On Friday, June 3, S&P Global Ratings announced that it would not downgrade South Africa’s credit rating to junk, letting South Africa breathe a sigh of relief. The outlook, however, remained negative. While some experts were confident that the rating would not be cut, most continued to warn that future economic or political turmoil could spark a downgrade later this year. The South African Treasury agreed, but remained positive releasing a statement saying:

Government is aware that the next six months are critical and there is a need to step up the implementation [of measures to boost the economy] … The benefit of this decision is that South Africa is given more time to demonstrate further concrete implementation of reforms that are underway.

South Africa, whose current rating stands at BBB- (one level above junk), has been facing weak economic growth—at 1 percent—over past months. The International Monetary Fund has given a 2016 growth forecast of 0.6 percent. Many feared that a downgrade could have pushed the country into a recession. Borrowing by the government would have also become more expensive, especially as it tackles a 3.2 percent of GDP budget deficit for the 2016-2017 fiscal year.

Other credit ratings agencies also are concerned with South Africa’s economic performance. Last month, Moody’s Investors Service ranked the country two levels above junk but on review for a potential downgrade, while Fitch Ratings is reviewing its current stable outlook and BBB- rating.

For South African Finance Minister Pravin Gordhan’s thoughts on the South African economy, see the April 14 Africa Growth Initiative event, “Building social cohesion and an inclusive economy: A conversation with South African Finance Minister Pravin Gordhan.”

This week, the Extraordinary African Chambers—located in Dakar and established in collaboration with the African Union—sentenced former Chadian President Hissène Habré to life in prison. Habré seized power in 1982, overthrowing then President Goukouni Oueddei. He fled to Senegal in 1990 after being ousted by current Chadian President Idriss Deby. After he fled to Senegal, the African Union called on Senegal to prosecute Habré. In 2013, the Extraordinary African Chamber was created with the sole aim to prosecute Habré. The Habré trial is the first trial of a former African head of state in another African country.

Habré faced a long list of charges including crimes against humanity, rape, sexual slavery, and ordering killings while in power. According to Chad’s Truth Commission,  Habré’s government murdered 40,000 people during his eight-year reign. At the trial, 102 witnesses, victims, and experts testified to the horrifying nature of Habré’s rule. His reign of terror was largely enabled by Western countries, notably France and the United States. In fact, on Sunday, U.S. Secretary of State John Kerry admitted to his country’s involvement in enabling of Habré’s crimes. He was provided with weapons and money in order to assist in the fight against former Libyan leader Moammar Gadhafi. Said resources were then used against Chadian citizens.

Also this week, Simone Gbagbo, former Ivorian first lady, is being tried in Côte d’Ivoire’s highest court— la Cour d’Assises—for crimes against humanity. She also faces similar charges at the International Criminal Court though the Ivoirian authorities have not reacted to the arrest warrant issued in 2012. In March 2015, Simone Gbabgo was sentenced to 20 years in jail for undermining state security as she was found guilty of distributing arms to pro-Laurent Gbagbo militia during the 2010 post-electoral violence that left 3000 dead. Her husband is currently on trial in The Hague for the atrocities committed in the 2010 post-election period.

On Monday, May 30, South African chemical and energy company Sasol Ltd announced that Mozambique’s ongoing debt crisis and continuing low global gas prices would not slow down its Mozambican gas project. The company expressed confidence in a $1.4 billion processing facility upgrade stating that the costs will be made up through future gas revenues. In explaining Sasol’s decision to increase the capacity of its facility by 8 percent, John Sichinga, senior vice president of Sasol’s exploration and production unit, stated, “There is no shortage of demand … There’s a power pool and all the countries of the region are short of power.” In addition, last week, Sasol began drilling the first of 12 new planned wells in the country.

On the other hand, on Monday The Wall Street Journal published an article examining how these low gas prices are stagnating much-hoped-for growth in East African countries like Tanzania and Mozambique as low prices prevent oil companies from truly getting started. Now, firms that flocked to promising areas of growth around these industries are downsizing or moving out, rents are dropping, and layoffs are frequent. Sasol’s Sichinga remains positive, though, emphasizing, "We are in Mozambique for the long haul. We will ride the waves, the downturns, and the upturns."

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

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

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

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

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

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

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

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

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

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

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

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

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

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2015 is a pivotal year. Three major workstreams among all the world’s nations are going forward this year under the auspices of the United Nations to develop goals, financing, and frameworks for the “post-2015 sustainable development agenda.” First, after two years of wide-ranging consultation, the U.N. General Assembly in New York in September will endorse a new set of global goals for 2030 to follow on from the Millennium Development Goals (MDGs) that culminate this year. Second, to support this effort, a financing for development (FFD) conference took place in July in Addis Ababa, Ethiopia, to identify innovative ways of mobilizing private and public resources for the massive investments necessary to achieve the new goals. And third, in Paris in December the final negotiating session will complete work on a global climate change framework. 

These three landmark summits will, with luck, provide the broad strategic vision, the specific goals, and the financing modalities for addressing the full range of systemic threats. Most of all, these three summit meetings will mobilize the relevant stakeholders and actors crucial for implementing the post-2015 agenda—governments, international organizations, business, finance, civil society, and parliaments—into a concerted effort to achieve transformational outcomes. Achieving systemic sustainability is a comprehensive, inclusive effort requiring all actors and all countries to be engaged.

These three processes represent a potential historic turning point from “business-as-usual” practices and trends and to making the systemic transformations that are required to avoid transgressing planetary boundaries and critical tipping points. Missing from the global discourse so far is a realistic assessment of the political decisions and institutional innovations that would be required to implement the post-2015 sustainable development agenda (P2015).

For 2015, it is necessary is to make sure that by the end of year the three workstreams have been welded together as a singular vision for global systemic transformation involving all countries, all domestic actors, and all international institutions. The worst outcome would be that the new Sustainable Development Goals (SDGs) for 2030 are seen as simply an extension of the 2015 MDGs—as only development goals exclusively involving developing countries. This outcome would abort the broader purposes of the P2015 agenda to achieve systemic sustainability and to involve all nations and reduce it to a development agenda for the developing world that by itself would be insufficient to make the transformations required.

Systemic risks of financial instability, insufficient job-creating economic growth, increasing inequality, inadequate access to education, health, water and sanitation, and electricity, “breaking points” in planetary limits, and the stubborn prevalence of poverty along with widespread loss of confidence of people in leaders and institutions now require urgent attention and together signal the need for systemic transformation.

As a result, several significant structural changes in institution arrangements and governance are needed as prerequisites for systemic transformation. These entail (i) political decisions by country leaders and parliaments to ensure societal engagement, (ii) institutional innovations in national government processes to coordinate implementation, (iii) strengthening the existing global system of international institutions to include all actors, (iv) the creation of an international monitoring mechanism to oversee systemic sustainability trajectories, and (v) realize the benefits that would accrue to the entire P2015 agenda by the engagement of the systemically important countries through fuller utilization of  G20 leaders summits and finance ministers meetings as enhanced global steering mechanisms toward sustainable development.   Each of these changes builds on and depends on each other.

I. Each nation makes a domestic commitment to a new trajectory toward 2030

For global goal-setting to be implemented, it is essential that each nation go beyond a formal agreement at the international level to then embark on a national process of deliberation, debate, and decision-making that adapts the global goals to the domestic institutional and cultural context and commits the nation to them as a long-term trajectory around which to organize its own systemic transformation efforts. Such a process would be an explicitly political process involving national leaders, parliaments or rule-making bodies, societal leaders, business executives, and experts to increase public awareness and to guide the public conversation toward an intrinsically national decision which prioritizes the global goals in ways which fit domestic concerns and circumstances. This political process would avoid the “one-size-fits-all” approach and internalize and legitimate each national sustainability trajectory.

So far, despite widespread consultation on the SDGs, very little attention has been focused on the follow-up to a formal international agreement on them at the U.N. General Assembly in September 2015. The first step in implementation of the SDGs and the P2015 agenda more broadly is to generate a national commitment to them through a process in which relevant domestic actors modify, adapt, and adopt a national trajectory the embodies the hopes, concerns and priorities of the people of each country. Without this step, it is unlikely that national systemic sustainability trajectories will diverge significantly enough from business-as-usual trends to make a difference. More attention needs to now be given to this crucial first step.  And explicit mention of the need for it should appear in the UNGA decisions in New York in September.

II. A national government institutional innovation for systemic transformation

The key feature of systemic risks is that each risk generates spillover effects that go beyond the confines of the risk itself into other domains. This means that to manage any systemic risk requires broad, inter-disciplinary, multi-sectoral approaches. Most governments have ministries or departments that manage specific sectoral programs in agriculture, industry, energy, health, education, environment, and the like when most challenges now are inter-sectoral and hence inter-ministerial. Furthermore, spillover linkages create opportunities in which integrated approaches to problems can capture intrinsic synergies that generate higher-yield outcomes if sectoral strategies are simultaneous and coordinated.

