewer child deaths in the region each year. Thus while education may lack the “quick fix” appeal of vaccinations, it can powerfully reinforce health policy interventions.

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Ghana attained middle-income status after rebasing its National Accounts, pushing per capita gross domestic product (GDP) of the country above $1,000 in 2007. After recovering from economic recession in 1984 on account of the Bretton Woods sponsored economic reform introduced at that time, Ghana’s growth has been remarkably strong, with its lowest economic growth of 3.3 percent recorded in 1994. The country’s growth rate reached its peak of 15 percent in 2011 on the back of the commencement of commercial production of oil, making it one of the fastest growing economies globally during that year. This has translated into increased per capita income, which reached a high of about $1,900 in 2013.

The concern, however, has been the ability of the country to sustain this growth momentum given the level and quality of education and skills, and, more importantly, the failure of this strong growth performance to be translated into the creation of productive and decent jobs, improved incomes and livelihoods. The structure of the economy remains highly informal, with a shift in the country’s national output composition from agriculture to low-value service activities in the informal sector. The commencement of commercial production of oil raised the share of the industrial sector in national output. However, the continuous decline in manufacturing value added undermines Ghana’s economic transformation effort to promote high and secure incomes and improve the livelihoods of the people.

Structural change towards higher value added sectors, and upgrading of technologies in existing sectors, is expected to allow for better conditions of work, better jobs, and higher wages. But the low level and quality of human resources not only diverts the economy from its structural transformation path of development but also makes it difficult for the benefits of growth to be spread through the creation of gainful and productive employment. Thus, productive structural economic transformation hinges on the level and quality of education and labor skills. A highly skilled, innovative and knowledgeable workforce constitutes a key ingredient in the process of structural economic transformation, and as productive sectors apply more complex production technologies and research and development activities increase the demand for education and skills. However, the observed weak human capital base does not provide a strong foundation for structural economic transformation of Ghana.

Ghana’s employment growth lags behind economic growth, with an estimated employment elasticity of output of 0.47, suggesting that every 1 percent of annual economic growth yields 0.47 percent growth of total employment.

There is also widespread concern about the quality of the country’s growth in terms of employment and inequality, as well as general improvement in the livelihood of the people (see Alagidede et al. 2013; Aryeetey et al. 2014; Baah-Boateng 2013). A key indicator for measuring the extent to which macroeconomic growth results in gains in the welfare of the citizenry is the quality of jobs that the economy generates. Ghana’s employment growth lags behind economic growth, with an estimated employment elasticity of output of 0.47 (see Baah-Boateng 2013), suggesting that every 1 percent of annual economic growth yields 0.47 percent growth of total employment. Besides the slow rate of job creation is the dominance of vulnerable employment and the working poverty rate in the labor market. In 2010, 7 out of 10 jobs were estimated to be vulnerable while only 1 out of 5 jobs could be considered as productive jobs that meet the standard of decent work (Baah-Boateng and Ewusi 2013). Workers in vulnerable employment tend to lack formal work arrangements as well as elements associated with decent employment such as adequate social security and recourse to effective social dialogue mechanisms (Sparreboom and Baah-Boateng 2011). The working poverty rate remains a challenge with one out of every five persons employed belonging to poor households.

The article seeks to provide an analytical assessment of Ghana’s economic growth as one of Africa’s growth giants over a period of more than two decades and the implication for labour market and livelihood outcomes. Growth of labor productivity at the national and sectoral level is examined, as well as the sectoral contribution to aggregate productivity growth. The article also analyses the effect of growth on employment and the employment-poverty linkage in terms of elasticity within the growth-employment-poverty nexus in Ghana. It also delves into a discussion of the constraints on growth and productive employment from both demand and supply perspectives, and identifies skills gaps and the opportunities offered in the country, which has experienced strong growth performance. The article has five sections, with an overview of Ghana’s economic growth performance in Section 2, after this introductory section. This is followed by an overview of the developments in the labor market, specifically in the area of employment, unemployment, poverty, and inequality in Ghana in Section 3. The growth-employment-poverty linkage analysis is carried out in Section 4 followed by a discussion of constraints to growth and employment generation in Section 5. Section 6 provides a summary and conclusion, with some policy suggestions for the future.

