Universal Health Coverage V

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

The Challenges of Health Coverage in High-Income Countries

We’ve been looking at the challenge of health in the very poorest parts of the world. I’m going to move all the way to the other end of the income spectrum, and look at the challenge of health in the upper income countries in the richest parts of the world. You’d say what is the challenge life expectancy is high and the healthcare system is technically very sophisticated.

And while in the poor countries we scramble and wrack our brains to figure out how to reach a level of $60 per person per year. In the high income countries, the spending is typically around $3,000 to $4,000 per person per year in the public budget and if one looks in the United States at public and private spending for help, it’s $8000 per person per year. What’s the problem? Well, the problem especially in the United States is $8,000 per person per year. The health system has become incredibly expensive. So expensive that it is a major burden on the economy.

A major burden on the budget. A major burden on poor people who are priced out of the health care market even in the rich countries. And especially among those rich countries in the United States, where we have high inequality of income and prices of health care completely out of sight. And, as we’ve seen earlier, a rather limited or tattered social safety net. So many people not covered by government programs. The puzzle I want to explore is a specific one to the United States. In one sense, why is the U.S. healthcare system so expensive? But it is a more general lesson about the role of the public and the private sector in healthcare provision. One of the reasons why the U.S. system is so expensive is that it is a privately oriented health delivery system. Well, something isn’t right about that from the point of view of the common insistence that the private sector is very efficient and the public sector is bureaucratized and very costly. In the United States, where health care is provided mostly by private sector providers, the costs are completely out of sight. And this is a purpose that I’d like to look into now to understand why that is because it teaches something more general. For health systems around the world, it helps us to understand what are the boundaries between public and private. And in general it helps us to overcome a presumption, among at least some people, that the free market is always the solution to one’s problems. Well, we don’t believe that at sustainable development because we see that the solutions to the challenges of sustainable development require the interaction and often the cooperation of government, business, civil, society and academia. But sometimes it’s argued naively. Let the markets do it and the problems will be solved. In the United States, while healthcare is by no means a free market commodity. It’s more market oriented than in just about any other high income country. And the results are peculiar, to say the least. Well, we should know right from the start that health isn’t exactly a normal market kind of commodity. For one reason, it’s a merit good. We want health to reach everybody. Once it’s a merit good, it’s quite different from a bot, a can of soda or a piece of furniture or a, a new kind of car. Those may be desirable goods to some people but they’re not merit goods in the sense that we would expect on a moral or ethical basis. Universal coverage of those commodities, they’re not a basic human right. So, we know that health starts out in a very specific situation, just as does education. We also know, therefore, that public provision of those services is important. If for no other reason than to help ensure that the poor, alongside the rich, are able to gain access to those merit goods. But the problem goes even deeper than that. Kenneth Arrow, the great Nobel Laureate economist, observed all the way back now fifty years ago indeed, that health could not really operate like a competitive market sector. Because there’s a fundamental problem. Patients do not know what’s best for them in general. There’s a huge asymmetry of information. And Kenneth Arrow noted that when there is such an asymmetry of information, it violates one of the basic assumptions of the free market economy. Or I should say the basic assumptions of why the free market economy works well, and that is full information of consumers as well as information of suppliers. What happens when only the suppliers have the information? You go in to your doctor, and your doctor says, you need such and such test. Generally, if you’re like me, say, you’ve got it, let’s go for it. Maybe you go online and you see a whole debate about this. But then you don’t know what to do. You ask for a second opinion or a third opinion. Somewhere you’re going to, most likely, listen to what the doctor says. In the United States, oddly enough, doctors own a lot of the imaging equipment for CAT scans or for x rays or for other equipment. They order a lot of tests. And there is inherently a problem. When there is a symmet, a symmetric information, a symmetry of information, and the supplier is the one that has the knowledge, and the consumer is the one that generally follows along. One can see that if the incentives are not done just right, one could get over use, over charging, over billing of consumers who are in the hands of their doctors. Moreover with health if you’re like me, you don’t want to play around and especially if somebody is very sick. You don’t start negotiating in the emergency room or in the in the coronary care unit. when, the doctor or the hospital says that something’s needed almost all of the time you say yes, please proceed. And this is at its core one of the fundamental barriers to simply organizing the health sector as a, a normal market activity. There are others health requires insurance because bad luck, a bad bout of disease it a person stricken with a a, a very costly ailment would not be able to pay out of pocket. So, people buy insurance in the United States or receive a public insurance in other countries. And with insurance markets there are many, many problems as well. One problem with insurance markets is if individuals know their health conditions but the insurance company doesn’t necessarily. Perhaps only the sick will register for insurance and if they’re asymptomatic they will sign on as needed. Healthy people won’t. The insurance companies will find that their burdens of disease are unexpectedly large. They’ll raise the fees. That will keep healthy people outside of the system. Only the sick or those who have the likelihood of becoming sick will be covered. And what can ensue is sometimes called an insurance stat spiral. Where a smaller and smaller, but sicker and sicker proportion of the population is faced with insurance. Prices soar for the insurance premia and the rest of the population opts out or simply rationed out of the market by the very high costs. Another aspect of the health system that I think is quite notable, is that it is a system. With a sick patient facing a complicated set of conditions, you want the generalists to be dealing with several specialists. You don’t want each specialist taking all the same tests again. Ih, you would like the doctors analyzing a case to be working in a systematic, cooperative way in which information is freely flowing throughout the system. Sometimes health care works like that. But very often it does not. If it’s not organized that way. If individual doctors have their individual practices. Then a private market economy can drive up the costs considerably. If the government reimburses private providers in particular ways that do not encourage the building of those systems it makes matters even worse. Well, now you’re looking at a graph where, that dotted black line at the top is the cost of spending in the United States per person. It’s soaring. Back in 1980 the average spending on health per person in the United States was about $1,000 per person. By the year 2009, $8,000 per person. And you can see, by far, the most expensive in the world. Norway, another rich country, comes next. But at a level much lower, say $5,500 per capita, roughly $2,500 per person less than in the United States. And in general, the rest of the countries are clustered around this lower level. Typical spending perhaps around $4,000 per person per year, outside of the U.S. half of the U.S. level. If you look at the next graph you see the spending now divided by national income because we’re looking at the share of health outlays as a percentage of income. And you can see that back in 1980 the United States was spending about 9% of its national income on health. By 2009, that had doubled to 18% of national income. Notice that back in 1980, all of the countries, including the U.S., were rather tightly clustered between 6 and 9% of national income. Since then, the U.S. has separated from the pack, becoming by far the most expensive health care system in the world. In general, health costs have been rising and health outlays as a share of national income have been increasing, but in other places not by anything close to the increase experienced in the United States. You can see that as of 2009, for most countries, the spending is on the order of about 10% of gross national product, not the 18% in the United States. Well, this is shown for the year 2011 in the next bar chart, again you see that the United States, all the way on the right, has the highest level of spending as a share of Gross Domestic Product. The next chart also, this set of columns by country, also for the year 2011, shows the United States as another kind of outlier. What this graph is showing is the proportion of the total spending. Say the U.S. $8,000 that comes from private spending, maybe the households buying health insurance, maybe the employer in the private sector paying for healthcare, maybe people paying out of pocket. As supposed to what government programs are funding. What you can see is that the private health outlays in the United States are a bit over half of the total spending. So a bit more than $4000 per person comes from private spending by the households, the employers and so forth. But in all of the rest of the high income countries this share of private spending is much less, or to put it the other way, the proportion of