Month: October 2014

The high cost of talking down to policy practitioners

Poor understanding of how markets work is a big stumbling block in developing country health policy making. I have seen the stumbling block in action, and concluded that it is an urgent priority to provide accessible knowledge resources and learning opportunities in this area. There are few good resources and fewer learning opportunities for policy practitioners working in, and on, developing countries.

So, I was delighted when I discovered USAID’s Healthy Markets for Global Health: A Market Shaping Primer. The Primer aims to provide developing country policy practitioners with some essential, practical knowledge about markets and forming policies to influence markets. I stayed up way past my bedtime pouring over it. And….I got a headache. The authors decided to use a unique definition of a market. They implicitly defined a market as: the set of actors making decisions related to production, distribution, and delivery of “global health products”. Now, whatever this “thing” is, it is decidedly not a market. There are different ways of saying it, but a market consists of the interaction between all the buyers seeking something and all the sellers from whom they may get it. The Primer team opted for their simpler alternative, presumably, to make the Primer’s content more accessible to practitioners.

A brief aside: I believe the quality of health policy in developing countries is undermined, considerably, by what I think of as “the wall”. “The wall” is my shorthand for the observably low interaction between the developing country health policy and ops research community and the developed country health policy and ops research community. Let’s leave aside, for the moment, the size of “the wall” and its foundations. I believe most of us believe that more interaction between these two worlds or “tribes” is better; we need more interaction, more communication, and, more engagement across these tribal boundaries. I believe both tribes would benefit. Given the paucity of content on the topic of markets in the health sector in the developing country literature, in this domain, more communication would especially benefit the developing country policy practitioner tribe.

And, you know what doesn’t help? Making up, and disseminating, special definitions for core concepts, like, oh…say…markets.

Perhaps you think using different words for core concepts, and different concepts for oft-used words, is but a minor offense.

Having sat through many, long, frustrating, discussions on public-private partnerships in the health sector, I must disagree. In my experience, when members of the developing country policy practitioner tribe try to engage in, and learn about, these issues, their ability to do so is greatly diminished when the vast majority of the existing knowledge is made inaccessible, or even impenetrable, because of “translation” problems. Check out this ppt – my small contribution to a Rosetta Stone for PPP discussions across tribal boundaries.

My point is this: teaching developing country policy practitioners about markets is a worthy aim. Making the content accessible is important. However, teaching practitioners a unique-in-the-world definition for market is a bad call. All the learners reached will hence forth find the vast body of knowledge on the topic of markets even less accessible and useful than if they knew nothing at all.

Perhaps the primer-makers believe they have re-packaged (“translated”) all the knowledge about markets the target learners will ever need; in which case, increasing the height of “the wall” between them and the rest of the world does no harm.  If so, I disagree.

What do you think?

Why are promising strategies to engage the private sector unappealing?

I have been working with policymakers on private sector engagement in the health sector for seventeen years. So very often, policymakers opt for unpromising strategies to engage the private sector, frequently those which hold some promise of mobilizing large volumes of private investment. NB: such strategies are not always unpromising, but they frequently are in developing countries’ health system context. I have long wondered, and worried, about this. I believe I have untangled at least one thread of the mystery, it appears to derive from the perspectives and mental models of the key government stakeholders. Let me explain.

Governments’ efforts to engage the private sector commonly involve three distinct cadres and perspectives: budget professionals; political authorities; and, health professionals. See this excellent paper by Joe White which outlines the distinct perspectives and mental models of the cadres of officials involved in health policy.


Budget professionals are attracted to engagement by the idea of getting more resources for health activities. Health budget officials see engagement as a way of containing public expenditure on health, reducing deficits, etc. Occasionally, these officials are attracted to services contracting, even without the prospect of reduced public expenditure, because they think it may offer a better “handle” to monitor the health sector, push for performance improvement, and control costs.

Political authorities’ are always conscious of the next election, and, hence, they prioritize delivering some observable health service improvements, ideally in the very short term. Their thinking about how to do so is often grounded in political beliefs or ideology. Where engagement is eagerly sought, political authorities often express a vague belief that markets and/private ownership will increase efficiency, productivity, responsiveness and/ or quality.

