The mining boom: will residents of mineral rich countries benefit?

BY GERRY BLOOM, RESEARCH FELLOW, IDS

As part of my ongoing work investigating health markets and the role of non-state actors in provision of health services, I am involved in a project concerning the role of mining companies in supporting the provision of health services to their employees and the wider community in mineral rich countries. This provided me with the opportunity to participate in the Mining Indaba 2012 in Cape Town in early February. This is an annual event for managers of mining companies, financiers, officials of multi-lateral organisations and Ministers from many African countries. The meeting was an eye-opener.

I had not been sufficiently aware of the magnitude of the present boom in the demand for minerals, which seems to be associated with rapid economic growth in many low- and middle-income countries and the enormous investments being made in the infrastructure of many large cities.

I was impressed by the size of investments being made in a number of African countries. Several new finds will provide large revenue streams for many years. There was a lot of discussion of ‘resource nationalism’, stimulated by high mineral prices. There was a view that companies need to earn their ‘licence to operate’ over the many years needed to recoup the large investment in a new mine. This was seen to involve much more than ‘traditional’ investments in corporate social responsibility.

Mamphela Ramphele, who chairs the Board of Gold Fields, presented a vision of a partnership between large corporations, community social investment organisations and national and local governments aimed at solving major problems with the provision of education, delivery of health services and the development of communities where mines are located. She called on large mining companies to play a leadership role in helping governments address these problems, suggesting that they operate on a time frame longer than the usual political cycle.

The unspoken alternative, of course, was the possibility that calls to nationalise mines could gain political support and that mining companies from countries where demand for minerals is growing rapidly might be potential partners for joint ventures with governments.

The take home message from the Indaba is that we are in the midst of a major mining boom. If mining companies, governments and civil society organisations can create effective partnerships for development, many people living in mineral rich countries will benefit a great deal. Otherwise, we may be witnessing another turn in a boom and bust cycle that enriches few and leaves many more in poverty.

[EDITOR'S NOTE: This blog originally appeared on the IDS Globalisation and Development blog. See also the IDS Globalisation Team’s Business and Development seminar series. Three of the five seminars under last autumn’s theme ‘Conflicting Interests: How Businesses Operate in Areas of Conflict’ focused on mining.]

Health dragons or health hydras? The challenges of regulation in Asian health systems

Dr Asha George of JHSPH discusses rural medical practitioners in India at HSRA

BY BARUN KANJILAL, IIHMR

Like most aspects of life in Asia, health systems have undergone massive changes in the last twenty years. And if we’ve seen some economic dragons, we’ve also seen some health dragons – with several countries posting impressive gains in health outcomes. For example, official figures indicate China has already achieved MDG 4 by reducing infant mortality rates from over 50 per 1000 live births in 1991 to under 14 in 2009, while under-five mortality has also dropped from 61 per 1000 live births in 1991 to just over 17 in 2009.

But ‘health dragons’ doesn’t quite capture the full picture. For the most part these changes have not been happening as a result of a controlled change process. Rather, they’ve been emerging from the diverse, unguided responses of some of the most populous countries in the world. This means they look more like another mythical creature: the many-headed hydra. 

This was made very apparent at this year’s Health System Reform in Asia conference held from 10-12 December at Hong Kong University. Organised by Elsevier and their journal, Social Science and Medicine (be on the lookout for a special issue from the conference out in 2012), the conference brought together some of the biggest names in health systems in Asia. The organisers of the 2^nd Global Symposium on Health System Research, which will be held in November 2012 in Beijing, had a strong presence, for example.

As I presented at the conference, the story of the Indian health system is a good example of the health hydra. Following significant economic reforms in the 1990s, the private sector soon outstripped the public in terms of health service provision – not only in hard-to-reach rural areas, but even in major urban hubs. Utilisation of in-patient care by private providers, for instance, jumped from less than 40% in the late 80s to more than 60% in the last decade. And outpatient care has even higher private sector penetration at roughly 77% across the country. 

Of course, when I say the ‘private sector’ the majority of those providers, especially in the outpatient care market, have little to no formal medical training. My colleague at JHSPH, Dr Asha George, presented a more detailed discussion of who these informal ‘rural medical providers’ are and why they play such an important role in the Indian health system. And indeed, the Future Health Systems consortium has a substantial body of work on the role of informal providers not just in Bangladesh and India, but also in Nigeria.

