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Cloud computing services over the Internet have the potential to spur a significant increase in government efficiency and decrease technology costs, as well as to create incentives and online platforms for innovation. Adoption of cloud computing technologies could lead to new, efficient ways of governing.

On April 7, the Brookings Institution hosted a policy forum that examines the economic benefits of cloud computing for local, state, and federal government. Federal Chief Information Officer Vivek Kundra delivered a keynote address on the role of the government in developing and promoting cloud computing. Brookings Vice President Darrell West moderated a panel of experts and detailed the findings in his paper, "Saving Money through Cloud Computing," which analyzes its governmental cost-savings potential.

After the program, panelists took audience questions.

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• Cloud Computing a Fiscally Smart Move
• Cloud Computing Saves Money, Makes Government More Open
• Cloud Computing Will Fundamentally Change Government Operations
• Government on Cloud Will Yield Cost-Effective System

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• The Economic Gains of Cloud Computing

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• Uncorrected Transcript (.pdf)

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Technology offers the greatest source for innovation in the public sector and one of the best examples falls within the area of cloud computing. As I noted in a recent paper, the U.S. federal government spends nearly $76 billion each year on information technology, and $20 billion of that is devoted to hardware, software, and file servers. Traditionally, computing services have been delivered through desktops or laptops operated by proprietary software. But new advances in cloud computing have made it possible for public sector agencies alike to access software, services, and data storage through remote file servers.

I looked at possible cost savings a federal agency might expect from migrating to the cloud. After undertaking case studies of government agencies that made the move, I found that the agencies generally saw between 25 and 50 percent savings in moving to the cloud. Public officials can save money by reducing the number of file servers they need to purchase, cutting software costs, relying on fewer information technology specialists, and improving the efficiency of their data storage utilization.

In 2008, Washington, D.C. city government shifted many of its 38,000 employee email services across 86 agencies to the cloud, and the migration saved 48 percent on email expenditures. In 2009, the city of Los Angeles moved email service for its 30,000 employees to the cloud. An analysis undertaken by City Administrative Officer Miguel Santana for the City Council found that the five-year costs of running the new Google system would be $17,556,484, which was 23.6 percent less than the $22,996,242 for operating GroupWise during that same period. And in terms of personnel savings, the city needed nine fewer people in its information technology department.

The U.S. Air Force 45th Space Wing is responsible for launching and tracking unmanned space vehicles from Cape Canaveral Air Force Station and employs more than 10,000 workers. The Wing had 60 distinct file servers, but found that it utilized only 10 percent of central processing unit capacity. Commanders modernized their system and saved $180,000 per year in annual computing costs. In addition, the unit saved money by not buying new hardware or deploying new software. These are just some of the ways the government is using technology to save money and increase efficiency of its operations.

      

Executive Summary

Government information technology is subject to a variety of rules, regulations, and procurement policies.  Computing is treated differently depending on whether the platform is based on desktops, laptops, mobile devices, or remote file servers known as cloud computing.  There are differences between the executive, legislative, and judicial branches of government, as well as in the level of privacy and security expected for various applications.  

Some people perceive higher security on desktop or laptop computers and lower security with the cloud because the latter’s information is stored remotely through third-party commercial providers.  In reality, though, there are serious security threats to all electronic information regardless of platform, and cloud server providers often take security more seriously than mass consumers or government officials employing weak passwords on their local computers. 

In this paper, I review current federal IT policy and discuss rules, practices, and procedures that limit innovation.  There are a variety of obstacles that make it difficult for policymakers to take full advantage of the technological revolution that has unfolded in recent years.  After outlining these issues, I make recommendations on policy changes required to improve the efficiency and effectiveness of federal computing. 

My specific recommendations include:

1. Public officials should develop more consistent rules on computing across desktop, laptop, mobile, and cloud platforms.  
2. The use of video, collaboration, and social networking should be authorized for congressional offices.  This would make legislative branch policy consistent with that of the executive branch.
3. Judicial branch computing should be modernized, with greater emphasis on cloud computing. 
4. There should be a more uniform certification process for federal agencies.  Right now, each agency is responsible for certifying its own applications.  It makes sense to have a “joint authorization board” with the power to review management services and certify particular products for use across the government. 
5. Congress should update the Electronic Communications Privacy Act to change the process by which law enforcement agents obtain electronic information.  Instead of using a prosecutor’s subpoena, legislation should require a “probable cause” search warrant that is approved by a judge.  This would provide greater safeguards in terms of online content, pictures, geolocation data, and e-mails.
6. Privacy rights should be placed on the same footing regardless of whether a person is using desktop or cloud computing.  It makes little sense to have weaker standards on one platform than another.  Consumers and government decision-makers expect the same level of protection whether they are accessing information on a desktop, laptop, mobile, or cloud storage system. 
7. Congress should amend the Computer Fraud and Abuse Act to strengthen penalties for unwanted intrusion into computing systems.  The law has inconsistent penalties and prosecutors have found that it is hard to prosecute cyber-crimes. 
8. Apps.gov represents a big step forward and government use should be expanded because it makes procurement easier and speeds public sector innovation.  It is a model of how the government can reinvent itself through digital technology in ways that improve efficiency and effectiveness.
9. Countries need to harmonize their laws on cloud computing so as to reduce current inconsistencies in regard to privacy, data storage, security processes, and personnel training,  
10. There should be mechanisms for data exchange that encourage portability across platforms.  We should avoid vendor lock-in that precludes data exchange.
11. Data on uptime, downtime, recover time, archiving, and maintenance schedules would help build public trust by providing information on computing performance.

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The U.S. government spends billions of dollars each year on computer hardware, software and file servers that may no longer be necessary. Currently, the public sector makes relatively little use of cloud computing, even though studies suggest substantial government savings from a migration to more Internet-based computing with shared resources.

On July 21, the Center for Technology Innovation at Brookings hosted a policy forum on steps to enhance public sector adoption of cloud computing innovations. Brookings Vice President Darrell West moderated a panel of experts, including David McClure of the General Services Administration, Dawn Leaf of the National Institute for Standards and Technology, and Katie Ratte of the Federal Trade Commission. West released a paper detailing the policy changes required to improve the efficiency and effectiveness of federal computing.

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Although research suggests that considerable efficiencies can be gained from cloud computing technology, concerns over privacy and security continue to deter government and private-sector firms from migrating to the cloud. By its very nature, storing information or accessing services through remote providers would seem to raise the level of privacy and security risks. But is such apprehension warranted? What are the real security threats posed to individuals, business and government by cloud computing technologies? Do the cost-saving benefits outweigh the dangers?

On October 26, the Brookings Institution hosted a policy forum on the privacy and security challenges raised by cloud computing. Governance Studies Director Darrell West moderated a panel of technology industry experts examining how cloud computing systems can generate innovation and cost savings without sacrificing privacy and security. West will also present findings from his forthcoming paper “Privacy, Security, and Innovation in Cloud Computing.”

After the program, panelists took audience questions.

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Executive Summary

Cloud computing can mean different things to different people, and obviously the privacy and security concerns will differ between a consumer using a public cloud application, a medium-sized enterprise using a customized suite of business applications on a cloud platform, and a government agency with a private cloud for internal database sharing (Whitten, 2010). The shift of each category of user to cloud systems brings a different package of benefits and risks.

What remains constant, though, is the tangible and intangible value that the user seeks to protect. For an individual, the value at risk can range from loss of civil liberties to the contents of bank accounts. For a business, the value runs from core trade secrets to continuity of business operations and public reputation. Much of this is hard to estimate and translate into standard metrics of value (Lev, 2003) The task in this transition is to compare the opportunities of cloud adoption with the risks. The benefits of cloud have been discussed elsewhere, to the individual to the enterprise, and to the government (West, 2010a, 2010b).

This document explores how to think about privacy and security on the cloud. It is not intended to be a catalog of cloud threats (see ENISA (2009) for an example of rigorous exploration of the risks of cloud adoption to specific groups). We frame the set of concerns for the cloud and highlight what is new and what is not. We analyze a set of policy issues that represent systematic concerns deserving the attention of policy-makers. We argue that the weak link in security generally is the human factor and surrounding institutions and incentives matter more than the platform itself. As long as we learn the lessons of past breakdowns, cloud computing has the potential to generate innovation without sacrificing privacy and security (Amoroso, 2006; Benioff, 2009).

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EXECUTIVE SUMMARY

Many web services are examples of cloud computing, from storage and backup sites such as Flickr and Dropbox to online business productivity services such as Google Docs and Salesforce.com. Cloud computing offers a potentially attractive solution to customers keen to acquire computing infrastructure without large up-front investment, particularly in cases where their demand may be variable and unpredictable, as a means of achieving financial savings, productivity improvements and the wider flexibility that accompanies Internet-hosting of data and applications.

The greater flexibility of a cloud computing service as compared with a traditional outsourcing contract may be offset by reduced certainty for the customer in terms of the location of data placed into the cloud and the legal foundations of any contract with the provider. There may be unforeseen costs and risks hidden in the terms and conditions of such services.

This document reports on a detailed survey and analysis of the terms and conditions offered by cloud computing providers.

