Dealing with (mis)alignment between public financial management & health finance


I’ve worked on health services reforms in more than 20 developing and transition countries. I’ve learned that the soundness of the interface between health finance arrangements and public financial management structures and processes is critical to the effectiveness of service delivery. Yet, health policy practitioners in these countries are rarely very knowledgeable about this topic; and, they tend to focus on finance mechanisms ‘further down’ (e.g. provider payment; or, how funds are managed within facilities). If the expertise gap is identified, more often than not, a general public financial management expert is brought in. This rarely helps though, as sound practices and principles for managing finances in the core of the public sector frequently conflict with managing finances for service delivery. And few public financial management experts are familiar with the institutional arrangements health agencies use to ‘govern’ finance. Both in the field, and in my teaching, I have longed for a high-quality, accessible resource on this topic. And Hurray! A top-notch team (Cheryl Cashin, Danielle Bloom, Susan Sparkes, Helene Barroy, Joe Kutzin, and Sheila O’Dougherty) at the WHO has developed one: “Aligning Public Financial Management and Health Financing: Sustaining Progress Toward Universal Health Coverage”. I heartily recommend it to any and all health policy practitioners and educators.

Disheartened by the protests

Given the continuous flow of bad news re the Trump administration and Congress, I understand why many of my friends were encouraged by the women’s marches. Me though…I am not feeling so encouraged.


Reading about the protests, I thought about the large numbers of Americans who voted for Trump and the Republicans in this past election. I wondered: how did the protests and related photos and media coverage look to them? Did the protests spark any reconsideration of their support? Doubtless many of these voters are die-hard Republican voters – and efforts to mobilize them, to persuade them to join the opposition will bear no fruit. But what about the more ‘marginal voters’? What about Peggy Sue in Iowa who voted for Trump with reservations? Or her cousin, Bobby Joe in Wisconsin who votes sometimes for Democrats and sometimes for Republican candidates, but went with the Republican candidates in this election?


There are many issues upon which Trump and co. should be opposed; yet the protests manifested a highly culture-focused opposition. Will this focus appeal to the many voters who weren’t sufficiently put off by the cultural elements of Trump’s campaign?  Think of the  many white women who heard Trumps disrespectful comments regarding women, yet still voted for him.


I realize that the opposition will not consist of protests only – and protests naturally tend toward cultural issues. But, I fear the protests signaled the likely focus and tone of their future efforts. And, it’s hard to imagine the Trump opposition will appeal very much to Peggy Sue or Bobby Joe unless they broaden their topical focus and dial down the shriller voices on issues like abortion.


Most Americans have mixed feelings regarding policies toward abortion; yet, the protests gave the impression that those who lead the opposition to Trump will tolerate no constraints on access to abortion. In fact, they won’t tolerate people who feel differently on this point. NB. March leaders blocked participation by pro-life women’s groups.  An opposition that appeals only to the relatively small proportion of Americans who hold these views on abortion-related policies is unlikely to persuade Peggy Sue or her cousin to cross over.


Our country’s social gains re racism, homophobia and the like are precious. Perhaps Americans are taking these gains too much for granted; we clearly need to be vigilant. Yet, I do worry that Peggy Sue and Bobby Joe may not be mobilized by an opposition movement that puts combatting racism (and other -isms) at the top of their agenda.


Please understand, this is not a statement of my positions, or preference orderings. I’m pondering the possible appeal of these positions to hypothetical people who live well outside the coastal-cultural-elite bubble in which I reside. I’d love to hear what others think – whether they dwell inside or outside the bubble 😉


The perils of microaggression containment efforts.

Jonathan Haidt wrote a brief commentary The Unwisest Idea on Campus on the Lilienfeld piece that I mentioned in my blog entry It is time for a moratorium…  In the piece Haidt recounts the biggest perils from efforts to diminish microaggression. He notes how the efforts undermine openness and students’ ability to challenge each other, their professors and orthodox ideas. He lays out two other effects which I feel are less widely appreciated: diminishing individuals’ and groups’ ability to appraise; and, exacerbating certain personality traits that undermine individuals’ mental well-being.