total health spending by government is much higher. In essence the U.S. runs a system that is partly public, partly private with an accent I would say on the private sector. Whereas most of the rest of the high income world runs essentially a public finance system, with a small private sector alongside. The U.S. is the only one that goes for a very big private sector and private spending, that accounts for more than half of the total. What’s the problem? The problem evidently is that the private sector in the U.S. in very high priced. And what essentially is at play is the observation that Kenneth Arrow made 50 years ago. This is not a very competitive sector. Price competition does not work very well. In fact, individual patients often have no idea of how the price they’re paying compares with the price paid by other patients. So much so, that hospitals themselves engage in what’s called price discrimination. Charging very different prices to different patients within the same hospital unit. Shocking actually, because there is no standard public price that applies for all. There is instead a very hard to understand negotiating process where the unwary U.S. health consumer spends a often far more than the hospital charges to other patients facing the very same kinds of treatments and with the very same kinds of conditions. The result is that hospitals get away with a lot. They are not competitive they price discriminate. The prices that they charge are indeed very very high and one can see this in a systematic comparison of U.S. costs with the cost in other high income countries. In the United States for example the if, if the U.S. cost of 30 commonly prescribed medicines is set at an index of one, then the cost in New Zealand is 0.34, one third of the U.S. cost. The cost in Australia 0.49, in other words one half of the U.S. costs of those medicines. In the Netherlands 0.45, in other words 45% or 45 cents on the dollar of what’s spent in the United States. If you look at the cost of a visit to a physician you can see that, while the cost of a physician paid for by a public sector program, $60 is comparable to what is paid for in other countries. The cost that’s paid for by a private payer out of pocket or a private insurance company is out of sight. It’s twice the amount paid for by the public payer. And it’s much more in general than paid for in most other countries. Well, condition after condition, intervention after intervention, the U.S. system is simply out of sight. If on average a hip replacement is for a private payer is $2,000 in the United States, it’s $4,000. And this high price is found in every aspect of the U.S. system. One can look at the spending for each patient discharged from a hospital, how much was spent on that patient? In the United States in 2009, it was $18,000 per hospital discharge. In France and Germany, less than a third of that all the way at the other end of this graph. In the average of the OECD that is the high income country group, one third of the discharge cost on average in the United States. U.S. doctors make far more than doctors do in other countries. Orthopedic physicians in the United States make $440,000 in 2008. In Germany, less than half of that $202,000. So we can see that, essentially, the U.S. system is remarkably expensive. Not because it’s delivering a, a huge range of things that other countries are not doing. Not because the outcomes are better, but because the unit cost of the interventions is simply out of sight. What are some of the causes of this? Well, you could say this is very specific to the U.S., though that’s an important economy, but I think that the lessons are more general. In the United States, some of the things keeping the high costs high are the limited supply of doctors, controlled by the American Medical Association itself, which works with the medical schools to determine the flow of new doctors. Market power, that is the lack of competition. A true price discrimination in the hospitals. A true highly concentrated ownership of major hositals in a region. By the conflict of interest of doctors who own their own diagnosticlaboratories and then prescribe heavily imaging for instance MRIs or CAT scans on equipment that they themselves own. We see drug pricing at levels far above what is priced in other countries often because of close tie ups between the doctors and the pharmaceutical companies. Enormously high administrative costs because in the U.S., in the private economy, each hospital perhaps, or each group of hospitals has its own insurance connectors. The systems of different kinds of payers, public and private don’t communicate very well with each other. Whereas in other countries, in many cases there’s one single payer the government, and the government may be at the provincial or the national level, pays all the health bills. And so the administrative costs of managing America’s more privately oriented system is very high. And now I’ll add one final huge dimension, political economy. The health sector in the United States is powerful. It is one of our four most powerful lobbies in the United States, just along side Wall Street, thefinancial markets number one, big oil number two health sector number three and the military industrial complex number four. Four giant, powerful lobbies in the United States that also helped to prevent remedial action on these issues. Now, one of the leading organizations in understanding the U.S. health system the Institute of Medicine of the U.S. National Academy of Sciences did a recent study. They found something extraordinary. That the waste, fraud and abuse in the system, the over billing the waste of resources the repeated tasks, the outright fraud, the high management costs amounted to 5% of U.S. national income. That’s astounding. 5% of of, of U.S. national income is with a $15 trillion annual economy nothing short of $750 billion dollars a year in waste. And when you put that into context, the U.S. is spending 18% of gross national product in health. And what the Institute of Medicine is suggesting is that maybe out of that 18%, it’s getting 13% of national income in real value. Well why does this system persist? Partly because of its history of having organized itself as having a private sector economy that is not effective and doesn’t obey the principles of free markets. But partly because of the power of the lobby. And if you look at total lobbying outlays according to various sectors, you find something quite astounding. Adding up all of the registered lobbying outlays between 1998 and 2012. While miscellaneous businesses abroad grab bag category comes number one in the list. Number two in the list is the health sector. More than $5 billion of lobbying by private health companies to Congress, telling congressmen and the President and others influenced by this, don’t regulate us, don’t force us to expose our price discrimination. Don’t regulate us as other countries do so that there’s one price that applies to all patients within a certain category. Don’t regulate the prices that pharmaceutical companies charge on their patent protected medicines and so forth. Don’t try to reduce administrative costs, those are our profits those are our earnings those are our employment, say the big health insurers. And they do this through mega-lobbying. They also do it through campaign financing, shown on the next page. It’s the fifth of the sectors from the top, in the amount of financing spent by the industry during the most recent campaign cycle, complete campaign cycle, of 2011 to 2012. The health sector contributed, and this is means people from health companies registered as they make campaign con, contributions, giving about 260 million dollars of campaign contributions. You can understand that this leads to some attentiveness of the politicians to the interest of this concentrated group, not necessarily to the interest of the taxpayers, or the citizens more generally. What are some of the reform options? Let me conclude with that. First, would be to move to a single payer system like Canada has. It’s not simply in the imagination it’s in the real world. And Canada’s health system is far lower cost than the United States, with very high quality. A second possibility is what’s called an All Payer system. Sure, money would come from private employers, from out of pocket, from private insurance but there would be one price paid, per condition or diagnostic category or per individual covered per year. Rather than price discrimination where the hospital or the health, private health provider tries to get as much as possible. And if the unwary consumer doesn’t realize it it fleeces the unwary consumer by imposing costs far higher and prices far higher than other patients are paying. A third possibility is even more transparency, a certain fee paid by government or by employers per patient per year, so it’s not on the basis of services rendered, not on the number of tests, not on the number of hospital visits. That, the provider would have to provide efficiently, and at low cost if they want to make a profit. And so, another possibility is what’s called capitation. That the insurance company or the government would provide one amount of money per year, rather than fee for service. Another aspect would be increased supply. To remove the ability of the American Medical Association to constrict narrowly the number of doctors and specialists that come online. And finally I would mention how technology can be the friend of lower costs. With information technology, smarter systems, patients monitoring their vital signs at home or telemetry where a patients information is automatically being read at a distance at low cost and the patient comes in for visits only when the indication is there. Or community health workers, as in the low income countries working in the high income countries to reach people in their communities, rather than waiting for mega disease costs in the hospitals themselves. Plenty of reform, plenty of way forward, partly changing the incentives, partly employing new technologies. Of course that kind of reform also depends on politics. If the lobbies get their way, you get inflated costs. If this is a system that is run for the public benefit, there is tremendous good that can be done to reach more people, improve health outcomes, and accomplish that, especially in the United States at considerably lower cost.