The consequence of spillovers and synergies for national governments is that “whole-of-government” coordinating committees are a necessary institutional innovation to manage effective strategies for systemic transformation. South Korea has used inter-ministerial cabinet level committees that include private business and financial executives as a means of addressing significant interconnected issues or problems requiring multi-sectoral approaches. The Korea Presidential Committee on Green Growth, which contained more than 20 ministers and agency heads with at least as many private sector leaders, proved to be an extremely effective means of implementing South Korea’s commitment to green growth.

III.  A single global system of international institutions

The need for a single mechanism for coordinating the global system of international institutions to implement the P2015 agenda of systemic transformation is clear. However, there are a number of other larger reasons why the forging of such a mechanism is crucial now.

The Brettons Woods era is over. It was over even before the initiative by China to establish the Asia Infrastructure Investment Bank (AIIB) in Beijing and the New Development Bank (NDB) in Shanghai. It was over because of the proliferation in recent years of private and official agencies and actors in development cooperation and because of the massive growth in capital flows that not only dwarf official development assistance (concessional foreign aid) but also IMF resources in the global financial system. New donors are not just governments but charities, foundations, NGOs, celebrities, and wealthy individuals. New private sources of financing have mushroomed with new forms of sourcing and new technologies. The dominance of the IMF and the World Bank has declined because of these massive changes in the context.

The emergence of China and other emerging market economies requires acknowledgement as a fact of life, not as a marginal change. China in particular deserves to be received into the world community as a constructive participant and have its institutions be part of the global system of international institutions, not apart from it. Indeed, China’s Premier, Li Keqiang, stated at the World Economic Forum in early 2015 that “the world order established after World War II must be maintained, not overturned.”

The economic, social and environmental imperatives of this moment are that the world’s people and the P2015 agenda require that all international institutions of consequence be part of a single coordinated effort over the next 15 years to implement the post-2015 agenda for sustainable development. The geopolitical imperatives of this moment also require that China and China’s new institutions be thoroughly involved as full participants and leaders in the post-2015 era. If nothing else, the scale of global investment and effort to build and rebuild infrastructure requires it.

It is also the case that the post-2015 era will require major replenishments in the World Bank and existing regional development banks, and significantly stronger coordination among them to address global infrastructure investment needs in which the AIIB and the NDB must now be fully involved. The American public and the U.S. Congress need to fully grasp the crucial importance for the United States, of the IMF quota increase and governance reform.  These have been agreed to by most governments but their implementation is stalled in the U.S. Congress. To preserve the IMF’s role in the global financial system and the role of the U.S. in the international community, the IMF quota increase and IMF governance reform must be passed and put into practice. Congressional action becomes all the more necessary as the effort is made to reshape the global system of international institutions to accommodate new powers and new institutions within a single system rather than stumble into a fragmented, fractured, and fractious global order where differences prevail over common interests.

The IMF cannot carry out its significant responsibility for global financial stability without more resources. Other countries cannot add to IMF resources proportionately without U.S. participation in the IMF quota increase.   Without the US contribution, IMF members will have to fund the IMF outside the regular IMF quota system, which means de-facto going around the United States and reducing dramatically the influence of the U.S. in the leadership of the IMF. This is a self-inflicted wound on the U.S., which will damage U.S. credibility, weaken the IMF, and increase the risk of global financial instability. By blocking the IMF governance reforms in the IMF agreed to by the G-20 in 2010, the U.S. is single-handedly blocking the implementation of the enlargement of voting shares commensurate with increased emerging market economic weights.  This failure to act is now widely acknowledged by American thought leaders to be encouraging divergence rather than convergence in the global system of institutions, damaging U.S. interests.

IV. Toward a single monitoring mechanism for the global system of international institutions

The P2015 agenda requires a big push toward institutionalizing a single mechanism for the coordination of the global system of international institutions.  The international coordination arrangement today, is the Global Partnership for Effective Development Cooperation created at the Busan High-Level Forum on Aid Effectiveness in 2011.  This arrangement, which recognizes the increasingly complex context and the heightened tensions between emerging donor countries and traditional western donors, created a loose network of country platforms, regional arrangements, building blocks and forums to pluralize the architecture to reflect the increasingly complex set of agents and actors. This was an artfully arranged compromise, responding to the contemporary force field four years ago.

Now is a different moment. The issues facing the world are both systemic and urgent; they are not confined to the development of developing countries, and still less to foreign aid. Geopolitical tensions are, if anything, higher now than then.  But they also create greater incentives to find areas of cooperation and consensus among major powers who have fundamentally different perspectives on other issues. Maximizing the sweet spots where agreement and common interest can prevail is now of geopolitical importance.  Gaining agreement on institutional innovations to guide the global system of international institutions in the P2015 era would be vital for effective outcomes but also importantly ease geopolitical tensions.

Measurement matters; monitoring and evaluation is a strategic necessity to implementing any agenda, and still more so, an agenda for systemic transformation.  As a result, the monitoring and evaluation system that accompanies the P2015 SDGs will be crucial to guiding the implementation of them.  The UN, the OECD, the World Bank, and the IMF all have participated in joint data gathering efforts under the IDGs  in the 1990s and the MDGs in the 2000s.   Each of these institutions has a crucial role to play, but they need to be brought together now under one umbrella to orchestrate their contributions to a comprehensive global data system and to help the G20 finance ministers coordinate their functional programs.   

The OECD has established a strong reputation in recent years for standard setting in a variety of dimensions of the global agenda.  Given the strong role of the OECD in relation to the G20 and its broad outreach to “Key Partners” among the emerging market economies, the OECD could be expected to take a strong role in global benchmarking and monitoring and evaluation of the P2015 Agenda.  The accession of China to the OECD Development Centre, which now has over fifty member countries, and the presence and public speech of Chinese Premier Li Keqiang at the OECD on July 1^st, bolsters the outreach of the OECD and its global profile.

But national reporting is the centerpiece and the critical dimension of monitoring and evaluation.  To guide the national reporting systems and evaluate their results, a  new institutional arrangement is needed that is based on national leaders with responsibility for implementation of the sustainable development agendas from each country and is undertaken within the parameters of the global SDGs and the P2015 benchmarks.

V.   Strengthening global governance and G20 roles

G-20 leaders could make a significant contribution to providing the impetus toward advancing systemic sustainability by creating a G-20 Global Sustainable Development Council charged with pulling together the national statistical indicators and implementing benchmarks on the SDGs in G-20 countries.  The G-20 Global Sustainable Development Council (G-20 GSDC) would consist of the heads of the presidential committees on sustainable development charged with coordinating P2015 implementation in G-20 countries.  Representing systemically important countries, they would also be charged with assessing the degree to which national policies and domestic efforts by G20 countries generate positive or negative spillover effects for the rest of the world.  This G-20 GSDC would also contribute to the setting of standards for the global monitoring effort, orchestrated perhaps by the OECD, drawing on national data bases from all countries using the capacities of the international institutions to generate understanding of global progress toward systemic sustainability. 

The UN is not in a position to coordinate the global system of international institutions in their functional roles in global sustainable development efforts.  The G-20 itself could take steps through the meetings of G-20 Finance Ministers to guide the global system of international institutions in the implementation phase of the P2015 agenda to begin in 2016. The G-20 already has a track record in coordinating international institutions in the response to the global financial crisis in 2008 and its aftermath. The G-20 created the Financial Stability Board (FSB), enlarged the resources for the IMF, agreed to reform the IMF’s governance structure, orchestrated relations between the IMF and the FSB, brought the OECD into the mainstream of G-20 responsibilities and has bridged relations with the United Nations by bringing in finance ministers to the financing for development conference in Addis under Turkey’s G-20 leadership. 

There is a clear need to coordinate the financing efforts of the IMF, with the World Bank and the other regional multilateral development banks (RMDBs), with the AIIB and the BRICS NDB, and with other public and private sector funding sources, and to assess the global institutional effort as whole in relation to the P2015 SDG trajectories.  The G-20 Finance Ministers grouping would seem to be uniquely positioned to be an effective and credible means of coordinating these otherwise disparate institutional efforts.  The ECOSOC Development Cooperation Forum and the Busuan Global Partnership provide open inclusive space for knowledge sharing and consultation but need to be supplemented by smaller bodies capable of making decisions and providing strategic direction.