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In a recent analysis, I highlighted how employment and disconnection among young people vary by age, race, and place. In this podcast, I dig deeper into the data on the Washington, D.C. region. Although the area generally performs well on employment measures, not all young people are faring equally well.

Listen to the full podcast segment here: 

       

       

       

       

Introduction

The post-World War II era has witnessed the nearly exclusive building of low density suburbia, here termed “drivable sub-urban” development, as the American metropolitan built environment. However, over the past 15 years, there has been a gradual shift in how Americans have created their built environment (defined as the real estate, which is generally privately owned, and the infrastructure that supports real estate, majority publicly owned), as demonstrated by the success of the many downtown revitalizations, new urbanism, and transit-oriented development. This has been the result of the re-introduction and expansion of higher density “walkable urban” places. This new trend is the focus of the recently published book, The Option of Urbanism: Investing in a New American Dream (Island Press, November 2007).

This field survey attempts to identify the number and location of “regional-serving” walkable urban places in the 30 largest metropolitan areas in the U.S., where 138 million, or 46 percent, of the U.S. population lives. This field survey determines where these walkable urban places are most prevalent on a per capita basis, where they are generally located within the metro area, and the extent to which rail transit service is associated with walkable urban development.

The first section defines the key concepts used in the survey, providing relevant background information for those who have not read The Option of Urbanism. The second section outlines the methodology. The third section, which is the heart of the report, outlines the findings and conclusions of the survey.

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Drive through any number of outer-ring suburbs in America, and you’ll see boarded-up and vacant strip malls, surrounded by vast seas of empty parking spaces. These forlorn monuments to the real estate crash are not going to come back to life, even when the economy recovers. And that’s because the demand for the housing that once supported commercial activity in many exurbs isn’t coming back, either.

By now, nearly five years after the housing crash, most Americans understand that a mortgage meltdown was the catalyst for the Great Recession, facilitated by underregulation of finance and reckless risk-taking. Less understood is the divergence between center cities and inner-ring suburbs on one hand, and the suburban fringe on the other.

It was predominantly the collapse of the car-dependent suburban fringe that caused the mortgage collapse.

In the late 1990s, high-end outer suburbs contained most of the expensive housing in the United States, as measured by price per square foot, according to data I analyzed from the Zillow real estate database. Today, the most expensive housing is in the high-density, pedestrian-friendly neighborhoods of the center city and inner suburbs. Some of the most expensive neighborhoods in their metropolitan areas are Capitol Hill in Seattle; Virginia Highland in Atlanta; German Village in Columbus, Ohio, and Logan Circle in Washington. Considered slums as recently as 30 years ago, they have been transformed by gentrification.

Simply put, there has been a profound structural shift — a reversal of what took place in the 1950s, when drivable suburbs boomed and flourished as center cities emptied and withered.

The shift is durable and lasting because of a major demographic event: the convergence of the two largest generations in American history, the baby boomers (born between 1946 and 1964) and the millennials (born between 1979 and 1996), which today represent half of the total population.

Many boomers are now empty nesters and approaching retirement. Generally this means that they will downsize their housing in the near future. Boomers want to live in a walkable urban downtown, a suburban town center or a small town, according to a recent survey by the National Association of Realtors.

The millennials are just now beginning to emerge from the nest — at least those who can afford to live on their own. This coming-of-age cohort also favors urban downtowns and suburban town centers — for lifestyle reasons and the convenience of not having to own cars.

Over all, only 12 percent of future homebuyers want the drivable suburban-fringe houses that are in such oversupply, according to the Realtors survey. This lack of demand all but guarantees continued price declines. Boomers selling their fringe housing will only add to the glut. Nothing the federal government can do will reverse this.

Many drivable-fringe house prices are now below replacement value, meaning the land under the house has no value and the sticks and bricks are worth less than they would cost to replace. This means there is no financial incentive to maintain the house; the next dollar invested will not be recouped upon resale. Many of these houses will be converted to rentals, which are rarely as well maintained as owner-occupied housing. Add the fact that the houses were built with cheap materials and methods to begin with, and you see why many fringe suburbs are turning into slums, with abandoned housing and rising crime.