The survey formed part of the Cloud Legal Project at the Centre for Commercial Law Studies (CCLS), within the School of Law at Queen Mary, University of London, UK. Funded by a donation from Microsoft, but academically independent, the project is examining a wide range of legal and regulatory issues arising from cloud computing. The project's survey of 31 cloud computing contracts from 27 different providers, based on their standard terms of service as offered to customers in the E.U. and U.K., found that many include clauses that could have a significant impact, often negative, on the rights and interests of customers. The ease and convenience with which cloud computing arrangements can be set up may lull customers into overlooking the significant issues that can arise when key data and processes are entrusted to cloud service providers. The main lesson to be drawn from the Cloud Legal Project’s survey is that customers should review the terms and conditions of a cloud service carefully before signing up to it.

The survey found that some contracts, for instance, have clauses disclaiming responsibility for keeping the user’s data secure or intact. Others reserve the right to terminate accounts for apparent lack of use (potentially important if they are used for occasional backup or disaster recovery purposes), for violation of the provider’s Acceptable Use Policy, or indeed for any or no reason at all. Furthermore, whilst some providers promise only to hand over customer data if served with a court order, others state that they will do so on much wider grounds, including it simply being in their own business interests to disclose the data. Cloud providers also often exclude liability for loss of data, or strictly limit the damages that can be claimed against them – damages that might otherwise be substantial if a failure brought down an e-commerce web site.

Although in some U.S. states, in E.U. countries and in various other jurisdictions the validity of such terms may be challenged under consumer protection laws, users of cloud services may face practical obstacles to bringing a claim for data loss or privacy breach against a provider that seems local online but is, in fact, based in another continent. Indeed, service providers usually claim that their contracts are subject to the laws of the place where they have their main place of business. In many cases this is a US state, with a stipulation that any dispute must be heard in the provider’s local courts, regardless of the customer’s location.

Perhaps the most disconcerting discovery of the Cloud Legal Project’s survey was that many providers claimed to be able to amend their contracts unilaterally, simply by posting an updated version on the web. In effect, customers are put on notice to download lengthy and complex contracts, on a regular basis, and to compare them against their own copies of earlier versions to look for changes.

The cloud computing market is still developing rapidly, and potential cloud customers should be aware that there may be a mismatch between their expectations and the reality of cloud providers' service terms, and be alive to the possibility of unexpected changes to the terms.

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Our former Brookings colleague Rebecca Blank, now at the Commerce Department, is today leading the first meeting of the Obama Administration’s Innovation Advisory Board, looking at the innovative capacity and economic competitiveness of the United States.

I applaud the effort.  Nothing is more important to America’s longterm competitiveness than emphasizing innovation.  As the council looks to the private sector and global markets, I urge it to examine how the U.S. government can lead innovation and contribute to economic growth.  The best place to look is new and emerging digital technologies that can make government more accessible, accountable, responsive and efficient for the people who use government services every day.

Here are some of the recommendations I made in a recent paper I wrote with colleagues here at Brookings as part of our “Growth Through Innovation” initiative:

• Save money and gain efficiency by moving federal IT functions “to the cloud,” i.e., using advances in cloud computing to put software, hardware, services and data storage through remote file servers.

• Continue to prioritize the Obama administration’s existing efforts to put unparalleled amounts of data online at Data.gov and other federal sites, making it easier and cheaper for citizens and businesses to access the information they need.

• Use social media networks to deliver information to the public and to solicit feedback to improve government performance.

• Integrate ideas and operations with state and local organizations, where much of government innovation is taking place today. 

• Apply the methods of private-sector business planning to the public sector to produce region-specific business plans that are low cost and high impact.

These improvements in government services innovations in the digital age can help spur innovation and support a robust business climate.  And, as a sorely needed side benefit, they can also serve to eliminate some of the current distrust and even contempt for government that has brought public approval of the performance of the federal government to near historic lows.  

      

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While research suggests that considerable efficiencies can be gained from cloud computing technology, concerns over privacy and security continue to deter governments and private-sector firms from migrating to the cloud. Senator Amy Klobuchar (D-Minn.) has advanced discussion of the “Cloud Computing Act of 2011,” draft legislation that would address these challenges by encouraging the U.S. government to negotiate with other countries to establish consistent laws related to online security and cloud computing. The bill also creates new enforcement tools for investigating and prosecuting those who violate online privacy and security laws.

On June 16, the Brookings Institution hosted a forum on the policy proposals in the Cloud Computing Act of 2011. Discussion included an overview of the international policy implications as governments and firms adjust to a coherent legal framework, changes and innovations in public procurement, and challenges for private industry as it balances consumer needs and compliance with these proposed cloud computing safeguards.

After the program, panelists took audience questions.

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Executive Summary

The move to the cloud is one of the defining information technology trends of the early 21st century. By providing businesses, universities, government agencies, and other entities with access to shared and often physically dispersed computing resources, cloud computing can simultaneously offer increased flexibility, reduced cost, and access to a wider array of services.

Cloud computing has also created a set of new challenges. For example, the issues of privacy and security in the cloud are well recognized and have been extensively discussed in the business and popular press. However, one critical issue that has received very little attention with respect to cloud computing is export control.

In the broadest sense, export control relates to regulations that the United States and many other countries have put in place to restrict the export of various sensitive items, information, and software.

There is an inherent tension between cloud computing and export control. While the concept of the cloud is centered on the premise of removing the need to track the details of data movement among various destinations, export control regulations are built largely around restrictions tied to those very movements.

If cloud computing is to reach its full potential, it is critical for providers and users of cloud services to address its implications with respect to export control. It is equally important to adapt the export control regulations to reflect the increasing prevalence of cloud computing in a manner that preserves the ability of American companies to benefit from the efficiencies of the cloud while also ensuring that American national security and foreign policy interests are adequately protected.

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In his new book The Mobile Wave: How Mobile Intelligence Will Change Everything (Vanguard Press, 2012), CEO of MicroStrategy Michael Saylor examines the transformative possibilities of mobile computing on business, society, economies and everyday life. Saylor argues that mobile technologies such as smartphones and tablet computers – “the fifth wave of computer technology” – will be indispensible tools for modern life and completely alter how we live.

On October 5, the Center for Technology Innovation at Brookings hosted a forum on mobile computing and its monumental impact on our future. Moderated by Vice President Darrell West, Michael Saylor discussed key highlights from his book and offered insights as to what sort of change we can expect from the macro level down to the most mundane of everyday humans tasks.

 

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The first instance of “cloud” computing came in 2006, when Amazon released its Elastic Compute Cloud, a service for consumers to lease space on virtual machines to run software. Now, the cloud enables the transfer and storage of data around the world, in an almost seamless fashion. Using cloud services are a seamless experience from the consumer perspective. This ease of use obscures significant regulation from governments on both sides of the Atlantic. The Safe Harbor Principles is a framework that ensures that personal consumer data being transferred from the EU to the US is still subject to a level of security in compliance with the EU’s stricter regulation on data protection. US companies must be certified within this framework, in order to transfer consumer data outside the EU.

A comprehensive data privacy arrangement that satisfies both sides of the Atlantic is necessary to preserve the free flow of data, and the resulting commerce, between the two regions. Speaking at the 2014 Cloud Computing Policy Conference, Cameron F. Kerry suggested that neither side of the Atlantic can afford to partition the Internet. Currently trade negotiators are assessing the viability including an update to Safe Harbor Principles as a part of the Transatlantic Trade and Investment Partnership (TTIP).

TTIP and the Future of Trade

The NSA revelations last year have only increased support for further regulation over the transfer of personal data in the cloud, especially in the European Union (EU). The revelations have also brought to light significant differences in the European and US conceptions of privacy. The ruling by the European Court of Justice on the “right to be forgotten” is a recent example of this transatlantic divide. In EU countries, citizens can now request Google to take down links from search results that lead users to potentially damaging information.

There are several disputes that negotiators must first resolve. Europeans would prefer that American regulators take a more active role in cases where US firms are violating the Safe Harbor principles. EU officials have also indicated they would like to include a mechanism to send an alert if data were improperly shared with US law enforcement officials. The expansion of the codes of conduct within the cloud would serve as a major step towards finalizing TTIP. A European Commission Analysis finds that TTIP would inject about $130 billion into the US economy. Ultimately both the EU and the US have so much to gain that both nations must find a way to resolve these thorny issues.

 

Kevin Risser contributed to this post.

       

Cloud computing is becoming omnipresent in the private sector as companies latch on to this innovation as a way to manage scalability, improve flexibility, and reduce cost. Analysts at IDC predict that, over the next six years, nearly 90 percent of new spending on Internet and communications technology will be on cloud-based platforms. Apple, Google, Amazon, Microsoft, and hundreds of smaller companies are positioning themselves to dominate the estimated $5 trillion worldwide market. While few companies will provide numbers, it is estimated that Amazon and Google may run as many as 10 million servers while Microsoft runs close to one million. In short, it is an innovation that makes a mockery out of Moore’s law.

But, like all innovations, cloud computing has potential pitfalls. Public sector organizations in particular have had difficulty taking advantage of new technologies. The Heritage Foundation keeps a list over 50 examples of government ineptitude including $34 billion in fraudulent Homeland Security contracts, National Institutes of Health renting a lab that it neither needs nor can use for $1.3 million per month, and the Department of Agriculture wasting $2.5 billion in stimulus money on broadband internet. Technological ineptitude received special attention with the failed launch of the Healthcare.gov, the release of classified data from Edward Snowden, and the costly FBI virtual case file debacle.