Following the agreements reached in the three U.N. workstreams for 2015, the China G-20 could urge the creation of a formal institutionalized global monitoring and coordinating mechanism at the China G-20 Summit in September 2016. By having the G-20 create a G-20 Global Sustainable Development Council (G-20 GSDC), it could build on the national commitments to SDG trajectories to be made next year by U.N. members countries and on the newly formed national coordinating committees established by governments to implement the P2015 Agenda, giving the G-20 GSDC functional effectiveness, clout and credibility.   Whereas there is a clear need to compensate for the sized-biased representation of the G20 with still more intensive G-20 outreach and inclusion, including perhaps eventually considering shifting to a constituency based membership, for now the need in this pivotal year is to use the momentum to make political decisions and institutional innovations which will crystallize the P2015 strategic vision toward systemic sustainability into mechanisms and means of implementation.

By moving forward on these recommendations, the G-20 Leaders Summits would be strengthened by involving G-20 leaders in the people-centered P2015 Agenda, going beyond finance to issues closer to peoples’ homes and hearts. Systemically important countries would be seen as leading on systemically important issues.  The G-20 Finance Ministers would be seen as playing an appropriate role by serving as the mobilizing and coordinating mechanism for the global system of international institutions for the P2015 Agenda.  And the G-20 GSDC would become the effective focal point for assessing systemic sustainability not only within G20 countries but also in terms of their positive and negative spillover effects on systemic sustainability paths of other countries, contributing to standard setting and benchmarking for global monitoring and evaluation.    These global governance innovations could re-energize the G20 and provide the international community with the leadership, the coordination and the monitoring capabilities that it needs to implement the P2015 Agenda. 

As the MDGs culminate this year, as the three U.N. workstreams on SDGs, FFD, and UNFCC are completed, the world needs to think ahead to the implementation phase of the P2015 sustainable development agenda. Given the scale and scope of the P2015 agenda, these five governance innovations need to be focused on now so they can be put in place in 2016.

These will ensure (i) that national political commitments and engagement by all countries are made by designing, adopting, and implementing their own sustainable development trajectories and action plans; (ii) that national presidential committees are established, composed of key ministers and private sector leaders to coordinate each country’s comprehensive integrated sustainability strategy; (iii) that all governments and international institutions are accepted by and participate in a single global system of international institutions;   (iv) that a G-20 monitoring mechanism be created by the China G-20 in September 2016 that is comprised of the super-minister officials heading the national presidential coordinating committees implementing the P2015 agenda domestically in G-20 countries, as a first step;  and (v) that the G-20 Summit leaders in Antalya in November 2015 and in China in September 2016 make clear their own commitment to the P2015 agenda and their responsibility for its adaption, adoption and implementation internally in their countries but also for assessing G-20 spillover impacts on the rest of the world, as well as for deploying their G-20 finance ministers to mobilize and coordinate the global system of international institutions toward achieving the P2015 agenda.

Without these five structural changes, it will be more likely that most countries and actors will follow current trends rather than ratchet up to the transformational trajectories necessary to achieve systemic sustainability nationally and globally by 2030.

Ye Yu, Xue Lei and Zha Xiaogag, “The Role of Developing Countries in Global Economic Governance---With a Special Analysis on China’s Role”, UNDP, Second High-level Policy Forum on Global Governance: Scoping Papers, (Beijing: UNDP, October 2014).

Zhang Haibing, “A Critique of the G-20’s Role in UN’s post-2015 Development Agenda”, in Catrina Schlager and Chen Dongxiao (eds), China and the G-20: The Interplay between an Emerging Power and an Emerging Institution, (Shanghai: Shanghai Institutes for International Studies [SIIS] and the Friedrich Ebert Stiftung [FES], 2015) 290-208.

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Colin I. Bradford, “Systemic Sustainability as the Strategic Imperative for the Future”, (Washington: The Bookings Institution, Global Economy and Development paper; September 2015). 

Wonhyuk Lim and Richard Carey, “Connecting Up Platforms and Processes for Global Development to 2015 and Beyond:  What can the G-20 do to improve coordination and deliver development impact?”, (Paris: OECD  Paper, February 2013).

Xiaoyun Li and Richard Carey, “The BRICS and the International Development System: Challenge and Convergence”, (Sussex: Institute for Development Studies, Evidence Report No. 58, March 2014).

Xu Jiajun and Richard Carey, “China’s Development Finance: Ambition, Impact and Transparency,” (Sussex :  Institute for Development Studies, IDS Policy Brief, 2015).

Soogil Young, “Domestic Actions for Implementing Integrated Comprehensive Strategies:  Lessons from Korea’s Experience with Its Green Growth Strategy”, Washington: Paper for the Brookings conference on “Governance Innovations to Implement the Post-2015 Agenda for Sustainable Development”, March 30, 2015).

Now that that the initial revelations regarding the VW scandal have sunk in it’s time to begin assessing the larger significance of those revelations. While the case and, we predict, VW, will continue for years (we are only at the end of the beginning, and far from the beginning of the end), we are far enough along to see five large questions emerging. These questions will tell us much about the economic, corporate and cultural future of VW and German enterprise. 

1) VW was an integral component of Germany's industrial reputation in Europe, across the Atlantic in the United States, and around the world. Now, that hard-won reputation is at risk. How broad will the damage be to German businesses' reputation not just for quality, but for "premium quality?"

2) Turning from the German business sector to the German economy as a whole, the VW scandal has many ironies, not least of which is that the company was a key driver (so to speak) of the famous German Wirthschaftswunder. Economic health propelled a vanquished Germany to the forefront of Europe’s post-WWII recovery and then made post-Cold War reunification a success. Does the VW scandal have the potential to slow down the overall growth of the German economy, and what are the European and global implications of that at a time when the Chinese economy is also sputtering?

3) From a corporate governance perspective, the scandal represents some of the most boneheaded thinking ever. Following disclosure of the fraud, €14bn (£10bn; $15.6bn) was wiped off VW's stock market value. Whoever knew/orchestrated the scheme thought they would get away with it, but did they really not foresee the consequences or even the likelihood of getting caught? We will long be studying the abnormal “fraud psychology" of this case.

4) Germany ranks among the top ten countries for low corruption according to Transparency International. Yet VW is not alone among German companies in making major headlines with massive ethics failures in recent years, joining Siemens, Bayer, Deutsche Bank, and many others. What does this mean for the future of Germany’s role as a force for anti-corruption at home and internationally?

5) Former VW CEO Winterkorn resigned but claimed he knew nothing about the scandal. What does this say about the structure and management culture of Germany’s largest companies? How widespread is “plausible deniability” in German business culture--and in all business culture everywhere? If so, what are the dangers of this going forward, and what should be done to address them?

The leaked information in the Panama Papers from the law firm Mossack Fonseca has captured the headlines for weeks and will continue to do so as further names are exposed. The scandal has placed Panama in the limelight and provided an unprecedented glimpse into the world of hidden money and tax avoidance. To understand its broader context, it is vital that we distinguish between legal corruption, like that exposed by the Panama Papers, and illegal corruption, like that exposed by the Unaoil scandal. Governments must seize the moment to take decisive action against both.  

The U.S., the U.K., and a range of other countries will announce commitments to combat corruption at the Anti-Corruption Summit on May 12, championed by Prime Minister David Cameron as a game-changing event. The question is whether these commitments will deliver concrete actions that target the most costly kinds of corruption that flourish globally today.  

Unfortunately, the world often engages in “summitry” filled with communiques, calls for coordination and exchanging information, or creating another toothless generic initiative, which offer media and photo opportunities that fulfill particular political objectives for some leaders. Let us see if it’s different this time.

Mossack Fonseca, and its home country Panama, are just a couple nodes in the vast and complex set of “enablers” of corruption and tax evasion around the world.     

For those seeking secret shelters and corporate shells, the mighty U.S. (which unsurprisingly doesn’t feature much in the Panama Papers) is one of the world’s most appealing destinations: Setting up a shell corporation in Delaware, for instance, requires less background information than obtaining a driver’s license. As seen in the chart below, this opacity, coupled with the size of the U.S. as a haven, means that it has been ranked the third most secretive jurisdiction among close to 100 assessed by the Financial Secrecy Index. Panama is 13th.

Figure 1: Financial Secrecy Index 2015 (Select jurisdictions, from the Tax Justice Network)

Source: The Tax Justice Network’s Financial Secrecy Index http://www.financialsecrecyindex.com/introduction/fsi-2015-results

This graph depicts the top 40 worst performing jurisdictions as well as four select better performing jurisdictions (right of dashed line). The Index combines a qualitative secrecy score based on 15 indicators and a quantitative measure of a jurisdiction's share in global financial services exports. 

And the U.K. is an important enabler of corruption: It has stood by as its offshore jurisdictions and protectorates operate as safe havens for illicit wealth, which the Panama Papers make clear. The British Virgin Islands, for example, were the favored location for thousands of shell companies set up by Mossack Fonseca.  