Our recent study of health care service provision in the Sundarbans of West Bengal paints an even messier picture. In addition to the publicly funded health clinics and hospitals and the raft of informal providers, the area is also serviced by an array of both local and international NGOs. Coupled with rapid advances in health technologies and pharmaceuticals – not to mention a fragile environment susceptible to frequent climate shocks, like Cyclone Aila which devastated the area in 2009 – it’s easy to understand how the system became so complex. 

But this poses a significant challenge: how can we improve these systems, with all their perverse incentives, to better serve the poor? In other words, how can we better regulate these health markets?

One phrase that kept popping up throughout the conference was the idea of ‘command and control’ – that through strong government intervention we could make significant and intentional changes in the way these health systems worked. But there was an even larger group who suggested that, when working in complex adaptive systems, ‘command and control’ is inefficient. There are simply too many interconnections that we cannot understand, which lead to a variety of unintended consequences when we intervene in these systems. 

Finding a model that works somewhere between ‘command and control’ and utter chaos was one of the challenges my colleague at IDS, Dr Gerry Bloom, put forward to the conference.

This led to a lot of discussion about ‘poly-centric governance models’, where the challenge of regulation doesn’t lie simply in the hands of the government. Rather, the argument goes, we must be working on all fronts: institutionalising professional bodies and standards to promote self-regulation in the private sector; establishing patient support groups – like the diabetes-related peer group MoPoTsyo in Cambodia – and improving their access to health information; and recognising non-traditional actors as part of the health system.

We tend to overlook the role that non-traditional actors, like social change entrepreneurs, the media and advertisers play in health markets. However, Dr Sachiko Ozawa’s presentation on trust in injections in Cambodia underscores this point. The average Cambodian receives six injections per year, usually because they think injections are more efficacious than other forms of treatment (e.g. oral tablets). This is such a firmly held belief that often patients will seek care outside of the formal sector (who usually deny inappropriate injections) to get what they want. Although her research didn’t delve too deeply into why there was such misplaced trust in injections, it might be at least in part due to substantial vaccination education campaigns from public health advocates. Working with media and advertisers will be an important part of improving knowledge here about appropriate use of injections.

They say that the best way to fight fire is with fire. Perhaps this ‘poly-centric governance structure’ is attempting just that – fighting hydra with hydra. I would expect to be hearing much more about what this model might look like in different Asian contexts in the near future.

CHMI highlights five emerging models for health service delivery and financing

BY ROSE REIS, CENTER FOR HEALTH MARKET INNOVATIONS

New approaches to improve health access and quality being pioneered by Future Health Systems

6000 Ugandan women die every year from preventable pregnancy and childbirth related complications. If women could only deliver under skilled care, about 80 percent of these deaths could be prevented. Enter Future Health System’s Safe Deliveries initiative: The program offers vouchers for transport and maternal services as well as training for health workers and provision of essential equipment, drugs and supplies. Its impact? The number of facility deliveries more than tripled during the pilot phase.

Vouchers are an example of a ‘health market innovation,’ a program that harnesses the private sector in low- and middle-income countries to deliver better health and financial protection for the poor. While many governments promise well-functioning, state-run public health systems, what often happens is much more chaotic and less centrally managed, with patients seeking care from a plethora of providers, including drug shops, village doctors, non-governmental organization (NGO) clinics, private hospitals, as well as government clinics.

Health market innovations help health systems improve quality, access, affordability and efficiency in transactions between patients and providers, promoting better health with less financial risk, especially for the poorest and most vulnerable. In 2010, the Center for Health Market Innovations (CHMI) was launched to serve as a global information source on these programs and policies—implemented by governments, NGOs, social entrepreneurs or private companies—that have the potential to improve the way health markets operate. 

With eight partners based in 16 countries, CHMI has identified more than 1000 programs in 108 countries—including several programs FHS studies.  These programs work to: 

• Better organize fragmented providers
• Mobilize funds and create financing mechanisms to provide purchasing power to the poor
• Set quality standards and monitor provider performance
• Educate consumers and providers to ensure that appropriate care is both demanded and provided
• Enhance quality and efficiency through standardized operational processes and innovative information technologies

In its 2011 Annual Highlights Report, CHMI identified five innovative emerging models that show promise, and may ultimately improve the performance of health markets in low- and middle-income countries.

1. Low-cost, high-quality retail pharmacies

Small family-owned drug shops line the streets of cities and villages across low- and middle-income countries. Unfortunately the quality of their offerings is equally all over the map, with many shops offering counterfeit drugs that don’t work and can be toxic. Professionalized pharmacy chains and franchise networks proliferating in Asia may improve drug quality and operational efficiency to keep prices low. In the Philippines, Botika ng Bayan and Generics Pharmacy are two popular franchise networks that have seen success. Similarly, in India, the pharmacy chain MedPlus originated in tech-hub Hyderabad and has since spread nationally.