Cloud computing is far more than just a simple technology change and requires a close examination of governance, sourcing, and security. We sought to understand how well state government is prepared to address the challenges of cloud computing.

The Approach

We have gathered and started to do a content analysis of the IT strategic plans for each state. For each plan, we performed a content analysis, which is looking for certain phrases or text within the IT strategic plan in order to have a structured way to understand the data. Details for our approach can be seen in our previous blog post.

How States Are Implementing the Cloud

We were not surprised to see a number of states preparing to study or embark on cloud computing.

While some states don’t mention it (e.g. Alabama), most states are eagerly exploring it. For example, North Dakota’s plan talks about cloud computing as an integral part of the future and seven of its thirteen major IT initiatives are centered on preparation for transitioning to the cloud “where and when it makes sense”.

Vermont puts itself squarely in the studying period. The plan describes that, “While the risks of enterprise-wide and cloud-based IT must be carefully managed, trends continue to just larger-scale operations.” Wisconsin also clearly lays out its view on cloud computing, writing that, “Flexibility and responsiveness (also) guide Wisconsin’s approach toward adoption of cloud services” and suggests that its version of a private cloud “…offers advanced security and service availability tailored for business needs.” West Virginia provides an equally balanced approach by requiring that only services with an acceptably low risk and cost-effective footprint will be moved to the cloud.

In short, all of the states that are considering cloud computing are taking a thoughtful and balanced approach.

The Good

One of the most critical aspects of cloud computing is security and, without question, states understand the importance of good security. A good example of this is Colorado who designates security as one of its four “wildly important goals” and sets the target of “10 percent reduction in information security risk for Colorado agencies by close of FY15”.

South Carolina echoed the same theme by asserting that security and confidentiality are “overriding priorities at every stage of development and deployment.” Connecticut’s plans explain the need to “continuously improve the security and safeguards over agency data and information technology assets”.

The Bad

Despite the interest in cloud computing, we were only able to find a single state (Georgia) that explicitly links governance to security and, to us, by extension to cloud computing. In Georgia’s plan, they start with the idea that “strong security programs start with strong governance” and then explicitly describe necessary changes in governance to improve security.

We were, however, impressed with the seriousness that New York, North Carolina and Massachusetts took governance but it was difficult to find many other states that did.

The Ugly

Unfortunately the results on sourcing were dismal. While a few states (e.g. Kansas, Ohio, and Massachusetts) specifically discuss partnerships, most states seemed to ignore the sourcing aspect of cloud computing. The most ominous note comes from Alabama where they make a statement that innovation in the state is being stifled by a lack of strong personnel.

While we have great enthusiasm for government to address cloud computing, some of the non-technical issues are lagging in the discussion. Good government requires that these items be addressed in order to realize the promise of cloud computing.

       

       

       

       

       

       

       

       

       

Much public focus is being given to a broader role for hospitals in improving the health of their communities. This focus parallels a growing interest in addressing the social determinants of health as well as health care policy reforms designed to increase the efficiency and quality of care while improving health outcomes.

This interest in the community role of hospitals has drawn attention to the federal legal standards and requirements for nonprofit hospitals seeking federal tax exemption. Tax-exempt hospitals are required to provide community benefits. And while financial assistance to patients unable to pay for care is a basic requirement of tax-exemption, IRS guidelines define the concept of community benefit to include a range of community health improvement efforts.

At the same time, the IRS draws a distinction between community health improvement spending–which it automatically considers a community benefit–and certain “community-building” activities where additional information is required in order to be compliant with IRS rules. In addition, community benefit obligations are included in the Affordable Care Act (ACA).

Specifically, the ACA requires nonprofit hospitals periodically to complete a community health needs assessment (CHNA), which means the hospital must conduct a review of health conditions in its community and develop a plan to address concerns. While these requirements are causing hospitals to look more closely at their role in the community, challenges remain. For instance, complex language in the rules can mean hospitals are unclear what activities and expenditures count as a “community benefit.” Hospitals must take additional steps in order to report community building as community health improvement.

These policies can discourage creative approaches. Moreover, transparency rules and competing hospital priorities can also weaken hospital-community partnerships. To encourage more effective partnerships in community investments by nonprofit hospitals:

• The IRS needs to clarify the relationship between community spending and the requirements of the CHNA. 
• There needs to be greater transparency in the implementation strategy phase of the CHNA. 
• The IRS needs to broaden the definition of community health improvement to encourage innovation and upstream investment by hospitals.

Download "Hospitals as Community Hubs: Integrating Community Benefit Spending, Community Health Needs Assessment, and Community Health Improvement" »

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The Center for Medicare and Medicaid Innovation (CMMI, or “the Innovation Center”) recently announced an initiative called Comprehensive Primary Care Plus (CPC+). It evolved from the Comprehensive Primary Care (CPC) initiative, which began in 2012 and runs through the end of this year. Both initiatives are designed to promote and support primary care physicians in organizing their practices to deliver comprehensive primary care services. Comprehensive Primary Care Plus has some very promising components, but also misses some compelling opportunities to further advance payment for primary care services.

The earlier initiative, CPC, paid qualified primary care practices a monthly fee per Medicare beneficiary to support practices in making changes in the way they deliver care, centered on five comprehensive primary care functions: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement; and, (5) planned care and population health. For all other care, regular fee-for-service (FFS) payment continued. The initiative was limited to seven regions where CMMI could reach agreements with key private insurers and the Medicaid program to pursue a parallel approach. The evaluation funded by CMMI found quality improvements and expenditure reductions, but savings did not cover the extra payments to practices.

Comprehensive Primary Care Plus uses the same strategy of conducting the experiment in regions where key payers are pursuing parallel efforts. In these regions, qualifying primary care practices can choose one of two tracks. Track 1 is very similar to CPC. The monthly care management fee per beneficiary remains the same, but an extra $2.50 is paid in advance, subject to refund to the government if a practice does not meet quality and utilization performance thresholds.

The Promise Of CPC+

Track 2, the more interesting part of the initiative, is for practices that are already capable of carrying out the primary care functions and are ready to increase their comprehensiveness. In addition to a higher monthly care management fee ($28), practices receive Comprehensive Primary Care Payments. These include a portion of the expected reimbursements for Evaluation and Management services, paid in advance, and reduced regular fee-for-service payments. Track 2 also includes larger rewards than does Track 1 for meeting performance thresholds.

The combination of larger per beneficiary monthly payments and lower payments for services is the most important part of the initiative. By blending capitation (monthly payments not tied to service volume) and FFS, this approach might achieve the best of both worlds.

Even when FFS payment rates are calibrated correctly (discussed below), the rates are pegged to the average costs across practices. But since a large part of practice cost is fixed, it means that the marginal cost of providing additional services is lower than the average cost, leading to incentives to increase volume under FFS. The lower payments reduce or eliminate these incentives. Fixed costs, which must also be covered, are addressed through the Comprehensive Primary Care Payments. By involving multiple payers, practices are put in a better position to pursue these changes.

An advantage of any program that increases payments to primary care practices is that it can partially compensate for a flaw in the relative value scale behind the Medicare physician fee schedule. This flaw leads to underpayment for primary care services. Although the initial relative value scale implemented in 1992 led to substantial redistribution in favor of evaluation and management services and to physicians who provide the bulk of them, a flawed update process has eroded these gains over the years to a substantial degree.

In response to legislation, the Centers for Medicare and Medicaid Services are working correct these problems, but progress is likely to come slowly. Higher payments for primary care practices through the CPC+ can help slow the degree to which physicians are leaving primary care until more fundamental fixes are made to the fee schedule. Indeed, years of interviews with private insurance executives have convinced us that concern about loss of the primary care physician workforce has been a key motivation for offering higher payment to primary care physicians in practices certified as patient centered medical homes.

Two Downsides

But there are two downsides to the CPC+.

One concerns the lack of incentives for primary care physicians to take steps to reduce costs for services beyond those delivered by their practices. These include referring their patients to efficient specialists and hospitals, as well as limiting hospital admissions. There are rewards in CPC+ for lower overall utilization by attributed beneficiaries and higher quality, but they are very small.

We had hoped that CMMI might have been inspired by the promising initiatives of CareFirst Blue Cross Blue Shield and the Arkansas Health Care Improvement initiative, which includes the Arkansas Medicaid program and Arkansas Blue Cross Blue Shield. Under those programs, primary care physicians are offered substantial bonuses for keeping spending for all services under trend for their panel of patients; there is no downside risk, which is understandable given the small percentage of spending accounted for by primary care. The private and public payers also support the primary care practices with care managers and with data on all of the services used by their patients and on the efficiency of providers they might refer to. These programs appear to be popular with physicians and have had promising early results.

The second downside concerns the inability of physicians participating in CPC+ to participate in accountable care organizations (ACOs). One of CMMI’s challenges in pursuing a wide variety of payment innovations is apportioning responsibility across the programs for beneficiaries who are attributed to multiple payment reforms. As an example, if a beneficiary attributed to an ACO has a knee replacement under one of Medicare’s a bundled payment initiatives, to avoid overpayment of shared savings, gains or losses are credited to the providers involved in the bundled payment and not to the ACO. As a result, ACOs are no longer rewarded for using certain tools to address overall spending, such as steering attributed beneficiaries to efficient providers for an episode of care or encouraging primary care physicians to increase the comprehensiveness of the care they deliver.