The Panama Papers speak only indirectly to core aspects of today’s global corruption challenge, which are neither about Panama nor taxes. We ought to view the resulting scandals in a broader light, and recognize the immense, complex webs of corruption that increasingly link economic and political elites around the globe.

Grand corruption

The most powerful figures who engage in high-level or “grand” corruption are hardly running scared following the Panama leak. These figures include kleptocrat leaders as well as oligarchs who wield enormous influence on government affairs. Often, these players interact and collude, forming high-powered public-private networks that make the traditional notion of corruption as an illegal transaction between two parties look like child’s play.

Corruption in these elite networks far transcends the unethical behavior of the typical tax avoider, as it involves the abuse of power to accumulate power and assets, often via the direct plunder of public resources, asset stripping, or large-scale bribery. The multi-billion-dollar scandal embroiling the Brazilian oil giant Petrobras illustrates the complexity of colluding networks, and how grand such corruption can inflict political and economic damage of historical proportions on a country. 

The oil sector provides many more illustrations of grand corruption. Few company officials may have been more relieved by the Panama Papers leak than those at Unaoil, whose own scandal had just erupted. Unaoil is an “enabler” company incorporated in Monaco that bribed and influenced government officials in various countries on behalf of multinational companies vying for lucrative procurement contracts. While overshadowed by the Panama leaks, the Unaoil case is at least as emblematic of the challenges in tackling global corruption. For instance, it shows the deeply ingrained practice of Iraqi government officials seeking bribes for the award of contracts and the willingness of companies to provide them.

Corrupt elites, including those embroiled in the Unaoil scandal, often use structures like shell corporations and tax havens (along with real estate and other investments) to hide their ill-gotten funds. However, even if the Panama Papers leak prompts more scrutiny on illicit financial flows and the reform of these opaque financial structures, grand corruption will continue in many locations.  It is noteworthy that the political fallout has been concentrated in relatively well-governed countries that do have accountability and anti-corruption systems in place, as illustrated by the resignations of the prime minister of Iceland, the industry minister of Spain, and the head of Chile’s Transparency International chapter. 

In sharp contrast, President Vladimir Putin brushed off the leaked Russian information as a Western anti-Putin conspiracy; in China, discussion and dissemination were muffled by media censorship; and, in Azerbaijan, exposure of details on President Aliyev’s family mining interests will hardly dent his hold on power. While reforms leading from the Panama leaks will hopefully deter tax dodgers and unethical corporations and individuals from hiding dirty assets, powerful corrupt leaders will continue to enjoy impunity.

Legal corruption and state capture   

The Panama Papers shed a sliver of light on the type of corruption that is perhaps most damaging and difficult to tackle: legal corruption and state capture. Around the world, powerful economic and political elites unduly influence laws and policies, shaping the rules of the game for their own benefit, or what has been called the “privatization of public policy and lawmaking.” This generates huge rents for the elite, increases their power, and exacerbates a country’s political and economic inequality.

Resource-rich countries provide many illustrations. In Angola, the Democratic Republic of Congo, Nigeria, and Venezuela, for example, political elites have used state-owned resource companies to serve patronage agendas, often—though not exclusively—through legal means.

In many industrialized countries, an example of state capture is the tax system itself. It is in the interest of elites to safeguard a worldwide network of secret offshore companies and tax havens as places to hide wealth—whether acquired legitimately or illicitly. The evidence on tax avoidance from the U.S. is telling: According to Zucman, since the 1950s the effective rate of corporate tax has decreased from 45 to 15 percent, whereas the nominal rate has only decreased from 50 to 35 percent. And U.S. companies make full use of foreign tax havens: According to a new Oxfam report, the top 50 American multinationals reported in 2008 that 43 percent of their foreign earnings came from five tax havens, accounting for only 4 percent of the companies’ foreign workforces. Further, Bourguignon reports that federal tax rates on the richest Americans fell by 15 percent between 1970 and 2004.

Risks of legal corruption in the U.S. run high because private money can so easily sway public affairs. Following the 2010 Citizen United ruling by the Supreme Court, private funds from deep pockets increasingly dominate the conduct of electoral campaigns. The avenues for private money to influence public officials may widen further, if forms of bribery traditionally considered illegal become legalized. A forthcoming Supreme Court decision could make it legal for public officials to receive gifts and other benefits from private individuals (potentially overturning the corruption conviction of a former Virginia governor for doing exactly that).  

Upfront, there are no easy solutions, especially because powerful decision-makers benefit from this status quo. But there is the opportunity, and public pressure, to reform.  As mentioned, the cause of tackling corruption often attracts token gestures, and David Cameron’s announcement of a new global anti-corruption agency could be at high risk of falling into this category. Rather, countries like the U.S. and U.K. must take firm action to reform their own practices, and push for the same from their partners such as the U.K. crown dependencies and overseas territories, the European Union and G20 members, and the recipients of overseas aid.

First, take legal corruption and state capture seriously. 

Transparency can be one game changer, especially if it addresses the channels of influence through which policy becomes “privatized.” Disclosures of campaign finance contributions, conflicts of interests, assets held by (and tax returns filed by) politicians and public officials, and parliamentary deliberations and votes can all discourage abuse and reveal hidden networks at play. Encouragingly, the Organisation for Economic Co-operation and Development (OECD) recently issued their first salvo, the report “Financing Democracy,” focusing on a few selected case studies, and as a next step it should be empowered to develop standards and carry out assessments on political finance for all OECD countries.

Transparency will only help if citizens can actively scrutinize and engage with their governments. Civic space is under attack in many jurisdictions, with activists and journalists facing intimidation, prosecution, or worse. Securing rights of expression and assembly should be the business of any international actor concerned with anti-corruption or economic governance. For instance, when considering funding requests from governments with weak records on protecting civil society—like Angola and Azerbaijan—the World Bank and International Monetary Fund as well as donors like the U.S. should prioritize civic accountability as well as broader transparency reforms.

Furthermore, grand corruption will not decline without more effective prosecutions and other sanctions that target bribe-takers, as well as the facilitators and middlemen of corruption, be they lawyers, accountants, or fixers like Unaoil. Of course, law enforcement authorities should also remain vigilant against bribe-paying companies; and governments—including OECD members implementing to varying degrees the OECD foreign bribery convention—would do well to emulate the active enforcement of the U.S. Foreign Corrupt Practices Act (FCPA) in this regard. But bribe-takers and facilitators have not faced sufficient scrutiny and sanction.

Second, get rid of shadowy corners.

Lessons yielded by recent events from the 2008 financial crisis to the Panama Papers suggest that major global players should not allow large corners of the global economy to escape scrutiny. The U.S. and the U.K. (with its offshores), should heed the calls for dismantling secrecy and tax havens. Seeds of effort, such as the U.S. government’s decision to require banks to know the identities of the individuals behind shell companies, are now coming to light, but broader efforts, including legislation, will also be required.  

Beneficial ownership transparency should become standard operating procedure, with governments following the example of the U.K., the Netherlands, and others in setting up public registries, and joining the movement toward a global registry. In the case of resource-rich countries, establishing sector-specific registries may be the right place to start. This practice is now mandated by the Extractive Industries Transparency Initiative.

Within the extractive sector, home country governments should subject commodity traders to payment disclosure requirements when doing business with governments and state-owned companies. Governments of countries like Switzerland, the U.K., and Singapore that are home to corporate actors shoulder significant responsibility, especially in the current era of low commodity prices, when traders are entering into profitable new deals with cash-strapped resource-producing countries. Shining light in dark corners like these will render them less susceptible to abuse.

Third, prioritize transparency and scrutiny when public resources are allocated.

Whenever a government allocates resources for exploitation, it ought to do so in a fully transparent fashion. The Open Contracting Partnership has made great strides in defining a gold standard for such reporting, including guidance on issues such as open data, corporate identifiers, and beneficial ownership reporting.

Natural Resource Governance Institute research on oil and mining sector corruption shows that multiple types of high-value allocations require scrutiny and contract disclosure. These include the allocation of exploration and production licenses, but also on export, import, or transport rights, which have been associated with corruption in countries such as Indonesia, the Republic of Congo, and Ukraine. And most of the oil sector cases prosecuted under the U.S. FCPA have arisen around the award of service contracts, a segment of the oil industry where the Unaoil and Petrobras scandals also took place. Transparency should be the default setting for any transactions that allocate public resources. Further scrutiny is also needed on the abuse of (mis-)managed exchange rate regimes that generates rents for the few and creates major economic distortions, such as currently in Nigeria, Venezuela, and Egypt.

Concrete impact will also require a major attack on impunity since transparency and freedom of expression are necessary, but insufficient. And governments including those of the U.S. and the U.K. should adopt reforms to address legal corruption and various forms of opacity—whether addressing the capture by money in politics or the “dark corners” among oil traders headquartered in Geneva and London. 