Lectures / Readings

Universal Health Coverage IV

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

The period of the millennium develop goals since the year 2000 has been an exciting one for public health. Because public health is really proved its worth showing how a science based approach starting with epidemiology. Building health systems supported by international help in the form of Official Development Assistance.

Malaria is a not only a lethal disease but it’s a disease that spreads very widely. And in many parts of Africa is what’s called holoendemic. Endemic meaning that people are infected. Holoendemic meaning that the whole community, everybody is infected and basically the whole year round. So to control malaria is really it’s a great feat. And malaria is being controlled right now in Sub-Saharan Africa. Thanks to the focused efforts of the Global Fund to Fight AIDS to be malaria or the U.S. initiative of PMI and others alongside it. And because of the great advances in public health and in technologies that make it possible. Long lasting insecticide treated bednets.

Community health workers who go into the communities, rather than waiting for sick people to carry their young. Often dying children many, many kilometers in their arms, hoping to arrive at a distant clinic in time. With the community health workers out in the communities, cases can be picked up much faster. Lives can be saved. A prick of the finger allows a community health worker to know within a few minutes whether that child is infected with malaria. And new medicines that replaced those fading, failing medicines like Chloroquine now based on Artemisinin. Very interesting story because Artemisinin is a molecule, extraordinarily effective in fighting malaria that was identified by Chinese scientists. How did they come to that? Because there was an ancient Chinese herbal treatment for malaria and for other fevers that came from a, a plant that the Chinese called (XXX) And that we know as Wormwood, or in its Latin, as Artemisia annua. And that was an ancient herbal remedy. But when the Chinese scientists went after it, the found out what is the active molecule and that we now call Artemisinin. When Artemisinin is put into medicinal form now, it’s enormously effective to control Malaria. And that’s one of the breakthroughs of recent years as well. If deaths of children under five have declined from 12 million back in 1990 to under 8 million in 2010, that’s a huge progress. But obviously, far from where we should be because most of those 8 million deaths are also preventable. We’ve gotten half way to building the primary health systems and we should take inspiration from that. And understand what it would mean finally to fulfill the commitments that was made already back at the founding of the United Nations and the World Health Organization. The commitment that was enunciated once again in Alma-Ata 1978. The commitments that was the motive spirit of the Millennium Development Goals of ensuring health for all and universal health coverage. Let me give ten basic recommendations of how we can move from the improved situation today. To the full breakthrough of universal health coverage and health for all within a short period of time, even within a decade. The first is a financial point. If we look at what the poor counties simply can’t afford on their own and need to be filled by official donor assistance. We can calculate how much aid should be directed at the health sector. Now mind you, I’m not talking about aid, year in, year out forever. I’m talking about an amount of aid that will shrink, as the poor countries develop, and reach a threshold, of income, where on their own, they can fund their own health systems. That threshold is reached probably somewhere around $1,200 per person per year, measured in current prices and market exchange rates. If you calculate the gap that the poor countries simply can’t manage out of their own budget, it’s around $40 billion a year Roughly $40 per person for a billion people that need that extra help. 40 billion how should we think about that is that a big number or a small number for the rich world. Well one way to think about it is that as we know there about a billion people in the rich world so it’s on the order of about $40 from each of us in the rich world, to save millions and millions of people in the poor countries. But $40 per person in the rich world is the bargain of the planet in terms of the lives that could be saved. Let me put in terms of the proportion of the rich world income. We know, that the average income of the rich countries is on the order of $40,000 per person per year. For the billion people in the rich world, it comes to about $40 trillion of income of the countries that give Official Development assistance. 40 billion out of 40 trillion is one out of a thousand, it’s one tenth of 1% of our income. Or to put it another way it would be like saying for every $100 in the rich world take a dime put it aside, next $100, take a dime put it aside. One tenth of 1% of the income, would accumulate into a total fund of $40 billion per year. So the starting point, number one, in the recommendation is a, annual flow of funds from the rich countries to the poorest. 40 billion a year right now. A number that would shrink over time. One tenth of 1% of high income world output each year. That would close the financing gap and enable millions of lives to be saved. Second recommendation. Put that money into highly effective organizations. My own recommendation would be to build the Global Fund to Fight AIDS, TB, and Malaria. Which has done such an outstanding job, into a Global Health Fund more generally and channel through it about $20 billion per year. So that the Global Health Fund could effectively support the basic health systems in the poorest countries. Letting those countries know that as they develop and lower disease will help them to develop. They will get less and less over time, because they will eventually graduate from the aide itself. Now third is that the low income country’s have to do their bit. They can’t fund their health systems just on their own. But they can make the valiant effort needed, they should contribute as much as feasible. And as I’ve mentioned, most fiscal experts that have looked at this regard 15% of the total budget as a stretch. But realistic and reasonable target for funding help. So the third recommendation is that the poor countries would be called upon to meet what became known as the Abuja Targets. Because of a meeting that took place in Abuja, Nigeria. The Abuja Target calls for the poor countries to devote 15% of their budget revenues to the health sector. The fourth recommendation is to finish up this job of comprehensive malaria control. Malaria is getting under control. You’d think I’m a little bit obsessed with it. And the fact in the matter is you’re right. Malaria is such a pernicious disease. Such a killer. Such a burden on development. ut so much within reach of control that we do need to put the focus on it. And we’re close to getting the job done, but still underfunded roughly by half. So my third recommendation, fourth recommendation is that the world should adopt a plan for comprehensive malaria control. That would cost roughly, $3 billion a year. Which enable the poor countries to finish up the supply chains, the funding of community health workers, the rapid diagnostic tests, the medicines and so forth to really get the job done. Fifth recommendation. The leading donor countries should fulfill their longstanding commitment to providing universal access to antiretroviral medicines for individuals infected with HIV. And having the clinical indications for antiretroviral treatment. These medicines work. The treatment to poor people saves their lives. It’s been shown to be highly effective. More treatment would mean lower transmission of the disease because when an individual is treated with antiretroviral medicines. The viral load, that is the concentration of the virus in the body diminishes sharply. Making it much less likely for the virus to be transmitted from one individual to another. Sixth recommendation. That the leading donor countries should also fulfill their commitment to partnership with the poor countries. In funding following the global plan to stop TB, to stop tuberculosis. This too has a financing gap on the order of $3 billion a year, roughly $3 per person per year in the high income world. Roughly, cup of coffee at your favorite coffee shop in a high income country would be what is needed incrementally in order to build the requisite fund. Recommendation seven. That the world, especially the donor countries and their financing and the poor countries and their implementation, should guarantee access to sexual and reproductive health services. This would include emergency obstetrical care for safe childbirth, antenatal care for safe pregnancy, and contraception. Because many, many women around the world want to have fewer children. They want to use modern contraceptives. But they lack access or they lack the funds to, be able to afford it on a market basis. And so we need full funding of family planning services, contraception and emergency obstetrical care. Pregnancy safe management. And, again, at a very low budget. These services could be made universal. Eighth, the Global Health Fund would take up what have sometimes been called neglected tropical diseases. The neglected tropical diseases are diseases less in the headlines than malaria. Less in the headline than AIDS. The experts in those disease communities feel a little bit neglected because they are saying wait a minute, we also have powerful tools to fight deeply debilitating diseases. And yet, we are sometimes overlooked because our diseases that we’re studying and trying to control are not in the headlines. And when I tell you the names you’ll say, you’re right, not in the headlines, never heard of them at least for some of them. But among these neglected tropical diseases are hookworm, that I presume most have heard. Ascaris which is a kind of worm infection. Trichuris another worm infection. Onchocerciasis, yet, another infection in the tropical areas that is absolutely a killer, but can be prevented and can be treated. Schistosomiasis, a disease in which a snail plays an important role in the life cycle of this disease. Filariasis, lymphatic filariasis, another vector borne tropical disease with, terrible consequences. Also controllable through bed nets. and, with, ample effort and organization, a disease whose burden could be reduced very, very sharply. And various forms and causes of blindness including trachoma, that is an infection of the eye that can cause blindness. And that can be prevented,ah, that is wide spread, a major cause of blindness. Also, we know, one could add though it’s not in the usual list of the neglected tropical diseases, is cataracts. Where advances in surgery allow for remarkably low cost replacements of the lens when individuals are blinded by cataracts. And this is another case where communities especially elder, older people can be brought back to sight. With the tremendous benefits of course for themselves in the community at very, very low cost. So category eight, expand the Global Fund’s reach to these neglected diseases. Category nine, the Global Fund should establish special financing to complete the health systems. Not only the targeted diseases, but the training and deployment for example, of community health workers. This would be a crucial part of the, transformation from a disease targeted fund to a general global fund that’s providing a broad base of services. We have called at the United Nations for the deployment of a 1 million community health workers in Africa by the year 2015 as a major boost for achieving the Millennium Development Goals. Malaria control, it’s essential to get the community health workers out into the communities with their rapid diagnostic test with their Artemisinin in their backpacks. With their mobile phones for, getting advice from the clinics or being able to call an ambulance. When the community health workers are out there, the malaria burden, plummets. And finally, recommendation ten, is that there are now, a number of noncommunicable diseases. Typically that have been overlooked in many of these urgent MDG related efforts that also can be part of the primary health system. Dental care for example, treating cavities, something very basic, but often not present in poor countries. Eye care, mental health counseling and mental health interventions for the massive burden of depression for example which is pervasive around the world. Many cardiovascular diseases where people have undiagnosed high blood pressure, hypertension that can cause loss of life for adults. But if treated, brought under control can absolutely have the consequences meliorated or the adverse consequences controlled all together. A number of cancers can be addressed at very low costs. And of course, campaigns against tobacco use are part of any good public health system because tobacco remains a massive killer. That’s a behavioral challenge but it’s a behavioral challenge that we need to meet because it’s one of the most effective ways to save lives. Moral of the story, we’re close. It’s not so hard, the Millennium Development Goals have given a big spur to effort, we can now see a pathway to help for all. In the next phase of the Global Development Objectives, the Sustainable Development Goals. I would expect that universal health coverage will feature prominently in the next phase of goals. And we will have the opportunity indeed to complete what we have started. To finally achieve to realize health as a basic human right.

Lectures / Readings

Universal Health Coverage III

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

Designing and Financing a Primary Health System in Low-Income Settings

We have a challenge, a heavy disease burden in poor settings. We know that poverty itself is a major contributor to this disease burden. We know that most of the causes of disease are preventable or treatable. The question is how to design a delivery system in health and in the related sectors at low enough costs that it’s possible to make great headway even in the midst of poverty.