Keeping the physician participants in CPC+ out of ACOs altogether seems to be another step to undermine the potential of ACOs in favor of other payment approaches. This is not wise. The Innovation Center has appropriately not established a priority ranking for its various initiatives, but some of its actions have implicitly put ACOs at the bottom of the rankings. Recently, Mostashari, Kocher, and McClellan proposed addressing this issue by adding a CPC+ACO option to this initiative.

In an update to its FAQ published May 27, 2016 (after out blog was put into final form), CMMI eased its restriction somewhat by allowing up to 1,500 of the 5000 practices expected to participate in CPC+ to also participate in Medicare Shared Savings Program (MSSP) ACOs. But the prohibition continues to apply to Next Gen ACOs, the model that has created the most enthusiasm in the field. If demand for these positions in MSSP ACOs exceeds 1,500, a lottery will be held. This change is welcome but does not really address the issue of disadvantaging ACOs in situations where a beneficiary is attributed to two or more payment reform models. CMMI is sending a signal that CPC+, notwithstanding its lack of incentives concerning spending outside of primary care, is a powerful enough reform that diverting practices away from ACOs is not a problem. ACOs are completely dependent on primary care physician membership to function, meaning that any physician practices beyond 1,500 that enroll in CPC+ will reduce the size and the impact of the ACO program. CMMI has never published a priority ranking of reform models, but its actions keep indicating that ACOs are at the bottom.

The Innovation Center should be lauded for continuing to support improved payment models for primary care. Its blending of substantial monthly payments with lower payments per service is promising. But the highest potential rewards come from broadening primary care physicians’ incentives to include the cost and quality of services by other providers. CMMI should pursue this approach.

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Editor's note: This piece originally appeared in Health Affairs Blog.

       

High unemployment, the Gulf oil spill, and mounting fiscal worries clouded our July 4th celebrations. Yet, one patriotic highlight in President Obama's first year was bipartisan support of the Serve America Act, which expanded opportunities for Americans of all ages to meet urgent domestic challenges through community and national service. In the process, Americans who otherwise would have been unemployed are engaging in productive work, at low cost to taxpayers, to meet problems like the high school dropout epidemic. Similar efforts can expand volunteer service abroad.

As President Obama made clear in his first major policy speech to the international community in Cairo, Egypt, the world must unleash its collective imagination through social innovators, entrepreneurs and citizen diplomats to contribute to global development, respond to natural disasters, and initiate interfaith action to tackle preventable diseases like malaria. The moment is now.

Fifty years after John F. Kennedy's call for a Peace Corps, we might reconsider our obligations to meet needs around the world. President Kennedy said that the Peace Corps would be serious when 100,000 Americans were serving abroad each year. Although the Peace Corps is America's flagship international service program, today less than 8,000 volunteers are spread across 77 countries. Since 1961, America has sent and returned nearly 200,000 volunteers, a number significantly less than the millions Kennedy envisioned by his Peace Corps' 50th year. Had the Peace Corps grown at the rate Kennedy envisioned, the course of our country's foreign policy, diplomatic strategy and global awareness over the past 50 years would be very different.

Last week, ServiceWorld, an international service coalition of more than 300 non-profits, colleges, corporations and faith-based institutions, released a bold plan to meet President Kennedy's goal of mobilizing 100,000 Americans every year - and one million over a decade - to serve abroad. The proposed Sargent Shriver International Service Act calls for doubling Peace Corps to 15,000 by 2015, lowering costs per volunteer, and forging partnerships with the hundreds of non-profits that have emerged since its creation. Doubling of the Peace Corps is a goal that both Presidents George W. Bush and Barack Obama have embraced.

Volunteers for Prosperity will tap 75,000 skilled Americans for flexible term assignments to work on international challenges Congress and many Presidents have made priorities, such as HIV/AIDS, malaria, and clean water. Global Service Fellows will enable Members of Congress to nominate top talent from their districts and states, as they do for the military academies today, to serve for up to one year abroad. Together with the Peace Corps, these efforts will meet John Kennedy's goal of mobilizing 100,000 Americans to serve abroad each year.

The Service World plan focuses on multi-lateral partnerships and exchanges so Americans serve side-by-side with people from other countries, including in the United States. Under the plan, both skilled and non-skilled volunteers of all classes and ages will serve abroad for both long- and short-term assignments and veterans have specific opportunities to utilize their many skills in a civilian capacity. We believe an inclusive and mobile model of volunteering will contribute to the development of a new generation of global leaders, provide skills for U.S. citizens to compete in a global economy, increase international awareness, strengthen development, and improve the image of America abroad.

Volunteer service by people of all nations should become a common strategy in meeting pressing challenges in education, health, the environment, agriculture and more. By having national policies that engage more Americans in international service at every stage of life, we will be sharing our most valuable assets - the skills, talents and perspectives of our people - to make a significant difference in communities and nations throughout the world.

      

Volunteer, civil society and governmental delegates from 22 nations gathered in Johannesburg this month for the Southern Africa Conference on Volunteer Action for Development. The conference was co-convened by United Nations Volunteers (UNV) and Volunteer and Service Enquiry Southern Africa (VOSESA), in observance of the 10th anniversary of the United Nations International Year of Volunteers (IYV).

Naheed Haque, deputy executive coordinator for United Nations Volunteers, gave tribute to the late Nobel Laureate Wangari Mathai and her Greenbelt tree planting campaign as the “quintessential volunteer movement.” Haque called for a “new development paradigm that puts voluntarism at the center of community-centered sustainable development.” In this paradigm, human happiness and service to others would be key considerations, in addition to economic indicators and development outcomes including health and climate change.  

The international gathering developed strategies to advance three key priorities for the 15 nations in the Southern Africa Development Community (SADC): combating HIV/ AIDS; engaging the social and economic participation of youth; and promoting regional integration and peace. Research data prepared by Civicus provided information on the rise of voluntary service in Africa, as conferees assessed strategies to advance “five pillars” of effective volunteerism: engaging youth, community involvement, international volunteers, corporate leadership and higher education in service.

VOSESA executive director, Helene Perold, noted that despite centuries of migration across the region, the vision for contemporary regional cooperation between southern African countries has largely been in the minds of heads of states with “little currency at the grassroots level.” Furthermore, it has been driven by the imperative of economic integration with a specific focus on trade. Slow progress has now produced critiques within the region that the strategy for integrating southern African countries cannot succeed on the basis of economic cooperation alone. Perold indicated that collective efforts by a wide range of civic, academic, and governmental actors at the Johannesburg conference could inject the importance of social participation within and between countries as a critical component in fostering regional integration and achieving development outcomes. 

This premise of voluntary action’s unique contribution to regional integration was underscored by Emiliana Tembo, director of Gender and Social Affairs for the Common Market of Eastern and Southern Africa (COMESA). Along with measures promoting free movement of labor and capital to step up trade investment, Tembo stressed the importance of “our interconnectedness as people,” citing Bishop Desmond Tutu’s maxim toward the virtues of “Ubuntu – a person who is open and available to others.”

The 19 nation COMESA block is advancing an African free-trade zone movement from the Cape of South Africa, to Cairo Egypt. The “tripartite” regional groupings of SADC, COMESA and the East Africa Community are at the forefront of this pan-African movement expanding trade and development.

Preliminary research shared at the conference by VOSESA researcher Jacob Mwathi Mati noted the effects of cross border youth volunteer exchange programs in southern and eastern Africa. The research indicates positive outcomes including knowledge, learning and “friendship across borders,” engendered by youth exchange service programs in South Africa, Mozambique, Tanzania and Kenya that were sponsored Canada World Youth and South Africa Trust.   

On the final day of the Johannesburg conference, South Africa service initiatives were assessed in field visits by conferees including loveLife, South Africa’s largest HIV prevention campaign. loveLife utilizes youth volunteer service corps reaching up to 500,000 at risk youths in monthly leadership and peer education programs. “Youth service in South Africa is a channel for the energy of youth, (building) social capital and enabling public innovation,” Programme Director Scott Burnett stated. “Over the years our (service) participants have used their small stipends to climb the social ladder through education and micro-enterprise development.”

Nelly Corbel, senior program coordinator of the John D. Gerhart Center for Philanthropy and Civic Engagement at the American University in Cairo, noted that the Egyptian Arab Spring was “the only movement that cleaned-up after the revolution." On February 11^th, the day after the resignation of former Egyptian President Hosni Mubarak, thousands of Egyptian activists  removed debris from Tahrir Square and engaged in a host of other volunteer clean-up and painting projects. In Corbel's words: “Our entire country is like a big flag now,” from the massive display of national voluntarism in clean-up projects, emblematic of the proliferation of youth social innovation aimed at rebuilding a viable civil society.

At the concluding call-to-action session, Johannesburg conferees unanimously adopted a resolution, which was nominated by participating youth leaders from southern Africa states. The declaration, “Creating an Enabling Environment for Volunteer Action in the Region” notes that “volunteering is universal, inclusive and embraces free will, solidarity, dignity and trust… [creating] a powerful basis for unity, common humanity, peace and development.”  The resolution, contains a number of action-oriented recommendations advancing voluntarism as a “powerful means for transformational change and societal development.” Policy recommendations will be advanced by South African nations and other stakeholders at the forthcoming Rio + 20 deliberations and at a special session of the United Nations General Assembly on December 5, the 10^th anniversary of the International Year of the Volunteer.