An ambitious commitment to tackling corruption and impunity is not only needed now, but demanded by societies, as events in Brazil and elsewhere show. This is a potentially “game-changing” global moment to make real progress.  

This piece is also available in Spanish and French. 

From 2006 to 2011, Qatar was highly active as a conflict mediator within the greater Middle East, seeking political consensus in Lebanon as well as securing a key peace agreement regarding the Darfur conflict. What were the drivers of Qatari mediation during this time, and how successful were Qatari negotiators in their efforts? How has Qatar’s foreign policy during the Arab Spring affected its ability to act as a mediator? How might Qatar expand its mediation capacity in the future?

In an Analysis Paper, Sultan Barakat weighs the prospects for renewed Qatari mediation efforts in a changing regional landscape. He holds that Qatar’s turn towards a more interventionist foreign policy during the Arab Spring shifted the country’s focus away from mediation, while backlash against the country’s positions has limited its ability to engage with the region’s conflicts.

Drawing on interviews with government officials, Barakat concludes that Qatar’s efforts were much aided by financial resources and wide-ranging political ties which helped drive initial mediation efforts, yet were hampered by a lack of institutional capacity to support and monitor such mediation.

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The need to confront and drive back the forces of the Islamic State (IS) has pushed long-term reform efforts in Iraq far down the list of priorities. Yet pressing economic reforms – such as restructuring and rebuilding the country’s energy sector – increasingly seem a strategic necessity, as oil prices have fallen far below government projections. How can politicians be persuaded to invest in Iraq’s long-term future at a time of imminent security threats? How can the efforts to reform the Iraqi electricity network be harnessed to reestablish government authority in newly retaken areas?

Luay Al-Khatteeb and Harry Istepanian address these questions through analysis of past attempts at electricity sector reform. They argue that even before IS advances plunged Iraq into a deep political and security crisis, divisions within the Iraqi parliament and various government agencies had stymied efforts at reform. Still, they note that improving the provision of electricity is a clear opportunity to improve basic services to its citizens, boosting government legitimacy and acceptance in areas under its control, especially as it seeks to retake territory from IS.

Khatteeb and Istepanian hold that a comprehensive strategy is needed, one that incorporates an expanded role for the private sector, rationalized electricity tariffs, and a host of technical fixes to improve efficiency. Ultimately, they contend, much will depend on whether the government of Prime Minister Haidar al-Abadi views the IS threat as an excuse for inaction or an impetus for change.

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Over the past year, much attention has been given to the growing production of shale oil and the challenge that these unconventional sources of energy pose to traditional producers in the Gulf. As the world’s leading exporter of liquefied natural gas (LNG), Qatar faces related concerns – mounting competition from new LNG exporters and more competitive pricing in key Asian gas markets. How will this global gas boom unfold? How can Doha develop a robust response to growing volatility in gas pricing and demand?

In a new Brookings Doha Center Analysis Paper, Naser al-Tamimi examines Qatar’s position on the global gas stage and assesses the prospects of new competitors. He argues that new LNG production and exports – from Australia, the United States, and other countries – present a challenge to Qatar’s dominant status in global gas markets, particularly in the Asia-Pacific region. At the same time, diversification and slowing growth in this region’s major economies, such as China, South Korea, and Japan, may reduce LNG demand across the board.

Read "Navigating uncertainty: Qatar’s response to the global gas boom"

Ultimately, Tamimi argues that Qatar’s pricing mechanisms and export revenues will come under significant pressure as a result of these developments, posing a potential challenge to Qatari finances. He contends that an effective response from Qatari officials must emphasize greater exports to the Middle East/North Africa region, greater contract flexibility to attract new buyers, and cooperation with other GCC members to improve Gulf bargaining power in key regional markets.

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International jihad has undergone a wholesale internal revolution in recent years. The dramatic emergence of the Islamic State (IS) and its proclamation of a Caliphate means that the world no longer faces one Sunni jihadi threat, but two, as IS and al-Qaida compete on the global stage. What is the relationship between the groups and how do their models differ? Is IS’s rapid organizational expansion sustainable? Can al-Qaida adapt and respond?

Read "Jihadi Rivalry: The Islamic State Challenges al-Qaida"

In a new Brookings Doha Center Analysis Paper, Charles Lister explores al-Qaida and IS’s respective evolutions and strategies. He argues that al-Qaida and its affiliates are now playing a long game by seeking to build alliances and develop deep roots within unstable and repressed societies. IS, on the other hand, looks to destabilize local dynamics so it can quickly seize control over territory.

Lister finds that the competition between IS and al-Qaida for jihadi supremacy will continue, and will likely include more terrorist attacks on the West. Accordingly, he calls for the continued targeting of al-Qaida leaders, the disruption of jihadi financial activities, and greater domestic intelligence and counter-radicalization efforts. Lister concludes, however, that state instability across the Muslim world must be addressed or jihadis will continue to thrive.

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There is a marriage gap in America. This is not just a gap in choices and actions, but in norms and attitudes. Each generation is more liberal, on average, when it comes to issues like premarital relationships, same-sex marriage, and divorce. But generational averages can obscure other divides, including ideology—which in many cases is a more powerful factor.

Take opinions on the most important prerequisites for marriage, as explored in the American Family Survey conducted earlier this year by Deseret News and the Center for the Study of Elections and Democracy (disclosure: I am an adviser to the pollsters). There is widespread agreement that it is best to have a stable job and to have completed college before tying the knot. But there is less agreement in the 3,000-person survey on other questions, including premarital cohabitation.

In response to the question of whether it is “important to live with your future spouse before getting married,” a clear gap emerges between those who identify as Democrats and those who identify as Republicans. This gap trumps the generational one, with younger Republicans (under 40) more conservative than Democrats over the age of 40:

The importance of family stability for a child’s wellbeing and prospects is well-documented, not least in Isabel Sawhill’s book, Generation Unbound. The question is not whether stability matters, but how best to promote it. To the extent that biological parents stay together and provide a stable environment, it doesn’t much matter if they are married. For children living with both biological parents, there is no difference in outcomes between those being raised by a married couple compared to a cohabiting couple, according to research by Wendy Manning at Bowling Green State University.

But people who marry are much more likely to stay together:

Marriage, at least in America, does seem to act as an important commitment device, a “co-parenting” contract for the modern world, as I’ve argued in an essay for The Atlantic, “How to Save Marriage in America.”

Cohabitation can signal radically different situations. A couple who plan to live together for a couple of years, then marry, and then plan the timing of having children are very different from a couple who start living together, accidentally get pregnant, and then, perhaps somewhat reluctantly, get married.

There is some evidence that cohabitation is in fact becoming a more common bridge to marriage and commitment. First-time premarital cohabiting relationships are also lasting longer on average and increasingly turn into marriage: around seven in ten cohabiting couples are still together after three years, of whom four have married.

In the end what matters is planning, stability, and commitment. If cohabitation is a planned prelude to what some scholars have labeled “decisive marriages,” it seems likely to prove a helpful shift in social norms, by allowing couples to test life under the same roof before making a longer-term commitment. Sawhill’s distinction between “drifters” and “planners” in terms of pregnancy may also be useful when it comes to thinking about cohabitation, too.

The Horatio Alger ideal of upward mobility has a strong grip on the American imagination (Reeves 2014). But recent years have seen growing concern about the distance between the rhetoric of opportunity and the reality of intergenerational mobility trends and patterns.

The related issues of equal opportunity, intergenerational mobility, and inequality have all risen up the agenda, for both scholars and policymakers. A growing literature suggests that the United States has fairly low rates of relative income mobility, by comparison to other countries, but also wide variation within the country. President Barack Obama has described the lack of upward mobility, along with income inequality, as “the defining challenge of our time.” Speaker Paul Ryan believes that “the engines of upward mobility have stalled.”

But political debates about equality of opportunity and social and economic mobility often provide as much heat as light. Vitally important questions of definition and motivation are often left unanswered. To what extent can “equality of opportunity” be read across from patterns of intergenerational mobility, which measure only outcomes? Is the main concern with absolute mobility (how people fare compared to their parents)—or with relative mobility (how people fare with regard to their peers)? Should the metric for mobility be earnings, income, education, well-being, or some other yardstick? Is the primary concern with upward mobility from the bottom, or with mobility across the spectrum?

In this paper, we discuss the normative and definitional questions that guide the selection of measures intended to capture “equality of opportunity”; briefly summarize the state of knowledge on intergenerational mobility in the United States; describe a new microsimulation model designed to examine the process of mobility—the Social Genome Model (SGM); and how it can be used to frame and measure the process, as well as some preliminary estimates of the simulated impact of policy interventions across different life stages on rates of mobility.