Solving that problem has a huge, huge benefit. And not only would it tremendously improve health and we already see such improvements on the way, but it can break the poverty disease spiral and turn into a health development upward spiral. That’s our goal. The starting point for designing an appropriate health system is the science of public health. But what is public health? We know what medicine is. We think of doctors and nurses. They’re treating individual patients. Public health could be called population health. It is treating the health of a large population and partly of course through the work of doctors and nurses. But also through other tools that they don’t necessarily depend on doctors and nurses, through attention to safe drinking water, through attention to, The access of the community to anti-malaria bed nets through attention to widespread coverage of effective vaccines against the vaccine preventable diseases. So, public health looks at health from a population perspective. And scientifically addresses what should be done. The answer differs, differs by location, differs by income level because the answer in public health depends on the disease burden that needs to be addressed. I regard public health as being not not only highly effective, but quite systematic. And I would describe the public health approach this way. First, understand the Epidemiology of disease, that means understand the, nature of the diseased burden in a particular population. What is the DALY count? The disability adjusted life years. What is the prevalence of the disease that is it’s frequency in the population. What is the incidence of the disease? The number of new cases. In a given time period. Epidemiology measures the disease burden in a systematic way, and also focuses on the transmission mechanisms. Is the disease transmitted person to person, is the disease transmitted by in, intermediate vectors, so called, such as the anopheles mosquito Which bites one person infected with malaria and then later on bites another person, transferring the infection to that second person. In which case, the mosquito is serving as the vector of that disease so, the epidemiologists need to understand a lot about what kinds of diseases, who’s affected, how the diseases are transmitted. The second stage of good public health thinking is to examine the feasible and desirable interventions. What should be done? A lot of public health comes packaged, essentially, as apps. There’s an app for vaccines. There’s an app for distributing antimalaria bed nets. There’s an app for antenatal care. There’s an app for safe childbirth. Of course, that’s not the the, the way that the public health specialists might phrase it. They use the term interventions, but the, what they mean is systematic packages that address particular conditions. How to de-worm, how to control malaria, how to ensure safe childbirth, how to ensure neonatal survival how to get a new good nutritional outcome, how to face a diarrhoeal disease. How to break a cholera epidermic. These are the interventions. Based on the epidemiology, proceed to understand what are the interventions, both within the health sectors specifically and in the closely related sectors of nutrition, farming, safe water infrastructure and the like. Third is systems design. You have a list of interventions. Every child should get an immunization, every household should have bed nets, every mother should have anti-natal visits, every newborn should be visited by a health worker. Great. That’s a list. That’s a bunch of bullet points. How to deliver? That list effectively. Real implementation. That in essence is about systems design. Who should do that work? Who should give immunizations? Is that doctors? Is that nurses? Is that clinical officers? Is that community health workers? How should bed nets get distributed? Who guarantees the supply chain of medicines? Who reads the diagnostic tests? Who manages the work force? Who supervises the workers for their honesty, or for, their level of training and their competency This of course is the kind of challenge that a business faces in running an organization. Running a public health system is quite a complicated challenge. Building that system, often nearly from scratch in a very poor setting is extremely important because, comes to the question of training, recruitment, job designations and so forth. Now, part of that system, then, has to be translated into actual management and implementation. There are many things to do, especially when you’re starting in a very poor community and you’re building up a whole system, you have to invest, build an operating theater for emergency obstetrical care. And build an examination room, build a new clinic, build a new bore well for safe drinking water. You have to train a labor force, typically in a poor setting, a place where healthcare has been under invested for years, decades, or forever, there’s a tremendous amount of training to be done. Of course, there is community empowerment. The health system by it’s very core, involves the individuals in the community. They have to seek health care. They have to be. Connected with the health facilities. If they’re health workers, they have to trust the health workers into their homes, for example, or have the confidence to call the health workers. So community involvement and community empowerment is essential. Oversight, like in any business or any organization, How do you make sure the work is actually getting done, that the funds are being used properly and not being embezzled, that the disease burden is as it was thought, not some completely different and unexpected mode of disease transmission. And a good system has not only monitoring, but evaluation. Assessments, how are we doing? Why did mothers die last month in childbirth in this district? What went wrong? Were those deaths preventable? Is the doctor competent? Is the ambulance broken down? Is the power not actually available in the emergency room and so forth. So, this is the systems design that is absolutely crucial for practical success. Then comes financing. It’s not surprising that money looms large in this issue, we’re talking about poverty. We’re talking about places where the absence of money plays a pervasive role in the presence of disease burden. And the question is, even if a health system is designed that With high efficiency, very smart epidemiology, very cost effective interventions. Can a poor community afford this? If not, where can the incremental funds come can make this happen. Let me discuss just a few of these aspects, and, hope that some of you. Will go on to great careers in public health. I emphasize it again because I think it’s a such a wondrous profession that actually saves lives, delivers results, has the systematic and scientific approach that is so useful. Some of the interventions that are feasible based on the local epidemiology, include malaria, a disease that is a killer. It is a pathogen, a single-celled organism called plasmodium, which is transmitted from individual to individual. By a mosquito, that as I mentioned bites an infected individual, in a subsequent bite about two weeks later, infects a second individual unless there’s protection. What kind of protection? Well, it could be medicines that kill the pathogen in an infected individual and it could be a prevention of what’s called vector control because the mosquito is the disease vector. Vector control could be something like putting larvicide to kill the larvae of the mosquitoes before they hatch and can transmit the disease. Or it can be bed nets that block the mosquito from biting. Or, if the mosquito sits on one of these bed nets and takes up the insecticide, kills the mosquito before it can become ineffective and transmit the disease to somebody else. Vaccine preventable diseases, like measles, which otherwise claim huge numbers of lives. But we have many, many vaccines that are highly effective but often don’t reach the children in need. De-worming, as I’ve already mentioned, infections like hook worm. Which are very debilitating for children, rob children of nutrients create a loss of physical growth and many many other terrible health problems but are easily solved by very low cost de-worming medicines the problem is, the children aren’t getting them. Neonatal survival, a child is born, but doesn’t take a first breath. But it’s known there are simple interventions, that the pediatricians call helping babies breathe. Simple resuscitation techniques. That at almost no cost Could save huge numbers of new born’s lives. Famously oral re-hydration, when a child has a severe case of diarrhea and is losing water, and can, can die from the diarrhea itself, that child needs to be re-hydrated To have fluids reestablished, and the right kind of solutions can rehydrate the child and save lives. And this has been now known for many decades that even community health workers without medical degrees or nursing degrees can effectively Provide oral re-hydration and save children who would otherwise die. Antibiotics to fight respiratory infections. Many other kinds of preventions. A notable one that is a major global effort now is to prevent the transmission of an HIV virus from an infected mother to a newborn. Because it is the case that if a mother with HIV infection that may or may not yet be AIDS has a child, that child has a reasonable chance, maybe a, a third or half if no precaution is taken to contract HIV in childbirth or subsequently in breast milk during breastfeeding. And so there are now protocols to put the mother onto anti-retroviral medicines. Dramatically reducing the viral load of the HIV in the mother. And dramatically reducing the chance that the virus, thereby, is transmitted from the mother to the child in childbirth or breastfeeding. These are all examples of how a good epidemiology can be connected with a good set of interventions and the results can be very striking and hugely positive. Look at a picture, rather unpleasant but I think important for us to get a reality check. Of this very cute little girl with the kind of distended belly you would see in many villages in many parts of the world. Have a look at what came out of that belly. You see a, a horrifying plateful of worms that came out after the little girl was administered with the, the basic, very low-cost anti-worm infections. And as a result of her deworming, she and little children like her have a growth spurt afterwards, because those worms have been taking away her nutrients, her absolutely valuable nutrients necessary for her Brain development and her body development. They’d been taking them for, the worm’s growth, which is obviously the opposite of what we want. De-worming, therefore, allows a growth spurt, just like disease controls allows an economic spurt in countries that are otherwise burdened by massive disease burden. This set of interventions and others like them, properly identify through good epidemiology, can be administered at low cost in a highly effective very cost health system. In today’s dollars of say the year 2013. The cost of such a basic primary health system addressing the diseases, conditions that I just described, might reach no more than $60 per person in the community per year. A remarkably low cost to address all of those disease conditions. And you would say, 60 bucks per person per year to save all those lives and to reduce the disease. Why hasn’t it happened? And the irony is, and this is the really basic point, I sometimes call it the iron law of poverty. Even $60 is too much for a government in a very poor country. And this, I think, is the part that’s hard for us to appreciate because we assume and again, it makes sense intuitively, it’s just not correct, that if this kind of disease continues in poor communities, maybe the government’s not trying very hard. That’s not correct. Consider the following, a country, say, is at $400 per capital, not in purchasing power, but at current market exchanges rates. That’s the kind of pricing that I’m using for this $60 example. Now, a country at $400 per capital, a country like Malawi, might collect 20% of its national income in taxes. Probably wouldn’t be able to manage more than that because a lot of the income isn’t even monetary income, it’s just the production around the farm household itself. So, as a thought experiment, consider a country at $400 per capital. Whose tax collection is 20% of the national economy. 20% of $400 is 80 dollars per year. What that means is that the governments revenue out of its domestic revenue collection would be $80 per person per year in the country. What is that $80 per person have to go towards? Well, it has to run the government, the parliament, the courts, the president, the national defense, the police, the roads, the power, the infrastructure, water, sanitation. I, the it has to go for the schools, it has to go for construction for environmental conservation, and yes, part of it has to go for the public health system. But think of it, you have $80 in total You have to allocate it to all of those purposes, and experts that have looked at this repeatedly say that a country really focusing on health, but also on education, infrastructure, courts, decency, rule of law, might be able to stretch and devote 15% of the total budget. to the health sector what’s 15% of $80 per capital? Yikes. That’s just $12 per capital per year devoted to health. How much healthcare can you get for just $12 per capital? And keep in mind that in Europe and the United States, the public health budget is $3,000 per person per year. Or $4,000 per person, per year. The point is the following: for a poor country, even trying hard out of its own revenues, it can’t reach the $60 per person per year. On its own. This is why development assistance, ODA as we talked about it, Official Development Assistance, is so important for health. And now you can see the complexity of this challenge. On the one hand, we need good epidemiology to describe what should be done. Next, we need to identify effective interventions. Third, we need to identify the kind of system that can bring about those interventions. Fourth, we need to manage and implement such a system. And now, I’m saying, we have to pay for it, not a fortune, but an amount that is beyond the means of the poor country itself. The answer, in my view, is official development assistance Carefully, scientifically, professionally targeted towards improving the health of poor people. Helping them to build primary health systems. This is what I advocated when I chaired the commission on macroeconomics and health for the World Health Organization. And what I have championed for a dozen years as special adviser to UN Secretary General, Coffee Annan first, and now to UN Secretary General Ban Ki Moon, on how we can achieve the millenium development goals. We’ve taken the targets of reducing child mortality, maternal mortality, and the burdens of infectious diseases. To do the work, we now see scientifically how it can be done. We see, even, that the budget is very, very small, but too big for the poor countries. That’s why I am a strong believer in organizations like the global fund to fight AIDS, tuberculosis, and malaria, which I’ve participated in the design and launch, now a dozen years ago. We need extra funding to fight those three diseases. That’s why I’m a great fan of the global alliance for vaccines and immunization. GAVI, which provides extra financing for immunization coverage. That’s why I’ve been a great fan of the United States Pepfire program, the emergency program for Aids, and the USPMI Program the Presidents Malaria Initiative that has given extra income to Poor, malaria stricken countries to fight malaria. These kinds of targeted focus, official development aid programs have been hugely effective, very successful. Because you know how the money should be used. You can monitor it, you can watch it, you can assess it, you can evaluate it. And the results are very strong. And what’s heartening is the figure that you are looking at of the take off of official development assistance, especially bilateral assistance. That is from governments to other to low income country governments. Especially after the year 2000, because it is with the millennium development goals that these great breakthroughs are being achieved. Malaria is coming down, the AIDS urden is coming down, a treatment for tuberculosis is expanding. Under five mortality rates have come down considerably, maternal mortality rates have come down considerably. We’re seeing that public health works, but we’re not yet at the full system to deliver it in part because the budget gap remains significant even if it has declined. This has made a big difference, but there still is an important gap that needs to be closed so that we can truly achieve our long-standing and crucial objective of health for all.