       

       

       

It seems the Senate could have a really hot summer. Majority leader Harry Reid (D-NV) has reportedly threatened to “go nuclear” this July—meaning that Senate Democrats would move by majority vote to ban filibusters of executive and judicial branch nominees. According to these reports, if Senate Republicans block three key nominations (Richard Cordray to head the Consumer Financial Protection Bureau, Thomas Perez at Labor, and Gina McCarthy at EPA), Reid will call on the Democrats to invoke the nuclear option as a means of eliminating filibusters over nominees.

Jon Bernstein offered a thoughtful reaction to Reid’s gambit, noting that Reid’s challenge is to “find a way to ratchet up the threat of reform in order to push Republicans as far away from that line as possible.” Jon’s emphasis on Reid’s threat is important (and is worth reading in full).  Still, I think it’s helpful to dig a little deeper on the role of both majority and minority party threats that arise over the nuclear option.

Before getting to Reid’s threat, two brief detours. First, a parliamentary detour to make plain two reasons why Reid’s procedural gambit is deemed “nuclear.” First, Democrats envision using a set of parliamentary moves that would allow the Senate to cut off debate on nominations by majority vote (rather than by sixty votes). Republicans (at least when they are in the minority) call this “changing the rules by breaking the rules,” because Senate rules formally require a 2/3rds vote to break a filibuster of a measure to change Senate rules. The nuclear option would avoid the formal process of securing a 2/3rds vote to cut off debate; instead, the Senate would set a new precedent by simple majority vote to exempt nominations from the reach of Rule 22. If Democrats circumvent formal rules, Republicans would deem the move nuclear. Second, Reid’s potential gambit would be considered nuclear because of the anticipated GOP reaction: As Sen. Schumer argued in 2005 when the GOP tried to go nuclear over judges, minority party senators would “blow up every bridge in sight.” The nuclear option is so-called on account of the minority’s anticipated parliamentary reaction (which would ramp up obstruction on everything else).

A second detour notes simply that the exact procedural steps that would have to be taken to set a new precedent to exempt nominations from Rule 22 have not yet been precisely spelled out.  Over the years, several scenarios have been floated that give us a general outline of how the Senate could reform its cloture rule by majority vote. But a CRS report written in the heat of the failed GOP effort to go nuclear in 2005 points to the complications and uncertainties entailed in using a reform-by-ruling strategy to empower simple majorities to cut off debate on nominations. My sense is that using a nuclear option to restrict the reach of Rule 22 might not be as straight forward as many assume.

That gets us to the place of threats in reform-by-ruling strategies. The coverage of Reid’s intentions last week emphasized the importance of Reid’s threat to Republicans: Dare to cross the line by filibustering three particular executive branch nominees, and Democrats will go nuclear. But for Reid’s threat to be effective in convincing GOP senators to back down on these nominees, Republicans have to deem Reid’s threat credible. Republicans know that Reid refused by go nuclear last winter (and previously in January 2009), not least because a set of longer-serving Democrats opposed the strategy earlier this year. It would be reasonable for the GOP today to question whether Reid has 51 Democrats willing to ban judicial and executive branch nomination filibusters. If Republicans doubt Reid’s ability to detonate a nuclear device, then the threat won’t be much help in getting the GOP to back down. Of course, if Republicans don’t block all three nominees, observers will likely interpret the GOP’s behavior as a rational response to Reid’s threat. Eric Schickler and Greg Wawro in Filibuster suggest that the absence of reform on such occasions demonstrates that the nuclear option can “tame the minority.”  Reid’s threat would have done the trick.

As a potentially nuclear Senate summer approaches, I would keep handy an alternative interpretation.  Reid isn’t the only actor with a threat: given Republicans’ aggressive use of Rule 22, Republicans can credibly threaten to retaliate procedurally if the Democrats go nuclear.  And that might be a far more credible threat than Reid’s. We know from the report on Reid’s nuclear thinking that “senior Democratic Senators have privately expressed worry to the Majority Leader that revisiting the rules could imperil the immigration push, and have asked him to delay it until after immigration reform is done (or is killed).” That tidbit suggests that Democrats consider the GOP threat to retaliate as a near certainty. In other words, if Republicans decide not to block all three nominees and Democrats don’t go nuclear, we might reasonably conclude that the minority’s threat to retaliate was pivotal to the outcome. As Steve Smith, Tony Madonna and I argued some time ago, the nuclear option might be technically feasible but not necessarily politically feasible.

To be sure, it’s hard to arbitrate between these two competing mechanisms that might underlie Senate politics this summer.  In either scenario—the majority tames the minority or the minority scares the bejeezus out of the majority—the same outcome ensues: Nothing. Still, I think it’s important to keep these alternative interpretations at hand as Democrats call up these and other nominations this spring. The Senate is a tough nut to crack, not least when challenges to supermajority rule are in play.

       

       

       

       

       

       

The Roma people, the largest minority group in Europe and in many European countries, trail other ethnic groups in almost every characteristic that defines well-being. Perhaps of greatest importance, the Roma are less educated than other ethnic groups. But they also suffer from excess health problems, high unemployment, poverty, and political weakness. The Roma population of Bulgaria is certainly no less disadvantaged than the Roma in other countries. An especially poignant example of Bulgarian Roma disadvantage is that the death rate among children under age 1, a prime indicator of children’s health in any nation, is 25 per 1,000 for Roma children as compared with 9.9 for children of Bulgarian ethnic origin. The mathematics of death almost before life gets started is a symbolic indicator of the Roma burden in Bulgaria. Similarly, research conducted for UNICEF by the University of York shows that the poverty rate among Roma children in Bulgaria is 92 percent, perhaps the highest poverty rate for any ethnic group in Europe. By contrast, the poverty rate among children of Bulgarian heritage is less than half as high at 43 percent.

It is not surprising, then, that over at least the past decade, the European Union (EU) and most European governments, joined by the Open Society Foundation, the World Bank, and other organizations, have created important initiatives to address all these problems. It is possible to think that now is an historic moment in which European governments and dominant ethnic groups, after eight or nine centuries of the most pernicious types of discrimination against the Roma, are finally, albeit often reluctantly, admitting the problems facing their Roma populations and their own role in creating and sustaining these problems. Equally important, most of the Central and Eastern European (CEE) governments, where discrimination against the Roma has been and continues to be particularly intense, are gradually adopting policies to address the problems.

To the extent that the moment of Roma opportunity has arrived, perhaps the most important force moving Bulgaria and other CEE nations in the direction of integration and inclusion is the EU. In the period leading up to the ascension of Bulgaria and other CEE nations to membership in the EU, all the new member states were required to meet a host of conditions required by the EU as the price of admission. Among these conditions were laws outlawing discrimination and requiring equality of educational opportunity. The CEE nations complied with the EU directive to pass such laws, but implementation of the laws in Bulgaria and other nations has been something less than aggressive.

Nor is EU ascension the only force driving the CEE nations to reduce discrimination against the Roma and other minorities. The Open Society, the World Bank, and a number of other private organizations, including several Roma nongovernmental organizations (NGOs), have initiated a sweeping program to promote inclusion of the Roma in the civil society of the CEE nations. Called the “Decade of Roma Inclusion” (2005-2015) the initiative is notable for getting all the CEE nations (plus Spain) to participate, to commit themselves to activities designed to promote inclusion and nondiscrimination, and to make a financial commitment to a fund administered by the World Bank to promote the initiative. As a part of the initiative, Bulgaria and the other participating nations originated ten-year action plans. The Bulgarian action plan, the purpose of which is to create a set of goals and activities that will promote Roma integration, includes proposals for education, health care, housing, employment, discrimination and equal opportunity, and culture.

An important part of the Decade program was the establishment of the Roma Education Fund in 2005. Eight nations (Canada, Greece, Ireland, Netherlands, Slovenia, Sweden, Switzerland, and the UK), as well as several international agencies including the Open Society, pledged a total of 34 million Euros to support Fund activities during the Roma decade. The major goal of the fund is to “support policies and programs which ensure quality education for Roma, including the desegregation of education systems.”

By joining the EU, Bulgaria and the other CEE nations brought themselves into a well-developed culture of inclusion and a complex system of interlocking laws and agencies that not only outlaw exclusion and discrimination, but provide funds to implement inclusion policies and to monitor the extent to which EU nations are aggressively implementing these laws. The laws and directives include the EU Charter of Fundamental Rights, the European Commission against Racism and Intolerance, the Racial Equality Directive, and several others. It would be a mistake to conclude that every EU member, even the original 15 EU nations with relatively more advanced economies and longer histories as democracies than the CEE nations, faithfully implement every component of the various legal requirements of being an EU member. Even so, EU requirements and funds have initiated both profound legal changes and a host of programs to increase the social, economic, political, and cultural inclusion of the Roma as well as studies and evaluations that bring some light to the actual situation of the Roma and other minorities in member nations. Given the all but inevitable distance between the laws on inclusion and discrimination the CEE nations passed in order to join the EU and the actual implementation of those laws, studies commissioned by various EU agencies and NGOs illuminate the gaps between policies and implementation.