The good news is that there is great pent-up demand for walkable, centrally located neighborhoods in cities like Portland, Denver, Philadelphia and Chattanooga, Tenn. The transformation of suburbia can be seen in places like Arlington County, Va., Bellevue, Wash., and Pasadena, Calif., where strip malls have been bulldozed and replaced by higher-density mixed-use developments with good transit connections.

Reinvesting in America’s built environment — which makes up a third of the country’s assets — and reviving the construction trades are vital for lifting our economic growth rate. (Disclosure: I am the president of Locus, a coalition of real estate developers and investors and a project of Smart Growth America, which supports walkable neighborhoods and transit-oriented development.)

Some critics will say that investment in the built environment risks repeating the mistake that caused the recession in the first place. That reasoning is as faulty as saying that technology should have been neglected after the dot-com bust, which precipitated the 2001 recession.

The cities and inner-ring suburbs that will be the foundation of the recovery require significant investment at a time of government retrenchment. Bus and light-rail systems, bike lanes and pedestrian improvements — what traffic engineers dismissively call “alternative transportation” — are vital. So is the repair of infrastructure like roads and bridges. Places as diverse as Los Angeles, Phoenix, Salt Lake City, Dallas, Charlotte, Denver and Washington have recently voted to pay for “alternative transportation,” mindful of the dividends to be reaped. As Congress works to reauthorize highway and transit legislation, it must give metropolitan areas greater flexibility for financing transportation, rather than mandating that the vast bulk of the money can be used only for roads.

For too long, we over-invested in the wrong places. Those retail centers and subdivisions will never be worth what they cost to build. We have to stop throwing good money after bad. It is time to instead build what the market wants: mixed-income, walkable cities and suburbs that will support the knowledge economy, promote environmental sustainability and create jobs.

       

An economic analysis of a sample of neighborhoods in the Washington, D.C. metropolitan area using walkability measures finds that:

• More walkable places perform better economically. For neighborhoods within metropolitan Washington, as the number of environmental features that facilitate walkability and attract pedestrians increase, so do office, residential, and retail rents, retail revenues, and for-sale residential values.

• Walkable places benefit from being near other walkable places. On average, walkable neighborhoods in metropolitan Washington that cluster and form walkable districts exhibit higher rents and home values than stand-alone walkable places.

• Residents of more walkable places have lower transportation costs and higher transit access, but also higher housing costs. Residents of more walkable neighborhoods in metropolitan Washington generally spend around 12 percent of their income on transportation and 30 percent on housing. In comparison, residents of places with fewer environmental features that encourage walkability spend around 15 percent on transportation and 18 percent on housing.

• Residents of places with poor walkability are generally less affluent and have lower educational attainment than places with good walkability. Places with more walkability features have also become more gentrified over the past decade. However, there is no significant difference in terms of transit access to jobs between poor and good walkable places.

The findings of this study offer useful insights for a diverse set of interests. Lenders, for example, should find cause to integrate walkability into their underwriting standards. Developers and investors should consider walkability when assessing prospects for the region and acquiring property. Local and regional planning agencies should incorporate assessments of walkability into their strategic economic development plans and eliminate barriers to walkable development. Finally, private foundations and government agencies that provide funding to further sustainability practices should consider walkability (especially as it relates to social equity) when allocating funds and incorporate such measures into their accountability standards.

The Great Recession highlighted the need to change the prevailing real estate development paradigm, particularly in housing. High-risk financial products and practices, “teaser” underwriting terms, steadily low-interest rates, and speculation in housing were some of the most significant contributors to the housing bubble and burst that catalyzed the recession. But an oversupply of residential housing also fueled the economic crisis.

However, a closer look at the post-recession housing numbers paints a more nuanced picture. While U.S. home values dropped steadily between 2008 and 2011, distant suburbs experienced the starkest price decreases while more close-in neighborhoods either held steady or in some cases saw price increases. This distinction in housing proximity is particularly important since it appears that the United States may be at the beginning of a structural real estate market shift. Emerging evidence points to a preference for mixed-use, compact, amenity-rich, transit-accessible neighborhoods or walkable places.

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