Political authorities and budget professionals with these perspectives are often key figures in countries’ efforts to engage the private sector in health. They are most often located in ministries of finance, treasury, and/ or economy. They are rarely familiar with health systems/ health policy issues in general, nor specifically, evidence about approaches to private sector engagement.

Health professionals are the cadre with the deepest knowledge of health policy and strongest influence on day-to-day operation and delivery. They are rarely knowledgeable about, nor do they have a positive view of, private sector engagement. They may be attracted by the idea of increasing resources for their sector (e.g. accelerating acquisition of medical equipment; or upgrading facilities), though they would generally prefer to obtain more public resources for this. Health agencies are usually staffed by such professionals. Their knowledge of the sector is essential to identifying sensible approaches to engagement; and, implementation depends greatly on their actions.

This all-too-common alignment of expertise, responsibility and mental models is what drives governments to pursue appealing, rather than promising, private sector engagement strategies.

Focusing on private resource mobilization encourages pursuit of engagement modalities that expand private payment, which can undermine equity. NB: An exception is: when social insurance reimbursement rates cover capital costs, and payment is predictable enough to attract private investment.


Focusing on quick encourages choosing poor strategies and implementing them poorly. There is too little time to do situation analysis, consult with private actors, and slow-to-unfold strategies will be dismissed even if they are brought up.

The lack of buy-in and pro-active engagement of health professionals with their deeper health system knowledge decreases the likelihood that good strategies are selected. Good strategies are those which: fit the health system context; and, are associated with accelerated progress toward the health goals of: access, responsiveness, and/or efficiency.

Illustrative examples of good strategies include: Tanzania’s development of a commercial ITN delivery platform; Bangladesh’s development of a commercial ORS delivery platform; Tanzania’s accreditation of drugshops; Estonia’s primary care contracting; Nicaragua’s rural primary care contracting; China’s fortification of salt; Brazil’s hospital operation contracting (PPP); Colombia’s shift to wide use of generic drugs, China’s consolidation of distribution within the commercial drug delivery platform; Colombia’s construction of a social health insurance system. NB: I would argue the distribution of subsidized ACTs through the commercial supply chain and drugshops is another example. All these initiatives expanded access to essential products or services. In some cases, they also increased efficiency, and, in some cases, responsiveness. And, they did so with no deterioration in equity. Some even increased equity (Brazil hospital contracts/PPPs, Colombia’s generic promotion and social health insurance construction, Tanzania drugshop accreditation). Thoughtful engagement initiatives, aiming to improve access, efficiency, quality and/or responsiveness, would naturally turn to such strategies.
Engagement initiatives driven by political authorities and budget officials, with their common preferences and mental models, rarely find such strategies appealing, however. They may simply now know about them. Or, they seem too slow to “show results”, and, they hold little prospect of relieving health budgets of any spending responsibilities.

Services contracting is a strategy which constitutes an occasional exception. The strategy’s implementation time horizon can be relatively short (1-3 years), and results can be relatively easy to see. The strategy mobilizes little private investment, and hence does not hold the prospect of reduced demand for public spending; however, budget professionals can find contracting appealing – because they expect it will give them a tighter handle on health activities than existing budgeting mechanisms.

It strikes me that the preferences and mental models of the key cadres involved in health policy discussions on private sector engagement contributes to the relative infrequency of pursuit of promising, relative to appealing, engagement strategies. I think it comes down to this: the people who are “driving” the policy “car” have a bad map, and are likely heading for the wrong town; the people (e.g. health professionals) who have a better map, and know which town they should be heading for, are asleep in the back seat.

Am I oversimplifying? Undoubtedly, and on a number of points. However, I believe there is some truth to this narrative. I’d love to hear what others think.

“Better Practice” Regulation Can Work: Lessons from Tanzania’s Accredited Drug Dispensing Outlets initiative.