An excellent example of such illumination is a 2006 study commissioned by the Economic and Scientific Policy program of the European Parliament. The report is a hard-hitting assessment of the status of Roma throughout Europe with regard to their legal status and socio-economic conditions. The latter category includes assessments of Roma exclusion from employment, education, social services, health care, and community integration. The upshot of the report is that although there may be some progress in these important areas of integration, the Roma are still a second-class group throughout the CEE nations. Seemingly, good laws have not yet produced good results. Laws may be changed, but changing human behavior and culture takes longer.

CEE governments and their defenders are reluctant to admit the lamentable lack of progress in Roma integration. In part for this reason, the European Commission, based on extensive evidence from evaluations, surveys, and news reports of often ferocious discrimination against the Roma, felt the need to publish “An EU Framework for National Roma Integration Strategies up to 2020” in April 2011. The need for a new framework is a clear signal that the EU Commission believes the CEE governments in general and Bulgaria in particular are not achieving the results the EU hoped for when it approved these nations for EU membership and is therefore trying to push the governments of these nations into further action.

Following publication of the Framework, the Open Society released one of the most thorough and provocative reports on the situation faced by the Roma in Europe and strategies that should be adopted to attack the wide range of Roma disadvantages. Appropriately entitled “Beyond Rhetoric,” the Open Society report includes entire chapters on two issues that I will examine in more detail below.

First, the Open Society strongly recommends that nations collect ethnically disaggregated data. Logically enough, the report holds that it is impossible to document the effects of policy initiatives on the Roma and other groups unless outcome data, including measures of health, education, housing, employment, income, and death rates by age, are collected for individual ethnic groups. So important are ethnically disaggregated data that the report goes so far as to recommend that, if necessary, governments should change their statistical systems to “incorporate ethnic data components into regular statistical surveys.” A second recommendation that deserves special attention is the report’s emphasis on early childhood education and care. Virtually every report about the Roma emphasizes the vital importance of education in fighting Roma exclusion, but the Open Society report strongly recommends that nations implementing the EU Framework should “give urgent consideration” to establishing an early child development fund to “support innovative early development programs and allow for scale up of what works.”

Beyond these specific recommendations, the Open Society report emphasizes that the EU Commission stated explicitly in its Framework document that “member states do not properly use EU money for the purpose of effective social and economic integration of Roma. As if this judgment, which seems to represent the views of many EU agencies, the World Bank, the Open Society, and many Roma groups themselves, needed additional reinforcement, a United Nations expert on minority issues visited Bulgaria this summer and called upon the government to “turn its policies on Roma integration into concrete action.” She went on to give what seems to represent the views of all these groups on the flaws in the Bulgarian government’s approach to fighting Roma exclusion: “Many policies seem to remain largely only rhetorical undertakings aimed at external audiences – official commitments that are not fulfilled in practice.” The result, according to the UN expert, is that “all the evidence demonstrates that Roma remain in desperate circumstances at the very bottom of the socio-economic ladder.” In particular, she mentioned that the access of Roma children to quality education “remains overwhelmingly unfulfilled.”

If CEE nations are now entering a period in which governments will be working, often ineffectively or at a very modest pace, to improve the conditions of the Roma, judging by the efforts of other nations to reduce discrimination against minority groups and by the stately rate of progress so far in the CEE nations, it can be assumed that the fight for Roma equality in Bulgaria will be measured in decades. In the U.S., for example, the Civil Rights movement of the 1950s and 1960s was largely successful. By the mid-1960s, vital court decisions had dismantled major parts of the system of legal discrimination against blacks and the federal government had enacted programs to ensure voting rights and other fundamental rights to blacks. To enhance the legal war on poverty and discrimination, the federal government also initiated an army of social programs designed to boost the education, health, employment, housing, and political participation of the poor in general and blacks in particular. Yet today, nearly half a century after achieving legal rights and the initiation of large-scale government inclusion programs, blacks (and Hispanics) still trail whites by large margins in education, income, housing, poverty levels, and health. Although achieving significant progress against discrimination may require decades or generations, discrimination will not diminish until strong legal, economic, and social forces are mobilized against it. Expecting a long struggle cannot be a reason not to begin.

If the history of making substantial progress in overcoming ethnic discrimination in the U.S. can serve as a rough comparison to the situation of the Roma in CEE nations, several factors are going to be vital in the fight of the Roma to overcome discrimination and exclusion in Bulgaria and throughout Europe. These factors include an antidiscrimination plan, aggressive implementation of the plan by all levels of government, leadership by the Roma themselves, educational progress by Roma children and young adults, political activism by the Roma people, a media committed to accurate reporting and fairness, and a civil society that reflects underlying public opinion favoring integration and opposed to discrimination. Most of these factors appear to be present in Bulgaria, often in rudimentary and brittle form, but present and in many cases moving in the right direction nonetheless. The progress that is just now beginning can be greatly enhanced by the efforts of groups that have the resources, the will, and the vision to roll up their sleeves and help promote Roma inclusion.

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ABSTRACT

In recent decades economists have turned their attention to data that asks people how happy or satisfied they are with their lives. Much of the early research concluded that the role of income in determining well-being was limited, and that only income relative to others was related to well-being. In this paper, we review the evidence to assess the importance of absolute and relative income in determining well-being. Our research suggests that absolute income plays a major role in determining well-being and that national comparisons offer little evidence to support theories of relative income. We find that well-being rises with income, whether we compare people in a single country and year, whether we look across countries, or whether we look at economic growth for a given country. Through these comparisons we show that richer people report higher well-being than poorer people; that people in richer countries, on average, experience greater well-being than people in poorer countries; and that economic growth and growth in well-being are clearly related. Moreover, the data show no evidence for a satiation point above which income and well-being are no longer related.

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Many scholars have argued that once “basic needs” have been met, higher income is no longer associated with higher in subjective well-being. We assess the validity of this claim in comparisons of both rich and poor countries, and also of rich and poor people within a country. Analyzing multiple datasets, multiple definitions of “basic needs” and multiple questions about well-being, we find no support for this claim. The relationship between well-being and income is roughly linear-log and does not diminish as incomes rise. If there is a satiation point, we are yet to reach it.

Introduction

In 1974 Richard Easterlin famously posited that increasing average income did not raise average well-being, a claim that became known as the Easterlin Paradox. However, in recent years new and more comprehensive data has allowed for greater testing of Easterlin’s claim. Studies by us and others have pointed to a robust positive relationship between well-being and income across countries and over time (Deaton, 2008; Stevenson and Wolfers, 2008; Sacks, Stevenson, and Wolfers, 2013). Yet, some researchers have argued for a modified version of Easterlin’s hypothesis, acknowledging the existence of a link between income and well-being among those whose basic needs have not been met, but claiming that beyond a certain income threshold, further income is unrelated to well-being.

The existence of such a satiation point is claimed widely, although there has been no formal statistical evidence presented to support this view. For example Diener and Seligman (2004, p. 5) state that “there are only small increases in well-being” above some threshold. While Clark, Frijters and Shields (2008, p. 123) state more starkly that “greater economic prosperity at some point ceases to buy more happiness,” a similar claim is made by Di Tella and MacCulloch (2008, p. 17): “once basic needs have been satisfied, there is full adaptation to further economic growth.” The income level beyond which further income no longer yields greater well-being is typically said to be somewhere between $8,000 and $25,000. Layard (2003, p. 17) argues that “once a country has over $15,000 per head, its level of happiness appears to be independent of its income;” while in subsequent work he argued for a $20,000 threshold (Layard, 2005 p. 32-33). Frey and Stutzer (2002, p. 416) claim that “income provides happiness at low levels of development but once a threshold (around $10,000) is reached, the average income level in a country has little effect on average subjective well-being.”

Many of these claims, of a critical level of GDP beyond which happiness and GDP are no longer linked, come from cursorily examining plots of well-being against the level of per capita GDP. Such graphs show clearly that increasing income yields diminishing marginal gains in subjective well-being. However this relationship need not reach a point of nirvana beyond which further gains in well-being are absent. For instance Deaton (2008) and Stevenson and Wolfers (2008) find that the well-being–income relationship is roughly a linear-log relationship, such that, while each additional dollar of income yields a greater increment to measured happiness for the poor than for the rich, there is no satiation point.

In this paper we provide a sustained examination of whether there is a critical income level beyond which the well-being–income relationship is qualitatively different, a claim referred to as the modified-Easterlin hypothesis. As a statistical claim, we shall test two versions of the hypothesis. The first, a stronger version, is that beyond some level of basic needs, income is uncorrelated with subjective well-being; the second, a weaker version, is that the well-being–income link estimated among the poor differs from that found among the rich.

Claims of satiation have been made for comparisons between rich and poor people within a country, comparisons between rich and poor countries, and comparisons of average well-being in countries over time, as they grow. The time series analysis is complicated by the challenges of compiling comparable data over time and thus we focus in this short paper on the cross-sectional relationships seen within and between countries. Recent work by Sacks, Stevenson, and Wolfers (2013) provide evidence on the time series relationship that is consistent with the findings presented here.

To preview, we find no evidence of a satiation point. The income–well-being link that one finds when examining only the poor, is similar to that found when examining only the rich. We show that this finding is robust across a variety of datasets, for various measures of subjective well-being, at various thresholds, and that it holds in roughly equal measure when making cross-national comparisons between rich and poor countries as when making comparisons between rich and poor people within a country.