2. Affordable Primary Care Clinic Chains

These chains—often for-profit—are set up to standardize quality and give low-income people more care options. Many chains operate in urban areas where large volumes can help them keep prices down. Inspired by the U.S. drug store chain CVS and its Minute Clinics, Saúde 10 opened in 2011 in Rio de Janeiro, Brazil. In Nairobi, LiveWell's main clinic provides consultation, diagnosis, and treatment for a wide range of illnesses, while qualified clinical officers and registered nurses run satellite clinics. 

3. Vouchers

Vouchers—distributed for free as with FHS’s Safe Deliveries project in Uganda, or sold for a small fee, as with Kenya’s Output Based Aid Voucher Program—increase access to key health services by allowing low-income people to “purchase” (through demand-side donor or government subsidies) a specific package of services from approved clinics which often include both public and private facilities. Private maternity clinics have been able to expand their services and extend their customer base to poorer clients as a result.

4. Telemedicine

In many countries doctors and specialists cluster in urban areas leaving rural areas underserved. Telemedicine shows promise in bridging the rural-urban health divide. In one example of how this model works, World Health Partners is a promising not-for-profit chain using technology that allows doctors in urban areas to monitor vital signs, diagnose illnesses, and recommend treatment for patients in India’s rural north.

5. Health Hotlines

Health hotlines provide basic health information and connections to available health services. HealthLine — run by Dhaka’s Telemedicine Reference Center, an FHS partner — connects providers and patients in Bangladesh through a mobile phone based hotline number (789) to a call center manned by licensed physicians that provide medical consultations 24/7. MeraDoctor is a for-profit health line just launched in Mumbai. Popular throughout South Asia, these well-utilized businesses may soon be replicated in East Africa.

These models offer promising solutions to key health system challenges, but the question remains: do they really work in the long term? What programs are actually improving quality, affordability, and access? We look forward to working with Future Health Systems and other partners to collect and share better evidence, and then promote the scale-up and replication of high-impact programs. 

M4P Hub Conference proceedings series: Making informal health providers work better for the poor

EDITORS NOTE: This blog is a repost from the M4P Hub Conference news.

BY DR GERALD BLOOM, INSTITUTE OF DEVELOPMENT STUDIES

My presentation at the M4P Hub Conference reflects work by several members of the Future Health Systems Consortium on the implications of the rapid spread of markets for health-related goods and services.  These markets are complex with a variety of sellers of health related goods in terms of ownership, mission, reputation and relationship to the regulatory system. Poor people frequently use providers in unorganised markets. Studies in Nigeria and Bangladesh found that more than half of people seeking treatment for malaria in the former used a patent medicine vendor and sixty-five percent of people who visited a health provider in a rural district in the latter went to an informal village doctor. In both cases there were serious problems with safety, effectiveness and cost. The behaviour of informal providers of drugs and health services is influenced by their source of knowledge (formal training, informal apprenticeships, advertising, marketing by drug wholesalers and so forth), financial incentives (including profits from selling drugs and commissions from drug wholesalers) and strategies to build and maintain their reputation. In both countries, interventions sought to convince informal providers to pay more attention to the quality of drugs and appropriateness of prescriptions through training and the involvement of trade associations and local government leaders in measures to monitor their performance and build their reputation. Governments and other stakeholders need to find effective ways to engage with pervasive health markets to protect the interests of the poor.

 

The following lessons should be taken into account:

• Interventions should be based on an analysis of the market system including the drug distribution network and the growing role of knowledge intermediaries, such as mobile telephone companies.
• Effective interventions are likely to involve partnerships between organisations with different agendas and different capacities.
• ustainable interventions need to include realistic business models for informal providers and for other intervention partners.
• Politics and interests strongly influence outcomes when going to scale and effective strategic leadership is needed.

Dr Bloom describes the response at the conference: “There was a lot of discussion about whether the special characteristics of the health sector mean that the M4P approach is not applicable to it. We discussed how unregulated markets for health-related goods and services can expose individuals to risk from dangerous or ineffective treatment and also lead to the emergence of diseases that are resistant to the available drugs. We also discussed the many ways that health markets are similar to markets in other sectors. We agreed that the design and implementation of interventions to improve the performance of health markets needs to combine expertise in health and health systems with expertise in engaging with markets. There was some discussion of the difficulties in combining these approaches. However, there was general agreement on both the magnitude of the health problems in many low income countries and the degree to which health markets have spread in them. We concluded that it is time for serious work to develop practical approaches for improving the performance of health markets in meeting the needs of the poor”.