The noxious effect of moral certainty on appraisal. Referring to his 2006 book The Happiness Hypothesis (especially chapters 2 & 4 – link to chapter 4), Haidt reminds us how many of the great world thinkers pointed out the importance of appraisal:


The whole universe is change and life itself is but what you deem it. (Marcus Aurelius, 1964; Meditations , 4:3)


What we are today comes from our thoughts of yesterday, and our present thoughts build our life of tomorrow: our life is the creation of our mind. (Buddha, The Dhammapada, in Mascaro, 1973)


Haidt notes….the “ancients knew that we don’t react to the world as it is; we react to the world as we construct it in our own minds. They also knew that in the process of construction we are overly judgmental and outrageously hypocritical.” To construct a more accurate representation of the world, great thinkers over the ages have urged people to contain their moral certainty and to cultivate generosity of spirit:


Why do you see the speck in your neighbor’s eye, but do not notice the log in your own eye? . . . You hypocrite, first take the log out of your own eye, and then you will see clearly to take the speck out of your neighbor’s eye. (Matthew 7:3–5)


Microaggression containment initiatives encourage moral certainty and ungenerosity of spirit and undermine our capacity for appraisal. The training instructs in how to detect ever smaller specks in your neighbor’s eye. It tells students that “life itself is exactly what you think it is—you have a direct pipeline to reality, and the person who offended you does not, so go with your feelings.”

The harmful effects of individuals’ negative emotionality and self-perception as victims. Some students arrive on campus with personality traits of negative emotionality and a tendency to perceive themselves as victims. Haidt notes these traits are correlated with depression and anxiety disorders. And, “students who score high on these traits perceive more microaggressions in ambiguous circumstances.” In this way, these traits “bring misery and anger to the students themselves, and these negative emotions and the conflicts they engender are likely to radiate outward through the students’ social networks”.

Microaggression containment environment could exacerbate these problems. “How should colleges respond to the presence of students who score high on these traits? Should they offer them cognitive behavioral therapy or moral validation? Should they hand them a copy of The Dhammapada or a microaggression training manual?” Haidt suggests the latter is likely to “make the most fragile and anxious students quicker to take offense and more self-certain and self-righteous.”

The upshot. Growing numbers of students are learning “to react with pain and anger to ever-smaller specks that they learn to see in each other’s eyes.” This undermines the quality of discourse on campus. More than that, students are less likely to become good appraisers. And, students with strong negative emotionality and a tendency to perceive themselves as victims may become even more miserable than they otherwise would have been.

It is time for a moratorium on microaggression ‘containment’ initiatives.

The microaggression concept and initiatives to contain microaggressions have spread widely among college campuses and, increasingly, businesses. Given its roots in universities, you might think the concept is grounded in sound research. If you did though, you’d be wrong. Emory psychology professor Scott Lilienfeld reviewed the research, and lays out his findings in this article: Microaggressions: Strong Claims, Inadequate Evidence in the January 2017 issue of the journal Perspectives on Psychological Science.

Lilienfeld reviews the core premises of research on the microaggression concept, which are, “that microaggressions (1) are operationalized with sufficient clarity and consensus to afford rigorous scientific investigation; (2) are interpreted negatively by most or all minority group members; (3) reflect implicitly prejudicial and implicitly aggressive motives; (4) can be validly assessed using only respondents’ subjective reports; and (5) exert an adverse impact on recipients’ mental health.”

The literature, it turns out, provides “negligible support for all five suppositions.” Beyond that, the research on the microaggression concept is not connected to “key domains of psychological science, including psychometrics, social cognition, cognitive-behavioral therapy, behavior genetics, and personality, health, and industrial-organizational psychology.” While efforts to promote the microaggression concept have drawn the field’s attention to subtle forms of prejudice, Lilienfeld concludes “it is far too underdeveloped on the conceptual and methodological fronts to warrant real-world application.”

Lilienfeld lays out a research agenda to deepen our understanding of the microaggression concept and related ‘containment’ initiatives. Pending such research, he recommends abandoning the term “microaggression,” and calls for “a moratorium on microaggression training programs and publicly distributed microaggression lists.” I could not agree more.

Our prejudice problem

People are increasingly aware of the growing political polarization in the United States; for example, I hear many discussions about polarization among the political parties and the resulting problems created, for example, in Congress. I think, however, that relatively fewer people are aware of Americans’ prejudice at the individual level; I rarely hear concerns expressed about the negative attitudes Americans have towards people affiliated with the ‘other’ party. I have long been worried about this. And, people’s responses to the election have heightened my anxiety. I decided to educate myself on the topic and I want to share what I’ve found. The upshot, for my time- or attention-span challenged friends: when it comes to thinking about, or interacting with, people from the ‘other’ party, we Americans have a serious prejudice problem.