Lectures / Readings

Universal Health Coverage II

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

Poverty and Disease

The problems of health that are problems for all societies. In the rich world where health conditions are far better than in the poor countries. The problems of very high and rising costs of health care are front and center on the political and the economic agenda. In the poorest countries the challenges of course are also about finances but much more importantly about the tragic loses of life and the very high burdens of disease. Often from conditions that have been eliminated completely in the high income world.

Poverty and ill health go together and we need to understand that linkage of poverty and ill health because understanding it enables us not only to. Address the challenges of heavy diseased burdens of pour countries but also gives us an added and important tool for breaking the poverty trap itself. We should expect two-way causation, that poverty Contributes to disease in many, many ways, but disease of course also contributes to poverty. An individual suffering from disease loses income. A community or country with a heavy disease burden similarly loses income from. Sickness in the population, lack of productivity, other burdens that arise in the economy when there is a large amount of unattended disease. How does disease contribute to poverty? Think about the, the following pathways. First through the adverse life cycle development of a, of an individual. If a young child survives illness but is buffeted by repeated illnesses when you. We now understand better that not only is that likely to set the child back in terns of readiness for school perhaps in terms of school enrollment or primary school completion. But that early bout of illness can have a lifetime effect on cognitive and physical development and on vulnerability even.

At adult ages to various kinds of diseases unexpected diseases. Cardiovascular disease can be affected by nutrition that is poor in early age. So human development across the life cycle. Is strongly affected by health and disease. Disease can have long term individual consequences. Disease burdens of adults in the labor force of course can have large and adverse results for an economy. Think about a village that has to harvest the crop. The crop may be the absolute lifeline for the village to enable it to eat throughout the coming year. But in many places, just at harvest time, there’s also the risk of a malaria epidemic. Malaria is a disease that is transmitted by the bite of a mosquito. The mosquitoes are breeding during the rainy season, the same time that the crops are growing. By the time it’s right to harvest the crops, it may be that the larvae have developed into mosquitoes now transmitting malaria infection. It’s not uncommon, therefore, that just when harvest time comes, the whole community is knocked out by malaria and can’t harvest the crops. Think of the consequences of that for poverty for devastation, for hunger, even for famine in the coming year. Of course, another economic consequence of ill health is the direct cost of health care itself, if a community can afford the health care. That eats up a budget, and it can be very, very expensive treating the diseases for very poor people. Even what would seem to be, modest outlays of a few dollars or a few tens of dollars, for a disease. Amounts that would hardly be noticed in the rich world can be the margin of survival for poor families that hardly have enough to eat to start with and may lose their last remaining monetary income to the effects of a disease.

A disease burden contributes indirectly and over the long term to demographic problems. Remember how high total fertility rates can impede economic development, when the population’s growing rapidly, and when the community is supporting a lot of young children, and looking after them. And having to put them through school, and build new schools for a growing youth population. Who are not themselves earning income at the time, the burden of rapid population growth and a very young age distribution, I, is a huge hindrance for economic development. We’ve noted already on several occasions that a rapid voluntary reduction of fertility can be a big boost as it was in China to economic growth. But consider what happens when there’s a heavy disease burden. When out of every 1000 children born, 100 or 200 or 300 don’t survive to adulthood. Parents knowing of the high risks of children’s deaths. Therefore respond by having large numbers of children and if the household wants to be absolutely sure that there is a surviving son. For instance, for cultural reasons to perform the funeral rights or for very pragmatic economic reasons to support the mother and the father in their old age. Families may choose to have two or three or four sons to make sure that at least one survives but having two or three or four sons might mean having four or six or eight children as a whole. And so this is another indirect way often overlooked at how high disease burden is conducive to a perpetuation of poverty. Finally, one should note, investors are not so keen on investing into a high malaria zone or into a high AIDS region. Think of it that you are aware that your labor force could be very sick, could be dying young. A need to replace many, many workers as a hotel manager you’re aware that you’re trying to get guests to your hotel but after every rainy season there’s a malaria epidemic. It doesn’t seem very attractive for investment. You’re a mine manager. But you’re surrounded by infectious diseases like malaria. Well, foreign investors don’t like to head to those locations. This is yet another way how disease leads to poverty. But the arrow goes the other way as well. And I think that’s the direction that people perhaps most naturally consider how poverty contributes to disease.The answer that trips off the tongue and comes to mind is can’t afford a doctor. And of course poverty does mean a much lower access or no access at all to medicine to modern doctors to basic health services, but there are many, many other ways that poverty contributes to a heavy disease burden.