The three steps being taken in mobility research can be described as the what, the why, and the how. First, it is important to establish what the existing patterns and trends in mobility are. Second, to understand why they exist—in other words, to uncover and describe the “transmission mechanisms” between the outcomes of one generation and the next. Third, to consider how to weaken those mechanisms—or, put differently, how to break the cycles of advantage and disadvantage.

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Politicians and scholars often lament the persistence of poverty across generations. But affluence persists, too. In the U.S. especially, the top of the income distribution is just as “sticky”, in intergenerational terms, as the bottom. The American upper middle class is reproducing itself quite effectively.

Class reproduction is of course driven by a whole range of factors, from parenting and family structure through formal education, informal learning, the use of social networks, and so on. Some are unfair: playing the legacy card in college admissions, securing internships via closed social networks, zoning out lower-income families from our neighborhoods and school catchment areas. (These “opportunity hoarding” mechanisms are the focus of my forthcoming book, Dream Hoarders.)

It is natural and laudable for parents to want their children to prosper. It is also understandable that they’ll use the resources and means at their disposal to try to reduce the chances of their children being downwardly mobile. They are likely to try even harder if the drop looks big, in economic terms.

There is a significant earnings gap between those at the top and those in the middle. But this gap is much bigger in the U.S. than in other nations, and is getting bigger over time:

The cost of falling reflects the particular way in which income inequality has risen in recent years: namely, at the top of the distribution. The relationship between income inequality and intergenerational mobility is a much-disputed one, as regular readers of this blog know well. Overall, the evidence for a “Great Gatsby Curve” is quite weak.

But at the top of the distribution, there could be some incentive effects linking inequality and immobility. As the income gap has widened at the top, the consequences of falling out of the upper middle class have worsened. So the incentives of the upper middle class to keep themselves, and their children, up at the top have strengthened. It looks like a long drop, because it is.

Upper middle class Americans do seem worried. In 2011, while around half of American adults making less than $30,000 per year agreed that “today’s children will lead a better life than their parents,” only 37 percent of those making $75,000 or more were as optimistic.

The greater spending of upper middle class parents on “enrichment activities” is well known; recent evidence suggests the Great Recession did nothing to reduce it. American upper middle class parents are desperate to secure their children a high position on the earnings ladder. This makes sense, given the consequences of downward mobility for their economic fortunes. Inequality incentivizes opportunity hoarding, which reduces social mobility. Time, perhaps, to lower the stakes a little?

The Brexit vote has stunned us. It has shaken us. It has forced upon us a set of dreadful questions none of us ever wished answers were required for:

• How do you disarticulate deeply integrated economies? How do you prevent the rancor of the U.K.'s divorce from the EU wreaking more havoc, not only in Europe but in the rest of the world? The divorce metaphor is apt here as it signals the treacherous waters ahead when the feeling of betrayal and the temptation of revenge may result in a misguided punitive approach to separation. Let's not forget that almost half of U.K.'s referendum voters chose "remain." Let's not forget that the youth in the U.K. overwhelmingly chose the EU for their future. EU leaders therefore face the ultimate test of leadership. In negotiating exit terms they must strengthen this constituency for internationalism. The U.K. needs committed internationalists. We all need them.
• How do you prevent rising nationalism from dialing back globalization? Is the "Great Convergence" at risk? In the past few decades, developing countries have emerged into the international trading system, and in opening their economies they have lifted millions from abject poverty. Will this future be off-limits to the next round of poor nations seeking to avail themselves of the opportunities of the international marketplace? Has globalization already peaked and are we to be the unlucky generation that lives through the tumultuous process of retrenchment? Are we to feel firsthand the dread that the generation of a century ago experienced when they all suffered from beggar-thy-neighbor policies?
• Are we next? Are the forces of economic nationalism and nativism that drove the referendum outcome in the U.K. unstoppable elsewhere? Will they decide the outcome of the American presidential election this fall? And if so, what happens to the international economic order?

These are still imponderable questions, but I would venture two answers: Brexit is not the final indictment of globalization, and our futures are not yet destined to be ruled by the politics of grievance.

The United States need not become the next domino to succumb to the harmful influence of populism. The parallels in the anti-globalization campaign on both sides of the Atlantic are of course unnerving:

• Anti-elitism: Fueled by the sense of economic disenfranchisement of older white voters who feel that a future of "splendid isolation" is possible.
• Nationalism: Driven by a desire to "take back" our country.
• Nativism: Spurred by strong anti-immigration feelings and rejection of a multicultural polity.

But the differences are also striking, especially when it comes to the issue of trade which commanded so much attention during both the Brexit campaign and the American presidential nomination debates. In reading the "Leave" campaign's statement on trade policy, you will not find:

• The rejection of trade deals for "killing jobs" with special blame placed on developing countries (aka China) for inflicting a mortal wound on manufacturing prowess;
• The promise to impose punitive tariffs on major trading partners even at the risk of initiating a trade war;
• The call for a boycott of firms that relocate part of their production overseas.

Brexit then is not an endorsement of the Trump brand of predatory protectionism.

Instead, what the Leave campaign offered on trade policy are heaps of wishful thinking and hidden truths. It sought to downplay the importance of the EU market to U.K. producers in order to justify setting its sights on other horizons. It promised to open up trade opportunities and job growth by negotiating trade deals with emerging economies such as China and India. And it confidently stated that trade links with the EU could be restored through a U.K.-EU trade deal that would mirror what countries like Norway have done. But this optimistic prognosis left out a lot. For starters, a future U.K.-EU free trade agreement will most likely yield pared-down benefits. Norway gained access to the single market by agreeing to free movement of labor that Brexiters vehemently reject. Moreover, the U.K. cannot chart its own course on trade policy until its separation from the EU is complete. Restructuring U.K.'s trading relations will take years and the results are hard to predict. But the costs of uncertainty are immediate as companies and investors will recalibrate their strategies without waiting for a protracted process of trade negotiations.

Brexiters struck a xenophobic note, but did not produce an overtly protectionist manifesto. Yet, their success at the ballot did deliver a major blow to economic internationalism. Trumpism is both xenophobic and protectionist, and were it to prevail in the November election, its negative impact on globalization will be vastly more profound. But the die has not been cast, and there are sound reasons to doubt a Trump victory.

If we are to prevail in overcoming the politics of grievance, we must first reckon that populism did not materialize from thin air. It is based on a fact: As globalization intensified during the past two decades, the middle classes in the industrialized world experienced stagnant incomes. The inward push is enabled by the manipulation of this fact: Offering trade as an easy scapegoat for a vastly more complex set of factors producing economic disparities (such as technological change and political decisions on taxation, education, and safety nets). And this populism is based on a false promise—that "taking control," i.e., taking our countries out of the existing trading regime will make those left behind better off. Its one unmistakable deliverable will be to make all of us worse off.

In her February 25 Brookings report, Dr. Dale Farran questions the scientific case for endorsing widespread policy in preschool education. Indeed, she argues that enthusiasm for public preschool and its promise is “premature.” Her argument is founded on three points—that the data on impact is mixed, that we do not have scientific direction with respect to the key quality constructs, and that our measurement of these constructs lack empirical validity. There is a grain of truth in each of these statements. Yet, a closer look reveals that when the data are focused on high quality preschools, the weight of the evidence for effectiveness is compelling. The early childhood science is at least evidence informed on the skill sets that will promote later school and life success and valid measures exist for many of the important outcomes. While there is always more to be learned, the bulk of the scientific community contends that high quality preschool programs will play a role in preparing young children for success in school and beyond.

There is no doubt that the literature looking for relationships between preschool access and school readiness outcomes in literacy, mathematics, and other domains are mixed.  Both the Head Start Impact Study and recent findings from Farran’s own Tennessee pre-k study (Lipsey et al., 2015) indicate that preschool of less than high quality produce only modest short-term gains. 

The data do not look bleak, however, when we look across preschool outcomes in the aggregate. And when high quality programs are investigated, whether in well-controlled studies of intensive models (e.g., Perry and Abecedarian) or in studies of strong public programs in Boston (Weiland & Yoshikawa, 2013), Cincinnati (Karoly & Auger, 2016), New Jersey (Barnett et al., 2013), North Carolina (Peisner-Feinberg et al., 2015), and Tulsa (Hill et al., 2015), the results are downright promising  (Yoshikawa et al., 2013; Minervino. 2014). Society reaps benefits from fostering early skill development, as children participating in high quality preschool programs had lower rates of grade retention, less need for special education, decreased antisocial behavior, and greater productivity as adults (Reynolds & Temple, 2015; Cunha & Heckman, 2006). In 2014, over 1,200 scientists who work in the area of early education signed the ECE Consensus Letter for Researchers, attesting to the mountains of data in support of the role of preschool education in improving child outcomes in social development, language, pre-literacy, and mathematics.