I read this 2015 paper by Iyengar and Westwood “Fear and Loathing Across Party Lines: New Evidence on Group Polarization” which Jonathan Haidt describes in his 2016 Edge World Question essay. The authors report four studies (using nationally representative samples) in which they gave Americans various ways to reveal cross-partisan prejudice; they apply the same methods to assess cross-racial prejudice – to have a benchmark for comparison. All studies found prejudice towards people affiliated with the ‘other’ party; and in all cases, prejudice was much greater than any linked to race.

First they used the Implicit Association Test. The test measured peoples’ implicit positive and negative associations – by measuring how quickly and easily people can pair words that are emotionally good versus bad with words and images associated with Republicans vs Democrats; and then, Blacks vs. Whites. Both Blacks and Whites manifest mild preferences (positive associations) for their own group. The effect sizes for cross-partisan implicit attitudes were much larger than cross-race. When Americans look at each other or try to listen to each other, they are slightly biased in favor of their own race, but relatively strongly biased against people from the “other side” politically.

Haidt describes the second study: where the authors “had participants read pairs of fabricated resumes of graduating high school seniors and select one to receive a scholarship. Race made a difference—Black and White participants generally preferred to award the scholarship to the student with the stereotypically Black name. But Party made an even bigger difference, and always in a tribal way: 80 percent of the time, partisans selected the candidate whose resume showed that they were on their side, and it made little difference whether their co-partisan had a higher or lower GPA than the cross-partisan candidate.” I note in passing that Democrat-affiliated respondents exhibited somewhat higher bias.

In the third study, the authors had respondents participate in two games (the Dictator game and the Trust game). Peoples’ gaming decisions reveal their generosity toward and trust of the other player. In both games, effects of racial similarity were negligible and not significant. Effects of party-affiliation similarity were considerable – with players consistently revealing partisan preferences; they trust same-party players more, they are more generous towards same-party players. Democrat- and Republican affiliated players manifested similar levels of bias, except in the Trust game, where Democrats revealed much lower trust of Republicans. That is, they allocate considerably more resources when the other player is a Democrat, trusting the other player to behave appropriately.

In the fourth study, they used the same game structure to distinguish favoritism towards those in one’s own party, from animosity towards those in the other party. They found that peoples’ animosity toward the other was considerably more consequential than favoritism toward same-group affiliated players.

How I Improved My Public Speaking…in a MOOC

The past year or so I’ve been working with folks at the University of Edinburgh to develop a course to deliver as a Massive Open Online Course (MOOC). I was sure the course would fill an important ‘learning opportunity’ gap for health policy practitioners, and I was very excited about the work. I was much (much) less excited about making videos of myself. I am probably a ‘fair to middling’ public speaker and I rely heavily on connecting with the listeners in the room….which, of course you don’t have when you are lecturing to a video camera. I was looking for an opportunity to improve my public speaking that could fit in to my way-too-busy life. Though I’m familiar with the MOOC format, I was looking for a ‘real world’ course. I didn’t think the MOOC format would work well for public speaking. As the video-making dates loomed ever closer, and I hadn’t found any face-to-face options, I decided to check out MOOC options at  Class-Central (a database of MOOCs from most providers). I found the University of Washington would shortly launch an Introduction to Public Speaking course on the edX platform. Like most MOOCs, there was a free enrollment option, so I took the plunge.

The structure and delivery of the content was very good; the instructor, Matt McGarrity is a public speaking guru, and, not surprisingly, his video lectures were engaging and accessible. What surprised me was how well the ‘homework” worked. The homework was to prepare and deliver various types of speeches (e.g. informative, impromptu), which course participants record and upload to youtube [set to private viewing]. Prof McGarrity provides a grading rubric, which you use to review others’ speeches and provide feedback. I found these exercises amazingly effective. Knowing someone (anyone!) will view your speech elicits a fairly high degree of effort; and, reviewing others’ speeches with the rubric is illuminating also. For me, the fact that I had to VIDEO record my homework speeches was a huge plus. I think anyone interested in improving their public speaking skills would, however, find it very useful. I notice that Prof McGarrity is offering the course on the Coursera platform now. Check it out!

Challenging conventional wisdom: in praise of Galileo and other iconoclasts

As neuroeconomist Greg Berns pointed out in his 2008 book, Iconoclasts, humans face many constraints on innovative thinking, including the urge to conform, the tendency to interpret sensory information in familiar ways, and of course, the fear of missing out on a promotion, or even losing a job. Over 20+ years working in health and development, I’ve come to realize just how powerful these constraints are. I’ve observed many development policy and health policy experts following the dictates of conventional or ‘organizational’ wisdom, even as they perceived, ever more clearly, its unsoundness. Reflecting carefully, I’d have to place myself among those who have often “gone along, to get along”. These reflections have increased my appreciation of iconoclasts, those too-rare individuals who question even the most cherished, or revered, beliefs. I am thus inspired to share a few tidbits about Galileo, perhaps the most famous iconoclast in human history.