One that I’ve mentioned already is the immuno-suppression that comes from chronic under-nutrition. Children who are not fed well, who lack basic micronutrients, have immune systems that are tuned down, that are not as effective, not as able to resist disease. Poverty also tends to mean a more dangerous physical environment. Poor families in rural areas typically don’t have reliable sources of safe drinking water or reliable clean sanitation. There’s open defecation it means that many diseases cycle through the body and are spread by open deification and the pathogen getting back into the ground water. And back into the wells and back into the water supply a diseases like cholera are spread in this manner. And so poor communities have poor infrastructure lack of access to the basic environmental conditions for good health. Poor people live in adobe huts with thatch roofs, often with a gap between the thatch and the walls a gap in which various insects can easily enter, mosquitoes bearing malaria or flies bearing other diseases or other insects that are coming and spreading disease. So even the physical structure of the housing can make a very, very big difference. Poverty is related to the ecological conditions of disease. Worm infections like hookworm or Trichuris or Ascaris are in warm, wet, tropical climates. Poor people living in the warm, wet tropics are subject to a much heavier helminth or worm infection. That’s part of the reason for their poverty, but it’s also the cause of poverty coming from the disease burden. Malaria is a disease of the hot tropics and, as a result the poor people living in that region have this extra burden of disease. One can say that it’s a condition of poverty, it’s really a condition of the geography associated with poverty. Poverty is also associated often with illiteracy, innumeracy the lack of ability of individuals to seek health in the right way or to understand what to do or how to fill a prescription or how to adhere to a drug regimen if that’s what’s needed. And so, health seeking behavior is extremely important for all of us. Poor people have a harder time with less education and less ability to fair out the right kinds of help. That’s why workers like community health workers can be so important to help poor people make the connections with the health system itself. And people living in poverty are very, very vulnerable to doing dirty and dangerous work. Young women who because of their extraordinary vulnerability, end up in sex trades, for example. And vulnerable to AIDS and other sexually transmitted diseases or to violence, and to other life threatening conditions of life, is another aspect of poverty itself. And so once can see this two way direction. Poor health leading to poverty Poverty leading to poor health. Whenever you have the arrows working in both directions, you have the possibility of a vicious spiral. Poverty, poor health. Poor health, even more poverty. More poverty, worse health. Worse health, even worse economic outcome. But whenever you have a vicious spiral you generally have the possibility of a virtuous spiral as well. Disease control raising income, higher income improved health, further improvement of health. Even yet further improvements of income in a virtuous spiral, exactly the opposite of the vicious downward spiral. It’s part of the effort of health the policy to break the vicious circle that traps people in a poverty disease trap and to make it a positive spiral of a health development upward spiral. So how can this be done? How can one intervene to control disease and thereby start the virtuous spiral? First of course is implementing what the health ministers called for back in 1978 in Alma Ata. They called for a primary health system for all, and implementing that basic primary health system is a crucial first step. Second is helping poor communities to have better nutrition. Part of that may not be directly in the health sector but in the agriculture sector. More productive farmers growing more food will support healthier diets. The community may generate a surplus that can be used for school feeding progr, programs for example. And therefore, agricultural interventions can play a role not only in agriculture and income, but also in reducing the disease burden. Local infrastructure, is another kind of investment not in the health sector per se but in safe drinking water and sanitation in. Power supplied which is vital for everything. Electricity to run the refrigerator in the clinic to keep the vaccine supply chain adequate to ensure that doctors have the facilities. Water to pump the irrigation water to improve agriculture. And a thousand other uses of electricity absolutely vital to improving overall health. Mobile phone connectivity, internet connectivity. We don’t think of those as health interventions per se. But communities that have access to phones have access to better health. They can call the doctor, they can call the health worker, they can call the ambulance and so investments in infrastructure extremely important. Education at all levels absolutely essential just so individuals understand how to seek help. But also, education raises incomes, we know that higher incomes for all the reasons we’ve discussed improve health outcomes as well. And local business development by raising the incomes of the community also cut that downward spiral of poverty and disease. How far do we have to go we have a ways but we’ve made also a lot of progress have a look at the data on the mortality rates of children under the age of five. Back in 1990, 12 million children under the age of five died. By 2010, the number was under 8 million. This is a huge, huge victory for public health. It is still 7.6 million too many. It’s still multiple and preventable tragedies, but there’s progress. There’s very substantial progress in reducing the mortality rates. If you look at the next graph, those same mortality rates are put in terms of numbers per thousand live births rather than the aggregate number of millions. And this is quite important as well. In 1990, on average in the world, 88 of each 1,000 children did not live to their first, to the fifth birthday.

By the year 2010, that rate had declined to 57. Per thousand. Still, a high number, still a number of deaths that can be cut sharply. But the under five mortality rate is falling sharply. Now remember, we also have an important clue where we need to put the extra special effort. If you look at the total number of deaths in the year 2010, the 7,600, more than 6,000 of those deaths were in just two regions, Sub Sahara in Africa and Southern Asia. These are the epicenters not only of overall poverty but the epicenters of the disease burden and of the preventable and treatable diseases that could reduce this amount of suffering. And where are poor people succumbing to what kinds of conditions? That is shown by the estimates of the causes of deaths of children under five. And when you look at this chart, the 100% of that’s allocated in proportions to different diseases. What you see as the overwhelming message of this chart is this still very high burden of communicable, that is infectious diseases that can be spread from individual to individual. Diarrhoeal disease, pneumonia, measles, malaria, other infectious diseases, are a very large part of these deaths. What you also see are the number of deaths of children just in childbirth. As newborns, or neonates. And in the first four weeks of life. In the very vulnerable conditions just after birth. And so we see birth asphyxia. And the trauma, prematurity. A severe neonatal infections. A whole cluster of a causes of death related to childbirth and very often to the lack of sanitary conditions that face mothers giving birth. Threatening their own lives and threatening the survival of their children. Well, this is a, a good start for us in terms of understanding what to do. We have a poverty disease trap, each feeding on the other. Poverty feeding disease, disease feeding poverty. We know that this is heavily concentrated in Sub-Saharan Africa and in South Asia, we know that it’s heavily concentrated in diseases that are infectious and communicable. Or in conditions related to childbirth, or as a consequence in addition of chronic under-nutrition. So this gives us ideas where should the focus be how should we proceed? Building a primary health system that is responsive to those specific challenges is in essence the source and, and the starting point for addressing this wholly solvable but continuing crisis. We’ll now look at how that primary health system in a low income setting can best be designed

Lectures / Readings

Universal Health Coverage I

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

The Human Right to Health

Good health stands at the very center of sustainable development. It is one of the most important goals of humankind, in and of itself. And good health is also vital for everything else we hold dear. It’s vital for economic development through a productive workforce through the ability of children to not only survive disease, but also to flourish, to learn to make their way through school.

For the ability of a community to be able to undertake economic activities or to attract investment. So health has always been regarded as central to basic human rights, basic human needs, and to the aspirations of ending extreme poverty. It’s notable that in the millennium development goals, for example, of the eight goals about ending extreme poverty in all its forms, three of the goals, absolutely centrally, are about health. MDG-4 is about reducing child mortality. MDG-5 is about reducing maternal mortality. And MDG6 is about controlling the mass, killer epidemic diseases like AIDS and malaria. And one can absolutely say that, all of the other goals as well, ending poverty and hunger, having children in school, gender equality, a safe natural environment. Are also goals in which health plays an important role.

Both as a determinant of outcomes and also, as one of the main objectives. It’s also an area where there’s progress. And the science of public health breakthroughs in modern medicine and breakthroughs in other areas, such as in food production or in clean water from safe infrastructure in urban areas, have contributed to important gains. But we know that the challenges of achieving health for all as it’s often called, or universal health coverage, when we see a picture of this young child, sick with malaria and remember that hundreds of thousands of children like this one, will die, of malaria unless the control measures that are effective and accessible are actually implemented. We’re reminded of the kind of challenge that we still face. Millions and millions of children, especially in the very poor countries, die each year of utterly preventable, or treatable causes that could be ended.

These lives could be saved. Children who are dying today, or are left with lifetime disabilities could, with proper organization of our response, have happy lives and safe lives, that would give them the opportunities that of course, they want and we yearn for on their behalf. Since the beginning of the United Nations itself, the priority of health has been clear. And in the Universal Declaration of Human Rights back in 1948 it was already made clear that health is a human right, a part of our basic needs. As we know about the basic declaration, those were rights, are not the kind of rights that can be achieved all at once. They are to be progressively realized. But time is going, and we could move faster. When the World Health Organization was created as well, right in its central constitution, in 1948, it was declared that health the highest attainable standard of health, is a fundamental human right. Quote without distinction of race, religion, political belief, economic or social condition. Health for all, universal health coverage. One of the really notable global efforts to achieve health for all started in 1978 in Alma Ata now called Almaty Kazakhstan. When world health officials, the health ministers from around the world gathered and made a very important Alma Ata declaration. That called for health for all by the year 2000, a notable specific objective dated for 22 years after that event. Unfortunately, when the year 2000 came, it wasn’t health for all. Unfortunately, it was pandemics for many, many parts of the world almost contrary to the aspirations two decades earlier. The AIDS pandemic was running rampant millions and millions of people infected with the HIV virus. More then 20 million, millions dying every year. Malaria which is a tropical killer disease had risen tremendously in in number of infections and in number of deaths. Because the first line medicine used in Africa to treat malaria had lost its efficacy the parasite had become drug resistant to chloroquine and so 2000 was very bleak for malaria with a surging death toll.