“The quality of care in the private sector is unreliable. The regulatory framework needs to be strengthened.” How many times have you read that? Or, “the regulatory agency needs to do more to enforce the rules”? Do you recall any successes along these lines? No? Yeah, me neither. Until I learned about Tanzania’s Accredited Drug Dispensing Outlet (ADDO) initiative.

Drugshops constitute an important part of the primary care system in many developing countries. They provide a lot of care, especially in rural areas, especially to the poor. They provide care for a lot of illnesses which are especially important to children. They typically “practice” way beyond their skills. The quality is not reliable quality. However, they are not going away. Generally, little is done to address this cadre. Invariably, regulations exist that prohibit them from doing more than dispense a “safe” lists of medicines. They don’t comply. And if they did, diabetics who live in rural Ghana would have to travel 1,2, even 6 hours to get their insulin. Same for Nigeria, etc. Some donor-disease projects have sought to improve their practice in one area or another e.g. family planning, malaria. Education activities targeting drugs shops and their customers usually succeed in improving practice (Wafula Goodman 2011). But none have been done at a large scale, and since the better practice often requires drugshops to lose income, sustainability is questionable.

Then comes the ADDO initiative. ADDO initiative demonstrated that with a “better practice” approach to regulation it is possible to reach the entire cadre of drug shops, to change their practice for the better, and to bring them in to play a considered role in a country’s primary care system. The ADDO experience showed that by using this approach to engaging private providers, it is possible to recover regulation as a social policy instrument.

Missing-in-action: regulation policy instrument. In most countries, drugshops daily practices go well beyond what regulation permits. And this gap is a big (big) problem. Why? Because it means that policymakers no longer have regulation as an instrument to influence behavior.  Let me explain.

Keep in mind, outside of police states, most citizens’ rule-compliance behavior is voluntary – it is not done in fear that doing otherwise may lead to being caught and punished. Buy-in to the rules is likewise a very important element of health practitioner and facilities compliance in all well-functioning health systems (Hort et al 2013). Practitioners’ associations’ involvement in developing the rules, and the responsibility that take in bringing along their members towards compliant behavior is an essential ingredient. And, with respect to drugshops in many developing countries, they are so many, and so widely geographically dispersed, virtually all compliance with rules will have to be achieved through practitioners’ voluntary decisions.

The large practice-vs-regulation gap in most countries tells us that the content of existing rules is not seen as legitimate. Neither the individuals nor their colleagues nor their association feels “it is the right thing to do” to follow all the provisions in the rules. They feel neither intrinsic nor social pressure to comply.  Hence, policymakers can pull on the regulation policy “lever” all they want, but nothing happens, because it is no longer attached to the practitioner cadre’s domain.

Tanzania’s ADDO initiative showed it is possible to recover regulation as a policy instrument. It’s not easy. But it’s doable. And it is doable – even for this hard-to-reach, but hugely important practitioner cadre.


 How did they do it? From discussions in a recent workshop on drugshops and pharmacies in developing countries hosted by PATH, my understanding of the process is:


1.      “Start where you are” principle. Professionals involved with ADDO emphasized how much time and effort they devoted to characterizing what was going on with the drugshops at the beginning. Who was using them? For what? What did drugshops do? Really? What medicines did they sell? With what advice? Where did they get their medicines? This is a core practice of the “whole systems approach” to improving service delivery, which emphasizes starting off with mapping existing provision capacity and utilization patterns to identify providers/ services which may otherwise be overlooked. See Stevenson 2001.

2.      Inclusive policy dialogue. They started and sustained dialogue between practitioner representatives, regulators and other key stakeholders.

3.      Negotiate to a middleground. They negotiated their way to a new scope of practice – in consultation and sustained interaction between practitioner representatives and technical experts and other politically important stakeholders (e.g. pharmacists) which constituted a better, safer scope of practice. The scope was more limited than their actual, current practices, but broader than the scope permitted in current regulations. Drugshop representatives thought their members could comply without undermining their ability to operate as sustainable businesses.