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2016: une année décisive

Les décideurs politiques et les spécialistes du développement sont désormais confrontés à une nouvelle série d’enjeux suite à l’établissement, par consensus mondial, du triumvirat composé du Programme d’action d’Addis-Abeba, du Programme d’action 2030 et de l’Accord de Paris [1]  : mise en œuvre, suivi et passage en revue. Les professionnels des politiques de développement doivent aborder ces enjeux tout en y intégrant ces trois piliers du développement durable que sont le développement social, la croissance économique et la protection environnementale, sans oublier les trois volets intersectoriels du consensus mondial précités, tout cela en opérant au sein d’un contexte dans lequel la planification des politiques reste accomplie de façon cloisonnée. Ils doivent également incorporer le caractère universel de ces nouveaux accords en tenant compte des différentes circonstances nationales ; à savoir les divers besoins, réalités, capacités, niveaux de développement nationaux, de même que les diverses priorités et politiques nationales. Ils doivent aussi accroître considérablement l’allocation des ressources et les moyens de mise en œuvre (comme le financement, le renforcement des capacités et le transfert de technologies) pour changer les choses et améliorer les nouveaux partenariats réunissant plusieurs parties prenantes en vue de restreindre les mouvements mondiaux de toutes sortes (notamment la migration, le terrorisme, les maladies, la fiscalité, les phénomènes météorologiques extrêmes et la révolution numérique) dans un monde résolument interconnecté. Il va sans dire que la tâche est très ambitieuse !

Ces difficultés sont à l’origine de nouveaux accords nationaux et internationaux visant à honorer les engagements pris pour répondre à ces enjeux sans précédent. Plusieurs États africains ont déjà commencé à créer des comités interministériels et des groupes de travail pour assurer l’alignement entre les objectifs mondiaux et les processus, les aspirations et les priorités actuels. 

L’Afrique prépare, en collaboration avec la communauté internationale, le premier Forum politique de haut niveau depuis l’adoption du programme d’action 2030 qui aura lieu en juillet 2016 et dont le thème sera « Veiller à ce que nul ne soit laissé pour compte ». Afin d’éclairer le leadership, l’orientation et les recommandations relatifs au Programme d’action 2030, six pays africains [2] parmi les 22 États membres de l’ONU se sont portés volontaires pour présenter des études nationales sur le travail accompli en vue d’atteindre les Objectifs de développement durable (ODD), soit une opportunité unique de fournir un examen objectif sans compromis et de mettre en avant les leviers d’exploitation et les limites à surmonter afin d’avoir un impact.

Les Nations Unies ont déployé de nombreux efforts de coordination parallèlement au travail de terrain réalisé par l’Afrique : en premier lieu, la création d’un groupe de travail interinstitutions chargé de préparer le forum sur le financement du développement de suivi synchronisé avec le Forum mondial pour l’infrastructure, qui consultera sur les investissements en infrastructures, un aspect crucial pour le continent ; un groupe composé de 10 représentants nommés dont la mission consiste à soutenir le Mécanisme de facilitation des technologies aux fins du développement, du transfert et de la diffusion de technologies pour les ODD, soit un autre aspect très important pour l’Afrique ; et enfin une équipe de conseillers indépendants dont la mission consiste à fournir des conseils sur le positionnement à plus long terme du système de développement de l’ONU dans le contexte du Programme 2030 communément appelé  « UN fit for purpose », parmi tant d’autres efforts.

Ces obligations bureaucratiques écrasantes pèseront à elles seules lourdement sur les capacités limitées de l’Afrique. C’est la raison pour laquelle le continent à tout intérêt à regrouper ses ressources en tirant parti de ses robustes réseaux régionaux pour atténuer cet obstacle de façon cohérente et coordonnée et en capitalisant sur la convergence entre les textes nouvellement adoptés et l’Agenda 2063, le programme de transformation mis en place par l’Union Africaine sur une durée de 50 ans, avec l’aide d’institutions panafricaines.

Régionalisation en Afrique : l’engrenage menant vers la phase suivante du développement

Outre les échelons nationaux et internationaux, il convient de tenir compte d’une troisième dimension : l’échelon régional. Ainsi, les trois principaux accords conclus en 2015 privilégiaient le soutien aux projets et aux cadres de coopération encourageant l’intégration régionale et sous-régionale, en particulier en Afrique. [3] C’est la raison pour laquelle des politiques industrielles communes et cohérentes relatives aux chaînes de valeur régionales formulées par des institutions régionales renforcées et portées par un leadership transformationnel volontariste s’imposent comme le meilleur moyen de favoriser l’insertion de l’Afrique au sein de l’économie mondiale.

L’Afrique considère depuis longtemps l’intégration économique régionale, partie intégrante de ses principaux « piliers », à savoir les huit Communautés économiques régionales (CER), comme étant une stratégie de développement de base.

Le continent s’est manifestement engagé dans cette voie : l’été dernier, trois CER, le Marché commun pour l’Afrique de l’Est et de l’Afrique australe (COMESA), la Communauté d’Afrique de l’Est (CAE) et la Communauté de développement de l’Afrique de l’Est (SADC) ont créé le Traité de libre-échange tripartite (TFTA) regroupant 26 pays, avec plus de 600 millions d’habitants et un PIB global de mille milliards de dollars US. Cet accord tripartite ouvre la voie à l’accord « méga-régional » de l’Afrique, la Zone de libre échange continentale (CFTA) et à l’instauration d’une vaste communauté économique africaine. Si la régionalisation permet la libre circulation des personnes, des capitaux, des biens et des services, c’est la connectivité intra-africaine accrue en découlant qui stimulera les échanges commerciaux au sein de l’Afrique, favorisera la croissance, créera des emplois et attira des investissements. Il devrait enfin faire démarrer l’industrialisation, l’innovation et la compétitivité. À ces fins, les institutions panafricaines, soucieuses d’exploiter les récentes performances favorables enregistrés par le continent, redoublent d’efforts pour créer un environnement propice à l’harmonisation des politiques et des réglementations et aux économies d’échelle.

Infrastructure and régionalisation

L’infrastructure, sans laquelle toute connectivité est impossible, constitue indéniablement le fondement de tout futur plan de régionalisation. Outre l’intégration du marché et le développement industriel, le développement des infrastructures est l’un des trois piliers de la stratégie du TFTA. De la même manière, l’agence pour le Nouveau partenariat économique pour le développement en Afrique (NEPAD), l’organe technique de l’Union africaine (UA) chargé de planifier et coordonner la mise en œuvre des priorités continentales et des programmes régionaux, a adopté l’intégration régionale en tant que méthode stratégique pour l’infrastructure. Le NEPAD a d’ailleurs organisé, en juin 2014, le Sommet de Dakar sur le financement des infrastructures ayant abouti à l’adoption du Programme d’action de Dakar qui présente des options en matière de mobilisation d’investissements dans des projets de développement des infrastructures, en commençant par 16 projets bancables clés issus du programme de développement des infrastructures en Afrique (PIDA). Il est intéressant de noter que ces « mégaprojets du NEPAD visant à transformer l’Afrique » ont tous une portée régionale.

Pour voir la carte des 16 mégaprojets du NEPAD visant à transformer l’Afrique, Cliquez ici

En complémentant les efforts du NEPAD et du TFTA, le Réseau d’affaires continental a été formé pour promouvoir le dialogue entre les secteurs public et privé sur la thématique de l’investissement en infrastructures régionales. Le Fond Africa50 pour l’infrastructure a été constitué en guise de nouvelle plateforme de prestation gérée commercialement en vue de combler l’énorme vide au niveau du financement des infrastructures en Afrique, un trou évaluée à 50 milliards de dollars US par an.

L’élaboration de propositions propres et les progrès institutionnels récemment observés témoignent de la détermination de l’Afrique à accélérer le développement des infrastructures, et donc la régionalisation. Lors du dernier sommet de l’UA, le Comité d’orientation des chefs d’État et de gouvernement a approuvé l’institutionnalisation d’une Semaine PIDA organisée par la Banque africaine de développement (BAD) en vue d’assurer le suivi des progrès accomplis.

L’élan des projets énergétiques régionaux en Afrique

Les partenariats énergétiques indiqués ci-dessous illustrent les avantages potentiels des méthodes de mise en œuvre et de suivi transfrontalières : l’Africa Power Vision (APV) réalisée avec Power Africa, le modèle du Centre pour les énergies renouvelables et l’efficacité énergétique(ECREEE) de la CEDEAO accompagnant l’initiative Énergie Durable pour Tous (SE4LL), une initiative mise en œuvre par la plateforme Africaine et la solution Africa GreenCo basée sur le PIDA.