The year 2000 was also bleak for tuberculosis another horrific scourge of humanity that claims millions of lives each year. With tuberculosis there was a surge partly riding on the HIV/AIDS pandemic, because immuno compromised individuals suffering from AIDS died in very large numbers from tuberculosis infection. There was also as with malaria, the crisis of drug resistance and new lethal very difficult to treat strains were spreading of what we called then, multidrug-resistant TB, tuberculosis bacteria that were resistant to way wide spectrum of traditional medicine. And this also became extreme multi drug resistant TB when even the rescue medicines lost their effectiveness as the bacteria continued to evolve resistance. In other words the year 2000 did not meet the hopes and aspirations of the health ministers who had assembled in 1978, nor did it fulfill the promise of the Universal Declaration of Human Rights, nor the Constitution of the World Health Organization. So, it was notable that in the year 2000, the Millennium Development Goals put three of the eight goals so centrally on health and took up the challenge of fighting these scourges that were spreading malaria, TB, AIDS, and other killer diseases. We’ve made a lot of progress since then. The distance from 2000 till now is a period of tremendous progress. It rekindles for us the hopes of 1978. Indeed we see within reach the possibility of truly honoring the commitment to help as a basic human right. Now health like education is a merit good. Remember that a merit good is a good that should be accessible very broadly or universally in the population. Health is considered to be such a good not only because it’s so vital for individuals that we feel from a moral and ethical point of view that everybody as human beings deserves access to health. But very practically, health is a merit good, because untreated disease is a threat for society and a threat that spills over to the rest of a population when an epidemic is left to fester and to spread. Think of the devastation that comes when a highly communicable disease races through a countryside, races through a continent, as AIDS has done. The death tolls that can result in the cost to the whole community are huge. We’ll see other reasons as well why government has a necessary leadership role, not only to ensure widespread coverage, but to ensure the efficiency and, the results orientation of the health care system. Now when we look at the actual experience, in health, this is like economic development itself, one of the real achievements of the modern era. Back in the industrial revolution, worldwide life expectancy was perhaps 35 years.

Of course, we don;t have the, records to establish with precision, a world wide number. But something around the order of 30 to 35 years of life expectancy is a reasonable estimate. This does not mean that people were dying at the age of 30 or 35. It means that a newborn on average would reach, an age of 30 or 35 taking in to account that a very large number of deaths would occur within the first month after birth or the first year or the first five years. Once individuals reached an age of 20 or 25 or 30 there would be a chance, a good chance that they might reach 55, 60, 65. So life expectancy at birth is a measure that is made at the start date of life, just at the time of birth. And from there, to estimate statistically how long on average an individual can expect to live within the society. Now from 35 years in, 19, 1800 or so. By the time we got to 1950, just after World War II, there had been some gains in the average in the world. But remember, how much of the world was still mired in poverty and also in the aftermath of war. It’s estimated that during the five year period 1950 to 1955, worldwide life expectancy was perhaps around 46 years. That’s the average as estimated by the United Nations, but if you look at this graph that divides the world according to high income developed regions developing regions and the least developed countries. You can see that, for the developed regions of the world, life expectancy, in the period 1950 to 1955, was somewhere around 65 years already. Of course much lower still around 35 years in the least developed countries. Probably quite close to the health conditions that had existed at the start of the Industrial Revolution. We see from this curve though that the world has made progress and every category of country has made significant progress. By today, world life expectancy is perhaps 70 years, twice the life expectancy, roughly, at the start of the Industrial Revolution.

This is one of the great achievements of modern humanity, one of the great achievements of modern science and of economic development. But one also sees the continuing large discrepancies between the high income and the low income world. In the high income, life expectancy is, almost 80 years. Whereas in the least developed countries, you can see from the graph,that life expectancy is, is still 60 years or even less. In other words roughly a 20 year, two decade gap in in life expectancy between the richest and the poorest countries. This gives us a, a measure of how much we have to do. Most of the causes of death in the poor countries are in some sense caused by poverty itself, suggesting that from a medical and public health point of view, these deaths are preventable. These diseases that are causing these deaths are treatable in many cases. In this interesting graph that you’re looking at we put on the horizontal axis the per capita income of countries. And on the vertical axis, the life expectancy at birth. And you see, in this graph, a rising curve. Richer countries, naturally, have a longer life expectancy. You also see in comparing the fitted curve for 1975 and for the year 2005, the two shown here with the dotted line for the earlier year, that the whole curve linking income and life expectancy has shifted up. This means that during that 30 year interval, at any given level of income, one expects a longer life in the more recent years.

Now why would that be? The answer is technological improvement, better ways to prevent disease. Better ways to treat diseases, that, that, occur, nonetheless. And the result is that even at the same income level year after year there is an improvement of health that comes from a rise of the productivity of our public health and medical systems, as well as of other parts of our economic life. For instance, the literacy and awareness of people themselves, so that they can pursue health seeking behaviors more ably, or they can use their mobile phones to call for emergency help, and this is one of the reasons why life expectancy rises. Now, what I find extremely pertinent about this graph is the very steep part of the curve at very low income. This means that when countries are very poor, small increments of income going from $1,000 per year to $2,000 per year leads to very steep gains of life expectancy. Those gains later on level off so that increases of income say from $25,000 per person per year to $26,000, the same absolute increase, would have a quite small effect on the average life expectancy. Whereas that gain at the very low levels of income have a massive increase. This is to be expect. There are, diminishing benefits of added income to many things including to happiness, but also to human health. But what’s important about this curve, in my view, is, it says that even small increases of income, or I would also argue, small increases in the amounts that we are able to invest in health, can have huge benefits for the level of health. One of the themes that I want to emphasize is that very low cost investments in poor settings can have huge effects on saving lives on extending life expectancy on extending the quality of life and the health of, of people during their lifespans.