A great scientist.     As most know, “Galileo made major discoveries about the motion of planets and stars, the motion of uniformly accelerated objects (i.e. that two objects would fall at the same rate regardless of their masses), sound frequency, and the basic principle of relativity, among other things—and major advancements in technology, including inventing or improving upon the telescope, microscope, thermometer, pendulum, and the compass. His work was central to most future developments in science, including those of Newton and Einstein, and most of what he discovered was in contradiction with conventional wisdom.” Summary by Tim Urban at

..and iconoclast.     What is most praise-worthy, in my view, is that Galileo did all this despite the threats and repression of the Catholic Church. Ultimately, Urban notes, in 1633, “the Church found him ‘vehemently suspect of heresy,’ and placed him under house arrest for the rest of his life.”

…and clever(?) public communicator.     Striving to get his not-acceptable-to-the-Church views understood more widely, Galileo wrote a book – Dialogue Concerning the Two Chief World Systems. It presents a series of discussions, among two philosophers and a layman, and is written in vernacular language. Salviati argues for, and explains, Galileo’s views; Sagredo is an intelligent layman who is initially neutral; and, Simplicio, presents the conventional wisdom about the structure of the universe. The 6:10 – 8:10 section of this episode of the Great Books TV series, gives a description of the book and a dramatic presentation of one of the exchanges. Despite the technical complexity of the topics, you can see, the dialogue is witty and engaging. Much of what Simplicio says were well known to be the views of the Pope (Urban VIII), indirectly insulting the Pope and contributing to Galileo’s later conviction and sentencing to house arrest. Nevertheless, the book, and all the trial-related publicity it received, doubtless helped draw attention to the problems with the conventional wisdom and persuade many to rethink their long held beliefs about how the universe is structured.

Dialogue Concerning Development Thinking? A few development policy and health/ development experts are working to challenge unsound, but deeply held, and operationally-entrenched, beliefs. Bill Easterly, Lant Pritchett, Michael Woolcock, and Matt Andrews come to mind. Reading bits of Galileo’s Dialogue, I couldn’t help but wonder whether something similar might be useful for challenging those beliefs.

What I’m listening to: “Conversations with Tyler” podcast

Many of you likely know Tyler Cowen through the Marginal Revolution blog he runs with Alex Tabarrok, or, perhaps his contributions to the New York Times Economic View column . Tyler recently began conducting interviews with a variety of people who are “making an impact on the world through their ideas” (e.g. Peter Thiel, Dani Rodrik, Jonathan Haidt, Luigi Zingales, Jeff Sachs). I find many of the interviews thought-provoking, and here is why: Tyler steers conversations down less-traveled paths thereby liberating his guests from recounting or rationalizing their position on topics for which they are known. He asks quirky, sometimes provocative, questions. For more reflective interviewees, this approach elicits responses which are far more interesting than what you’d encounter in their most recent “book talk”. The rich conversations with Dani Rodrik, Jonathan Haidt and Luigi Zingales vividly illustrate the virtues of this approach. Tyler’s off-piste interview style doesn’t work as well with less reflective guests. Jeff Sachs, for example, appears to have little of interest to say, beyond recounting and justifying his well-known positions. But hey, it’s a pod- and vid-cast, you can easily skip to the next episode.

You can subscribe to audio and/or video feeds of “Conversations with Tyler” through your favorite podcast manager or youtube.

Pakistan’s unusually useful education report card

Alif Ailaan just published a report ranking Pakistan’s districts according to how well they are performing in education. They collect information not only on performance but also policies and practices, and they do so annually. The data can be used to illuminate policies and practices which distinguish the education leaders from the laggards. Importantly, the “better” policies and practices are demonstrably relevant and feasible in the Pakistani context.  Other types of benchmarking and report cards (e.g. cross country, single point-in-time) very rarely yield such useful insights. I won’t elaborate here as to why this is so. If it’s not obvious, I suggest you google “complex systems” and “external validity”. I commend Alif Ailaan staff, and their funder, the UK Department for International Development, for this excellent work. I am perplexed as to why it is so rare in both health and education. HT to Harry Patrinos.

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?