Complexity, complexity, complexity

BY PROFESSOR DAVID H PETERS, JHSPH

‘Simplicity, simplicity, simplicity!’ The mantra may have worked for Henry David Thoreau as he sat around Walden pond, but there’s a growing recognition within the health systems, development and humanitarian relief communities that ‘complexity, complexity, complexity’ is more appropriate these days. Complexity science isn’t new, but applying it in these fields is relatively recent. My new paper with Ligia Paina, ‘Understanding pathways for scaling up health services through the lens of complex adaptive systems’, begins to unpack the implications for health systems if we take a complex adaptive system (CAS) lens to understand initiatives and scale up health services.

And while this blog looks at how a CAS approach can help us design and deliver better programs, Ben Ramalingam (a visiting fellow at the Institute of Development Studies and an expert on complexity science) and I have also recently sat down with Jeff Knezovich from FHS to produce a podcast looking at the issue in more depth. You can listen to the podcast below.

FHS Podcast 1: Complexity, complexity, complexity by Futurehealthsys on Mixcloud

Complex adaptive systems are described as such because, in addition to being comprised of many interacting components and agents, they have the capability to self-organize, adapt or learn from experience – what are sometimes known as emergent properties. Most social, biological and economic systems can be considered CAS, as well as many complex physical systems, such as those related to weather. The interactions of system components are non-linear, and are not easily controlled or predictable in detail.

Whereas scientific enquiry attempts to simplify understanding and create simple and elegant solutions, the CAS approach is important, as often our simpler models just aren’t good predictors of behavior. X doesn’t necessarily lead to Y, and indeed it might not even lead to one specific point. This can be a big problem when planning interventions.

Keeping a few CAS concepts in mind while framing projects and programs can certainly help improve them. In the paper, we look at several of these concepts and how they can be applied to health systems. In particular we look at: emergent behavior, path dependency, feedback loops, scale-free networks, and phase transitions. I encourage you to read the paper or see my presentation for more information about these concepts.

Focusing on ‘emergent behavior’, the first phase of FHS has shown us why this is important. The ‘Safe Deliveries’ intervention, which was led by the FHS Uganda team at Makerere University, worked both on the demand-side and supply-side to improve access to institutional deliveries in rural areas of Eastern Uganda. On the supply side, it led trainings for health workers and provided essential equipment, drugs and supplies. On the demand side, the program organized a significant voucher scheme for both maternal and newborn services (including antenatal screenings, delivery and newborn care) and for transport to clinics via boda boda (motorcycle taxis), as transport to facilities was a big factor preventing institutional deliveries. 

One of the interesting – if unexpected – things to happen, was that the boda boda drivers actually organised themselves in such a way that they started to keep track of and encourage pregnant women to go for care. Obviously there was a built in financial incentive, but this level of ‘enforcement’ had not been planned for – it emerged from the complex system. More importantly, it ended up playing a significant part in tripling the average monthly number of births in facilities.

All of these phenomena have an implication for what it means to create change. What a CAS approach tells us is that, when designing and delivering programs, we need to:

• Plan differently: Don’t expect to control change. Expect complexity. Expect emergent behavior (and feedback loops, and all those concepts I mentioned above) and expect the unexpected. This means looking beyond where a typical research program might be shining its light. In a complex adaptive system, a specific intervention is likely to cause shifts in other parts of the system, whether it’s through displacement or new actors or something else. In order to keep an understanding of what is happening in other parts of the system, this may also mean involving a wide number of stakeholders in both the planning process and the implementation phase.
• Plan to re-plan: We need to avoid too much of an emphasis on the first planning cycle and get away from blueprints. Detailed planning almost never works, and if it does, it probably didn’t need to be planned for in the first place. Allow for course correction by creating mechanisms that allow ‘learning by doing’. One approach to this might be to create more iterative, rapid learning cycles. This might include changing an intervention or, in research, changing what is being measured.
• Use mixed-methods research approaches: Having multiple perspectives and multiple methods helps to better identify changes in a system. Working with complexity is a data rich process. Having good access to information, and from multiple sources, makes it easier to make relevant decisions. Don’t just ask whether or not something works, look at how and look at why – both of which might be important for scaling up the interventions.

These are principles that we’re trying to embed into the next phase of the Future Health Systems project. Already we’ve had a training workshop with our FHS China team in Beijing to orient them to the approach and to help them make sure their research design incorporates some of these ideas. 

If you’re interested in finding out more about our growing body of work on complex adaptive systems, visit our theme page for more resources.