• Africa Power Vision : Les ministres Africains de l’énergie et des finances réunis à l’occasion du Forum économique mondial (FEM) de Davos en 2014 ont décidé de créer l’APV. La vision fournit un modèle stratégique de mobilisation de ressources afin de permettre aux entreprises, aux industries et aux foyers africains d’avoir un accès plus rapide à l’énergie moderne. Elle dresse une liste de projets énergétiques basés sur des priorités régionales établies par l’Afrique et extraites en grande partie du Programme d’action prioritaire du PIDA, à savoir l’éventail de projets à court terme devant être achevés à l’horizon 2020. Le projet hydroélectrique Inga III qui changera les règles du jeu, l’emblématique projet solaire DESERTEC Sahara et la gigantesque ligne de transport d’électricité nord-sud couvrant la quasi-totalité du TFTA sont parmi les 13 projets sélectionnés. La note conceptuelle et le plan de mise en œuvre intitulés « De la vision à l’action » élaborés par le NEPAD, en collaboration avec l’initiative Power Africa dirigée par le gouvernement américain ont été approuvés lors du Sommet de l’UA de janvier 2015. Le paquet présente des mesures permettant de surmonter les impasses afin d’atteindre des objectifs quantifiables, la « méthode d’accélération » basée sur l’Outil de classement de projets par ordre de priorité (PPCT en anglais), l’atténuation des risques et le financement de projets d’électricité. Une conception innovante a été élaborée pour éviter les doublons, économiser des ressources, améliorer la coordination et encourager des actions transformatrices en établissant des Conseillers transactionnels Power Africa – APV portant deux casquettes, qui supervisent les plans d’investissement jusqu’à la clôture financière si et quand des projets énergétiques d’intérêt commun viennent à se chevaucher. Globalement, comme il est basé sur le PIDA, le partenariat APV permet de mutualiser les expertises tout en promouvant l’intégration économique régionale au niveau de l’électrification.

• Centre pour les énergies renouvelables et l’efficience énergétique de la CEDEAO : Le secrétaire général des Nations Unies, Ban Ki-moon a lancé l’initiative Énergie durable pour tous dans le monde entier dès 2011, dans le triple objectif de garantir l’accès universel à des services énergétiques modernes, doubler le taux mondial d’amélioration de l’efficacité énergétique et doubler la proportion d'énergies renouvelables dans le bouquet énergétique mondial à l’horizon 2030. Depuis sa création, SE4ALL a suscité un fort enthousiasme sur le continent et compte désormais 44 pays africains participants. Par conséquent, la plateforme africaine SE4ALL a été la première plateforme lancée en 2013. Organisée par la BAD en partenariat avec la Commission de l’UA, le NEPAD et le Programme des Nations Unies pour le développement (PNUD), son rôle consiste à faciliter la mise en œuvre de SE4ALL sur le continent. Le troisième atelier annuel de la plateforme africaine de SE4ALL tenu à Abidjan en février dernier a révélé le potentiel de cette « coalition créative » (Yumkella 2014) pour produire des résultats tant au niveau des plans d’action nationaux et des approches régionales concertées conformes à la vision continentale qu’à celui de l’ODD7 pour l’énergie et aux Contributions prévues déterminées au niveau national (CPDN) créés pour l’Accord de Paris. Avant tout, l’atelier a prouvé que la plateforme est capable de commencer efficacement à harmoniser les processus pour obtenir un résultat dans les différents pays. En dépit du fait que les États membres de la CEDEAO participent à SE4ALL, les ministres ouest-africains ont chargé leur centre énergétique régional, le CEREEC, de coordonner la mise en œuvre des Programmes d’action de SE4ALL (PA), qui sont des documents décrivant les mesures que doivent prendre les pays pour satisfaire les objectifs en matière d’énergies renouvelables et de là les Prospectus d’investissement (PI), les documents présentant les critères d’investissement relatifs aux PA. Par conséquent, la Politique relative aux énergies renouvelables (PER) et la Politique relative à l’efficacité énergétique (PEE) de la CEDEAO ont été formulées et adoptées. Un cadre de surveillance régional visant à enrichir un Cadre de suivi mondial, le système de mesure et de préparation de rapports SE4ALL, est en cours de conception. L’efficace modèle du CEREEC, en créant un pont entre les inventaires nationaux et les acteurs mondiaux, est sur le point d’être reproduit dans deux autres régions d’Afrique, la CAE et la SADC, avec l’appui de l’Organisation des Nations Unies pour le développement industriel (ONUDI).

• Africa GreenCo : Enfin, des initiatives comme Africa GreenCo sont en cours d’incubation. Ce véhicule prometteur, actuellement financé au moyen d’une subvention accordée par la Fondation Rockefeller, se veut à la fois un négociant et un courtier en électricité indépendamment géré dont la fonction consiste à déplacer de l’électricité là où elle est nécessaire. Ainsi, Africa GreenCo cherche à capitaliser sur les projets énergétiques du PIDA : en sa qualité d’acheteur intermédiaire solvable, elle prévoit d’utiliser à l’avenir son statut régional en guise de valeur ajoutée au niveau de la garantie contre les risques. À ce jour, Africa GreenCo continue à peaufiner les aspects juridiques, réglementaires, techniques et financiers de sa future structure et forge des liens avec des parties prenantes clés du secteur (États membres, banques de développement multilatérales, services publics africains de génération et d’interconnexion appelés pools énergétiques) avant l’achèvement de son étude de faisabilité en juin 2016.

Devancement et changement de paradigme à l’horizon : vers le transnationalisme

Les partenariats précités indiquent des tendances encourageantes en direction d’une coopération plus symbiotique entre les différentes parties prenantes. Comme ils relèvent d’initiatives « faites maison », il est important de ne pas perdre de vue la dimension continentale. D’une part, les plans élaborés par l’Afrique ont plus de chances de réussir que des solutions importées uniformes et d’autre part, des efforts cohérents et combinés allant dans la même direction renforcent la confiance et l’émulation et attirent des soutiens. Ceci implique que pour remplir les accords intergouvernementaux, il est nécessaire avant tout de les adapter aux réalités locales à travers un processus d’intégration respectueux de l’espace politique. Cette intégration peut ensuite faire l’objet d’ajustements en fonction d’expériences fondées sur des données et des preuves concrètes. Entre ces engagements mondiaux et les procédures nationales, la dimension nationale demeure le lien indispensable : permettre aux pays de contourner le caractère artificiel de leurs frontières héritées de l’époque coloniale et leur offrir des choix concrets pour éradiquer la pauvreté dans l’unité. L’intégration régionale est donc le préambule à l’opérationnalisation du développement durable au sein de l’Afrique et une étape clé de son parcours en direction d’une participation active sur la scène mondiale. La régionalisation peut également faire évoluer les relations internationales, à condition qu’elle aille de pair avec un multilatéralisme équitable et une gestion durable des connaissances globales. C’est pourquoi l’ouverture qui en découle et la complexité rencontrée sont autant de paramètres utiles pour enrichir la conception de réponses locales pertinentes.

Ces réussites ouvrent de grandes perspectives en termes de nouvelles expériences et synergies. Elles représentent pour moi la promesse d’un monde meilleur. Celle que je me plais à imaginer est empreinte d’écosystèmes mutuellement bénéfiques pour les personnes et la planète. Elle encourage les liens inversés où tout le monde est gagnant, c’est-à-dire un monde où les économies en développement ont des retombées plus positives sur les pays industriels. C’est un monde où, par exemple, une région d’Afrique pourrait tirer des leçons de la crise grecque et vice-versa : un monde où la Chine pourrait tirer des enseignements du Corridor de développement de Maputo pour sa ceinture économique de la route de la soie. Un monde dans lequel des instituts jumelés effectuant des travaux de recherche conjoints dans les différents centres de connaissances régionaux prospéreraient, où des « fab labs » innovateurs pourraient ambitionner une aventure spatiale basée sur des déchets électroniques recyclés en imprimantes 3D. Dans un tel monde, des collaborations innovantes dans les domaines des sciences, des technologies, de l’ingénierie et des mathématiques (STEM) seraient encouragées. Celles-ci encourageraient la participation des femmes, et aussi celle de la diaspora en vue de développer des avancées techniques solides du point de vue écologique. Des efforts proportionnels, une volonté sans faille, une ingénuité autochtone et une créativité sans limites mettent cet avenir plus souriant à notre portée.

Au-delà de la reconnaissance de la voix africaine tout au long des processus intergouvernementaux, l’Afrique doit désormais consolider ses avancées en maintenant fermement sa position et en protégeant ses gains tout au long de la phase préliminaire. Le continent doit de toute urgence définir des tactiques spécifiques offrant le plus grand potentiel en termes d’inclusion et de création de capacités de production. Parallèlement, les acteurs du développement africain doivent démarrer un cycle vertueux d’apprentissage par la pratique en vue de créer une philosophie de développement endogène prenant en considération les meilleures pratiques adaptables et les échecs. Néanmoins, la seule approche capable de produire à la fois une transformation structurelle et un changement informé conformes aux stratégies à long terme propres au continent et dirigées par lui est… l’intégration régionale.  

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[1] Issus respectivement des négociations intergouvernementales à l’occasion de la Troisième Conférence sur le financement du développement (FFD3), l’Agenda du développement post 2015 et la Conférence des Nations Unies sur les changements climatiques (COP21).

[2] Égypte, Madagascar, Maroc, Sierra Leone, Togo et Ouganda

[3] Comme précisé au Programme d’action d’Addis-Abeba par exemple : « Nous engageons instamment la communauté internationale, notamment les institutions financières internationales et les banques multilatérales et régionales de développement, à accroître leur soutien aux projets et aux cadres de coopération qui favorisent cette intégration régionale et sous régionale, notamment en Afrique, et qui améliorent la participation et l’intégration des entreprises et notamment des petites entreprises industrielles, en particulier celles des pays en développement, dans les chaînes de valeur mondiales et les marchés mondiaux. »