Though Farran’s brief reviews only data from the United States, a growing literature suggests that preschool education has long and lasting and causal effects on outcomes around the globe (Atinc & Gustafsson-Wright, 2013). For example, an impact evaluation of a preschool program in Mozambique found that the program increased on-time enrollment into primary school among beneficiaries by 22 percent relative to the children in the control group. Enrolled children also experienced a 6 percent increase in fine motor development, and an 87 percent increase in cognitive development. More importantly, this is not just a story of “everything is bleak in the developing world so the program is bound to have an impact.”

With compelling data in the United States and across the globe, one might ask why there is such a great divide between Farran’s interpretation and that of the wider academic community? One reason appears to be that Farran discounts any data that did not emerge from random assignment longitudinal studies. While correlational studies are not the gold standard, they are informative. Surely practitioners and policymakers would not dismiss data on parenting practices because children were not randomly assigned to parents. Further, in the area of preschool education, there is no difference in findings between randomized trials and other methodologies with respect to targeted cognitive, achievement-related outcomes when other study and program features are taken into account (Duncan & Magnuson, 2013; Camilli et al., 2010). 

Farran also discounts many of the randomized trials because she says they do not tell us enough about cause and effect. She writes of the famous Abecedarian and Perry Preschool studies:

The primary difficulty with this approach as a basis for designing interventions is that there is no way to identify what specifically changed about children’s abilities that enabled them to perform better in school or to link those changes to any particular set of active ingredients in the treatment. Neither Perry nor Abecedarian explicitly describes beyond the broadest level the “treatment” that brought about their positive effects.

But the children did improve, and at some level—while it would be wonderful to isolate the exact recipe for preschool success—we need not deny children the benefits of preschool while scientists probe for the precise combinations of active ingredients that yield the best results. Consider an analogy: the impact of storybook reading on children. While numerous studies document that reading storybooks with children in a joint way improves vocabulary and early literacy, we have yet to isolate the exact causal factors that matter in book reading. Perhaps it is the cuddling that occurs between child and parent; perhaps this crucial unstudied variable is the key that has not yet been turned. But no one would argue that we should stop book reading as a way to foster young children’s interest in reading. So it is with preschool. A quality preschool can heighten young children’s desire to attend school and prepare them for learning—even if all the ingredients in the magic sauce have not yet been identified.

In short, the evidence does provide models of high quality preschool that effectively prepare children for entrée into school and that change a child’s trajectory toward success. Not knowing the exact mechanisms by which preschool exerts its impact is secondary to the fact that poor children need good preschools now and we know how to provide them.

Farran raises the very important point that a narrow focus on only reading and math outcomes would be misplaced in our quest to build high quality preschool curricula. We could not agree more. She goes on to write, however, that “premature as well is the presumption that solid research exists to guide the content and structure of pre-K programs.”

Here we beg to differ. There are thousands of studies that speak to the skill sets children need to achieve success in the changing world. Reading and math are among these skills—collectively bundled under what Golinkoff and Hirsh-Pasek (2016) call “content skills.” But there is overwhelming evidence that children need to master skills that move beyond just reading and math. Content knowledge has, at its base, language and executive function skills. Language is the medium of instruction and executive function skills empower children with the ability to control their impulses and attend. Flexibility and working memory (Galinsky, 2010; Blair, 2016), also part of executive function, enable children to shift gears and remember what they have been told. But even language and executive function are not enough. Children must be prepared to participate alongside others (collaboration), to question when they are unclear (critical thinking) (Kuhn, 1999), and to have the persistence needed to stick with difficult problems—grit (Duckworth et al., 2007). These skills have been tested, are predictive of later achievement, have been shown to be malleable and to relate to academic, social, and learning outcomes in school.

Farran argues that we cannot provide high quality preschool because we lack strong measures of quality. Again, there is some truth in her assertion, but it seems to us somewhat confused. Farran mixes together policy benchmarks, measures of classroom practice, and child outcome measures. All are useful, but for different purposes. The first is meant to set a floor across many domains including health and safety. The second is designed for providing feedback on classroom practice. The last allows us to assess children’s wellbeing and progress. Well-designed continuous improvement systems for pre-K have detailed standards for learning and teaching that align with assessments of classroom practice and systems operation as well as with child assessments. Together with program standards these can provide a clear vision of high quality. They set high expectations for children’s learning and development and for pedagogy. Our ability to specify all of this exceeds our ability to measure it with reasonable investments of time and money. Nevertheless, classroom observation measures and child assessments as elements of a continuous improvement system help inform teachers and administrators about where they are and what steps they need to take next (Hall et al., 2012; Sylva et al., 2006; Williford et al., 2013). None of us would argue that this is easy, or that any single measure of classroom quality or child development is sufficient. Providing guidance for the improvement of learning and teaching is hard work and domain specific, but it is not futile.

Farran closes her report by suggesting that “[the] proposition that expanding pre-K will improve later achievement for children from low-income families is premature.” Perhaps instead it is Farran’s prognosis that is overly pessimistic. Research to date indicates that sustained access to high quality preschool does alter the trajectory of low-income children who are otherwise not exposed to early math and to age-appropriate books. In several now classic studies, the effects of a quality preschool education has far reaching consequences linked to not only reading and math, but to fewer incarcerations, teen pregnancies, and higher employment well into adulthood. As economists have shown, high quality early learning programs save money for society—a finding that has been replicated in different programs across the globe—in the United States, Canada, the U.K., and Mozambique.

Do we need to know more about what constitutes high quality and how to harness this reliably? Absolutely. But science offers evidence-based and evidence-informed advice on what has worked and what should work when brought to scale. We have an obligation to use the best science to serve our struggling children. Recent surveys indicate that a majority of the American public—Republican and Democrat—agrees that all children deserve a chance to reach their fullest potential. Let the science progress and let us use what we know at this point in time to meet the promise that all children should have a fighting chance to succeed. Better to light a candle than curse the darkness.

Editor's Note: A new academic study by David Rothschild and Justin Wolfers concludes that poll questions about expectations—which ask people whom they think will win—have historically been better guides to the outcome of presidential elections than traditional questions about people’s preferences. David Leonhardt of The New York Times conducted an interview with Wolfers by e-mail, focusing on the implications of the study for current presidential polls.

David Leonhardt:In the article, I discussed only briefly the expectations polls about the 2012 race, and some of the Twitter feedback was eager for more. By my count, there have been five recent major polls asking people whom they expect to win — by ABC/Washington Post, Gallup, Politico/George Washington University, New York Times/CBS News, and the University of Connecticut. There is also sixth from Rand asking people the percentage chances they place on each candidate winning. How consistent are the polls?

Justin Wolfers: There’s a striking consistency in how people are responding to these polls. The most recent data are from the Gallup poll conducted Oct. 27-28, and they found 54 percent of adults expect Obama to win, versus 34 percent for Romney. Around the same time (Oct. 25-28), there was a comparable New York Times/CBS poll in which 51 percent of likely voters expect Obama to win, versus 34 percent for Romney.

But these results aren’t just stable across pollsters, they’ve also been quite stable over the past few weeks, even as the race appeared to tighten for a while. Politico and George Washington University ran a poll of likely voters on Oct. 22-25, finding 54 percent expect Obama to win, versus 36 percent for Romney. The University of Connecticut/Hartford Courant poll of likely voters got a somewhat higher share not venturing an answer, with 47 percent expecting Obama to win versus 33 percent for Romney. Finally, the ABC/Washington Post poll of registered voters run Oct. 10-13 found 56 percent expect Obama to win, compared to 35 percent for Romney.

I’m rather surprised by the similarities here – across time, across pollsters, across how they word the question, and across different survey populations (likely voters, registered voters, or adults) – but I suspect that is part of the nature of the question. You just don’t see the noise here that you see in the barrage of polls of voter intentions, which are extremely sensitive to all of these factors.

I always throw out the folks who don’t have an opinion, and count the proportions as a share of only those who have an opinion. By this measure, the proportion who expect Obama to win is: 61 percent (Gallup), 60 percent (The New York Times), 60 percent (Politico), 59 percent (Hartford Courant), 62 percent (ABC). The corresponding proportions who expect Romney to win are: 39 percent, 40 percent, 40 percent, 41 percent and 38 percent. Taking an average across all these polls: 60.3 percent expect Obama to win. Or if you prefer that I focus only on the freshest two polls, 60.7 percent expect him to win.

DL: The results do seem have tightened somewhat since the first debate, which Romney was widely seen to have won, right? Do the patterns — or lack of patterns — in the numbers help solve the issue of what most people are thinking of when they answer the expectation question: Private information (their friends’ voting plans, yard signs in their neighborhood, etc.) or public information (media coverage, speeches, etc.)?