4.      Elaborate the policy element of the new arrangement. In Tanzania they settled on using an accreditation regulatory instrument. This is  a regulatory instrument where providers’ participation is voluntary, and participation is motivated at least partly by improvement in market position (e.g. more customers because accreditation “mark” is valued by would-be clients).

5.      Pilot – they tested the new parameters for the initiative (scope of practice, role of practitioner assn, other implementation issues).

6.      Review and adapt.  Officials reviewed the pilot implementation experience and results in consultation with drugshop representatives and other stakeholders; and, together, they agreed on adapted parameters based on those insights.

7.      Strategic communication. They made conscious efforts to get buy-in from key public officials (e.g. parliamentarians, regulatory agency officials).

8.      Scale- up. With all this in place, they moved to scale up and roll out the initiative.

Initiatives to improve services in developed countries virtually always exhibit these features; they “start where they are”, they adapt the strategy as they go. And, critically, policy formulation and implementation is inclusive of those providers whose behavior and activities are targeted. Such efforts are rarely inclusive in developing countries, especially where the relevant providers are private. Surender et al noted the glaring omission when they compared South Africa’s approach to reforming primary care to that taken in developed countries. The low influence of regulations and low impact of regulatory efforts in developing countries surely derives significantly from this non-consultative, exclusive approach to policy. My take on the ADDO initiative is that it is important because it illustrates that if health policymakers shift to “better practice” approaches to regulation, they can reestablish regulation as a functioning instrument to exercise stewardship. And, they can do so even for drugshops – which constitute a critically important but hard-to-engage part of many countries’ primary care systems.

Are there “hedgehog” researchers?




According to Tim Harford’s write-up, the Good Judgment Project finds the following makes people better forecasters: some basic training in probabilistic reasoning; working in teams; having an ‘actively open-minded’ thinking style. And, you can improve your performance by tracking it. Thought-provoking, eh? When I learned this, I immediately wondered: would not all four factors apply to people’s performance in observing, studying, analyzing and learning about things in general? What about social science researchers? We know there is room for all kinds of bias in social science research; couldn’t these insights be applied to improve social science research? Could they be applied to give us a ‘red flag’ for studies that might manifest more a researcher’s “hedgehogian’ world view than an open-minded look at the evidence?



I should come clean. I am especially interested in the implications of an ‘open minded thinking style’. Because, if this thinking style is associated with more trustworthy research, then I have discovered some foundation for one of my long-standing rules-of-thumb: disregard the work of social science researchers whose findings consistently confirm the superiority of reforms moving social systems in one direction. Yes. I call them ‘hedgehog’ researchers. Though…not to their face.



Let me explain what I mean by “directionality”. Most studies of social system reform strategies can be categorized according to a “direction of change” in which the intervention moves the social system. Common directions include: more role for citizens & communities; larger role for markets; larger role for government, etc. Directionality can be more fine-grained, however. Reforms can be characterized in terms of whether they move a system in the direction of a social system prototype (e.g. an “NHS” like health system; a Bismarckian social health insurance system).  Much health services research  assesses the soundness of reform strategies which move health systems ‘away from” or “closer to” one of these prototypes. Some researchers do many studies that  use the social system of their native land as the prototype-benchmark. I have encountered this often with respect to health systems researchers, and especially those from the UK. Delve into their analyses, and you find they are often assessing the soundness of reform strategies which move health systems ‘away from’ or ‘closer to’ the structure of their very own NHS.



If you categorize researchers’ studies in this way, many show no pattern of directionality. A few are…worryingly consistent. For one, every initiative to expand the role of market forces generates positive results. For another, every strategy that moves a health system to be more “NHS-like” is better than the alternative.



Once I started tracking this pattern, I intuitively stopped trusting these Researchers of Unusual Consistency (R.O.U.C.s). I now see this consistency as a sign that the researcher lacks an ‘actively open-minded thinking style’. And, since the Good Judgment Project findings suggest that this thinking style is protective against bias, I think others would do well to keep their eyes open for such patterns.