JW: The results of the polls of voter intentions seem to have tightened a bit since the first debate. There’s an interesting school of thought in political science that basically says: voters are pretty predictable. But they don’t think too hard about how they’re going to vote until right before the election. So what happens is that public opinion through time just converges to where it “should” be. And viewed through this lens, the first debate was just an opportunity for people who really should always have been in Romney’s camp to figure out that they’re in Romney’s camp.

So why did the expectations polls move less sharply than intentions polls? One possibility is that your expectations are explicitly forward-looking, and perhaps people saw the race tightening as they saw that some of the support for Obama was a bit soft. Let me put this another way: There are two problems with how we usually ask folks how they plan to vote. First, the question captures the state of public opinion today, while the expectations question effectively asks you where you think public opinion is going. And second, polls typically demand a yes or no answer, when the reality may be that we know that our support is pretty weak, and it may change, or we aren’t even sure whether we’ll turn up to the polls. The virtue of asking about expectations is that you can think about each of your friends, and think not just about who they’re supporting today, but also whether they may change their minds in the future.

I worry that it sounds a bit like I haven’t answered your question, but that’s because I don’t have a super-sharp answer. If I had to summarize, it would be: expectations questions allow you to think about how the dynamics of the race may change, and so they are less sensitive to that change when it happens.

DL: Based on your research and the current polls, what does the expectations question suggest is the most likely outcome on Tuesday?

JW: If a majority expects Obama to win, then right there, it says that I’m forecasting an Obama victory.

But by how much? Here’s where it gets tricky. The fact that 60 percent of people think that Obama is going to win doesn’t mean that he’s going to win 60 percent of the votes. And it doesn’t mean that he’s a 60 percent chance to win. Rather, it simply says that given the information they have, 60 percent of people believe that Obama is going to win. Can we use this to say anything about his likely winning margin?

Yes. I’ll spare you the details of the calculation, but it says that if 60.3 percent of people expect Obama to beat Romney, then we can forecast that he’ll win about 52.5 percent of the two-party vote. That would be a solid win, though not as impressive as his seven-point win in 2008.

The proportion who expect Obama to win right now looks awfully similar to the proportion who expected George W. Bush to win in a Gallup Poll at a similar point in 2004. Ultimately Bush won 51.2 percent of the two-party vote.

Right now, Nate Silver is predicting that Obama will win 50.5 percent of the popular vote, and Romney 48.6 percent. As a share of the two-party vote, this says he’s forecasting Obama to win 51 percent of the vote. Now Silver’s approach aggregates responses from hundreds of thousands of survey respondents, while I have far fewer, so his estimate still deserves a lot of respect. I don’t want to overstate the confidence with which I’m stating my forecast. So let me put it this way: My approach says that it’s likely that Obama will outperform the forecasts of poll-based analysts like Silver.

DL: We’ll find out soon enough. Thanks.

The headlines seem pretty good. Unemployment fell a tick to 7.3 percent. And jobs growth continued, with payrolls expanding by 169,000 in August, which is just shy of the 175,000 new jobs that analysts were expecting.

But beneath the headline: blech!

The most important news was the revisions to what we had previously thought was a healthy and perhaps self-sustaining recovery. Instead, jobs growth in July was revised from 162,000, to a weak 104,000, and June was also revised downward. Taken together, this month's revisions means we've created 74,000 fewer jobs than previously believed. And the previous jobs report subtracted another 26,000 jobs through revisions. Moreover, for reasons that remain a mystery, revisions have tended to be pro-cyclical, meaning that the healthy recovery we thought we were having might have been expected to yield further upward revisions. All this means that analysts are hastily revising their views.

The other bad news comes from the household survey, where employment fell 115,000, leading the employment-to-population ratio to decline by 0.1 percentage points. So the decline in the unemployment rate isn't due to folks getting jobs; instead, it's due to people dropping out of the labor force.

I have two simple metrics I use to measure the "underlying" pace of jobs growth. The first puts 80% weight on the (more accurate) payrolls survey, and 20% weight on the noisier household survey. That measure suggests employment grew by only 112,000 in August. The alternative is to focus on the 3-month average of payrolls growth, which suggests we're creating slightly around 148,000 jobs per month.

Bottom line: This report says that we're barely creating enough jobs to keep the unemployment rate falling from its current high levels. Policymakers have been looking for a signal that the recovery has become self-sustaining. This report doesn't provide it. And until we're confident that the recovery will keep rolling on, we should delay either any monetary tightening, further fiscal cuts, and definitely postpone the legislative shenanigans that Congress is threatening.

Event Information

Forty years after its initial publication, Equality and Efficiency: The Big Tradeoff remains an influential work from one of the most important macroeconomists over the last century, Arthur M. Okun (1928-1980). Okun’s theory on market economies reminds readers of an engaging dual theme: the market needs a place, and the market needs to be kept in its place. Articulated in a way that remains relevant even during today’s discussions on broadening gaps in income inequality, Okun emphasized that institutions in a capitalist democracy prod us to get ahead of our neighbors economically after telling us to stay in line socially.

On May 4, The Brookings Institution Press re-released Okun’s classic work with a new foreword from Former Treasury Secretary Lawrence H. Summers, in addition to “Further Thoughts on Equality and Efficiency,” a paper published by Okun in 1977. The event included opening remarks from Brookings Senior Fellow George Perry, with a keynote address from Larry Summers. Following these remarks, David Wessel moderated a panel discussion with former Chair of the Council of Economic Advisers Greg Mankiw, Economic Studies’ Melissa Kearney and Justin Wolfers, and Washington Center for Equitable Growth's Heather Boushey regarding the history and impact of Okun’s work.

Download a copy of Lawrence Summers' opening remarks.

Ted Gayer, Vice President and Director of Economic Studies and Joseph Pechman Senior Fellow, reads Lawrence Summers's opening remarks.

David Wessel (right), Director of the Hutchins Center on Fiscal and Monetary Policy, moderates a panel discussion with N. Gregory Mankiw, Melissa Kearney, and Heather Boushey.

Janet Yellen, Chair of the Board of Governors of the Federal Reserve System, listens to the discussion from the audience. To Yellen's right is former Congressional Budget Office director, Doug Elmendorf.

Video

• 40 years later- The relevance of Okun’s "Equality and Efficiency: The Big Tradeoff"

Audio

• 40 years later- The relevance of Okun’s "Equality and Efficiency: The Big Tradeoff"

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20150504_okun_equality_efficiency_transcript
• 050415 Summers Okun Speech

Event Information

Education systems in many of the world's poorest countries are now experiencing the aftershock of the global economic downturn and millions of children are still missing out on their right to a quality education. After a decade of advances, progress toward the Education for All goals may stall or be thrown into reverse. Presenting a new estimate of the global cost of reaching the goals by 2015, the report challenges governments and the international community to act urgently to adopt targeted policies and practices to prevent a generation of children from being left without a proper education.

On January 20, the Center for Universal Education at Brookings hosted the launch of UNESCO’s 2010 Education for All Global Monitoring Report (GMR) with Kevin Watkins, director of the GMR. The report introduces a new, innovative tool to identify the "education-poor" who are excluded from accessing a quality education. A panel discussion followed featuring Elizabeth King of the World Bank; Barbara Reynolds of UNICEF; and Brookings Fellow Rebecca Winthrop. Brookings Senior Fellow Jacques van der Gaag moderated the discussion.

Audio

• Reaching the Marginalized: Is a Quality Education Possible for All?

Transcript

• Transcript (.pdf)

Event Materials

• 20100120_education_access
• 20100120_education_access_watkins

ABSTRACT

The AIDS pandemic in sub-Saharan Africa puts increasing pressure on the buffer capacity of low- and middle-income households without access to health insurance. This paper examines the relationship between health shocks, insurance status and health-seeking behaviour. It also investigates the possible mitigating effects of insurance on income loss and out-of-pocket health expenditure. The study uses a unique dataset based on a random sample of 1769 households and 7343 individuals living in the Greater Windhoek area in Namibia. The survey includes medical testing for HIV infection which allows for the explicit analysis of HIV-related health shocks. We find that the economic consequences of health shocks can be severe for uninsured households even in a country with a relatively well-developed public health care system such as Namibia. The uninsured resort to a variety of coping strategies to deal with the high medical expenses and reductions in income, such as selling assets, taking up credit or receiving financial support from relatives and friends. As HIV-infected individuals increasingly develop AIDS, this will put substantial pressure on the public health care system as well as social support networks. Evidence suggests that private insurance, currently unaffordable to the poor, protects households from the most severe consequences of health shocks.

Read the full article on Oxford Journals »