Not surprisingly, when you look at a world map such as this one, showing the mortality rates of under 5s. Meaning, for every thousand births the number of those children out of a thousand who will die before their fifth birthday. We see that the under five mortality rate is by far the highest in tropical Africa. And next is in south Asia. Those are our two locations we constantly see as being the epicenters of the challenge of extreme poverty. And much, much lower under five mortality rates in the other parts of the world. So our challenges in health are heavily focused in the poorest countries. And, that means geographically they’re heavily concentrated in two regions of the world, Sub Saharan Africa and South Asia. The next graph shows you another asp, very crucial aspect of health and this is maternal mortality. This is measured as the number of deaths related to pregnancy of, of women for every 100,000 live births. And so the numerator of this fraction, number of deaths in pregnancy, typically at childbirth, but it could also be pregnancy related has a huge variation between rich countries where very, very few women, thank goodness, die of pregnancy related causes. Compared with countries in the poorest regions, and poorest of all in tropical Sub-Saharan Africa, where maybe 1,000 woman die for every 100,000 births, an astounding risk of death due to pregnancy. Those numbers are coming down. We see that, that the maternal mortality rate in the developing regions is falling sharply. It was around 440 deaths per 100,000 live births back in 1990. And now below 250 deaths per 100,000 live births as of 2010. We see that in the high income regions, the developed regions, the numbers are very, very small, a few deaths per 100,000 live births. The reasons for death in rich and poor countries differ. But for one basic reason, the poor die of the same reasons that the rich die. They die of cancer, they die of cardiovascular diseases, they die of metabolic disorders, say, related to diabetes. But they also die of conditions that rich people no longer die of, mainly communicable diseases such as children dying of measles, or children dying of malaria, or children dying of other kinds of infections which would not kill their counterparts in the rich world. But do kill the children in the poor countries because the children are hungry, they’re undernourished. And one basic principle of health, is that under-nutrition leads to immuno-suppression. What does that mean? Under-nutrition leads to a camping down of the immune system, the ability to resist infectious diseases and so poor kids die of diarrhea or respiratory infections that would not kill a child in a rich country better nourished. But do carry away millions of children, into death in the poorest countries. The disparities between rich and poor and across ethnic groups, another kind of inequality that we’ve examined can apply within countries as well. The United States, we know being the most unequal of all the high income countries for reasons that we’ve discussed, also has very high disparities in life expectancy. This is a map showing the measure life expectancy across counties of the United States and we see that the Northeast seaboard of the United States. Say Boston or New York City have quite high life expectancies, but in the deep south of the United States, in Alabama, in, in Mississippi, in Georgia, in Louisiana life expectancy is several years less. And we also know that minority groups in the United States, especially the African American community, has many years less of life expectancy compared to the white, non Hispanic Americans. And so these gaps cross class lines. They cross racial lines and they have geographic counterparts as well related to ethnicity, race, and perhaps at least some direct effects of geography as well. To measure the variation over time and across countries in health we use a number of statistics. The life expectancy at birth is an example. Under five mortality, another example. Maternal mortality rate, a third example. Infant mortality rate, which is out of a thousand newborns the numbers who will die before the first birthday. There’s also a very important concept that I want you to know because it’s widely used and very useful called DALYs. DALYs is the acronym for Disability Adjusted Life Years. The idea is that a normal lifespan is 80 years, according to the calculations of DALYs[1]. If an adult dies at age 60, this is 20 lost life years. If that adult is sick between age 55 and 60 and not enjoying healthy years even in those final five years of life, that’s an added penalty for disability. Paralysis, blindness, the loss of a limb, other kinds of disabilities can be translated into a partial loss of a life year by making an assessment how much healthy life is lost by the particular disability. What DALYs calculate in any population is on average the number of lost life years plus the number of lost years to disability add up those two components from death and disability and you get dis you get disability adjusted life years. The DALYs. And these DALYs are used to understand the varying disease burdens across the world. An example of this is this rather complicated chart, but a very, very important one. Every bar on this chart is for a distinct region of the world. At the top is the high income countries. Next Europe and Central Asia. At the very bottom bar, of the chart, is Sub-Saharan Africa. What is being shown here, are the disability adjusted life years lost to disease per population. So a large bar means that there’s a lot of lost life years, either to death or to disability. And we see that Africa has, by far, the highest disease burden, and the high income world, not surprisingly, the lowest disease burden. But this bar in each grouping is divided by colors in a quite interesting way. Those colors refer to different disease categories. So take the dark blue, which is most to the left of each of the bars. That is the amount of loss of life years due to HIV/AIDS. We can classify all of the diseases into a few categories and then measure the disability adjusted life years lost to that particular set of conditions, and group that in a category. What do you see when you do this? Very, very important to note this, Sub-Saharan Africa, for example, has by far The highest disease burden of AIDS. This is not surprising. The very epicenter of the AIDS pandemic is in Sub-Saharan Africa. Now compare the bar for Sub-Saharan Africa with the bar at the very top for the high-income countries You can’t even see that the sliver for HIV/AIDS. That doesn’t mean,uh, of course that there are, is no, death and disease from HIV/AIDS in the high income world, of course there is. But it means that the burden of the disease per person in the population is very, very low compared to the massive burden in Sub-Saharan Africa. And look at the part of that bar for Communicable disease. You have to scrunch your eyes and see a tiny little sliver. Well why is that? It’s because in the high-income world the communicable and parasitic diseases like malaria, like measles, like diphtheria or typhoid are virtually gone, almost not heard of. Many of these diseases are completely and successfully prevented by immunizations. Others are treated by antibiotics. People, and mainly young children in the case of sub-Saharan Africa, suffer these diseases in the poorest countries, but not in the richest countries. And that’s good news in the sense that it means we have tools already to shrink the bar of DALYs, of the disability adjusted life years, in sub-Saharan Africa and in south Asia. So that the disease burden can get under control. So that life expectancy can rise. So that the quality of life lived is higher, and so that a healthy population can also play it’s part in in more dynamic e-, and more inclusive economic development. Let’s see how we can attack the those disease burdens by now going on to look in more detail at the nature of the diseases, and what can be done about them.

[1] http://vizhub.healthdata.org/gbd-cause-patterns/

Lectures / Readings

Why Did Some Countries Advance While Others Remained in Poverty? V

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

Which Countries Are Still Stuck in Poverty?

In our quest to understand sustainable development, and right now economic development we’ve focused on the modern era of economic growth We saw how the Industrial Revolution began in England and spread to all the world. Or, one should say, almost all the world because there are some places that still, even to this day, lack some of the basics, and lack some of the on-going economic growth that Indeed has reached almost all of the planet.

We’ve been undertaking a differential diagnosis to understand how those, moving ripples of economic development have reached some places in the world, and failed to reach others. We’ve explored the role of the poverty trap. We’ve explored the role of geography. The role of culture. The role of, politics. Let’s put the pieces together. By focusing on those remaining areas in the world that are still stuck. Below the threshold of self sustaining growth. And, as we’ve used the idea of passing that threshold, looking at the $2,000 per person, per year threshold. As a marker for us. When we look at the map of global development. We see that those countries shown in red. On this map are the ones that, as of today, are still below that takeoff level. What do we see? We see that the remaining regions are, mainly, tropical Africa. And then, the number of land locked countries, Afganistan. Napal, Mongolia, Louse, and a few other parts of the world, and of course with out question we have to regard sub saharan Africa as the greatest challenge of development, the place in the world still with the highest poverty Rates, and with the biggest challenges in meeting basic needs.

The good news is that in recent years especially since the year 2000, economic growth in sub Sahara Africa has picked up. There’s definitely progress, major advances in some of the key areas. Of disease control. Improved access to education, building infrastructre. But we’re still not yet in a sitatuion where there is self sustaining, rapid and dynamic growth, though one feels very much that it’s within reach. Let’s put our differential diagnosis. Perspective, therefore, on sub-Saharan Africa, and ask what we learn by taking that multidimensional view of a region to see what it implies for the priorities for economic and sustainable development. Africa has many distinct structural characteristics and many of these strustral charectarcistics are indeed sructeral problems for econmic development, if you look at the region of peverty in Africe That is below the Sahara Desert but above the southernmost countries. One is defining essentially the region of the tropics of Africa. Between the Tropic of Cancer at 23 Degrees north latitude in the tropic of Capricorn, and 23 degrees south latitude. And we know that the African tropics have many distinctive features that are relevant for economic development. Disease burden we’ve seen is very heavily concentrated in the tropic whether it’s malaria or other so-called vector-borne diseases, or worm infections that debilitate people, and that hold back whole societies. We’ve seen that.

Agriculture can be very difficult in tropical conditions. Often water scarcity, with the very high temperatures, drought propensity, soil nutrient depletion can be extremely pernicious in the tropical context. So this is one feature that needs to be addressed. Nothing impossible about these challenges because diseases like malaria are fully controllable, but they need to be controlled. We’ve seen that Africa has a distinctive feature of the most land-locked countries of any continent in the world. Roughly one in three African countries. Is land locked. 15 out of the 49 countries of Sub Saharan Africa. That’s a big problem. Why is that? Well, part of the reason is the colonial legacy. Remember that nature doesn’t draw national boundaries. Politicians do. And when the politicians divided up, Africa they divided it up into little parcels often cutting natural ecological areas dividing ethnic groups by artificial boundaries leaving a legacy. Of great difficulty making it hard for populations even to reach coasts. In many parts of Africa, the coastal physical environment is rather hostile. And in East Africa.

The eastern coast tends to be very dry. The trade winds come up to the coast from the east. They do not provide precipitation right on the coast, but as the highlands in the east coast carry those trade winds into higher altitudes, Then the rain is distributed in the interior, what’s called orographic rain fall, or rain fall that is caused by the uplift of the mountains, in this case, the highlands of East Africa. This means that the high population densities in East Africa are not at the cost but are in landlocked interior countries like Rwanda, for example, or Uganda. Where there is much more rainfall than one would find in their port of Mombasa, Kenya, which is in a, a much drier region. So, the distant from the ports has to do with history, it has to do with political boundaries It has to do, some historians think with the long legacy of even slave trade which caused populations in their self defense to move more into the interior. It has to do with the fact of rainfall being more propitious and able to support food production Often away from the coast and in the interior of the continent. We know that in many, many, other ways, the colonial legacy has played very difficult role. Have a look at the map of European colonial rule In Africa as of 1914. The first thing you see is the entire continent with the exception of of Ethiopia, was colonized. Africa was divided among the European powers, and the story of how it was divided is a rather shocking story. Actually, Africa was one of the last continents to succumb to European imperial rule. That may seem strange because Africa was very poor throughout history, therefore very vulnerable.

As exemplified by the slave trade. So why wasn’t it colonized earlier? Europeans attempting to move to the interior of Africa in the earlier parts of the 19th century to colonize, succumbed to malaria and other tropical diseases, the disease burden actually prevented europe from colonizing africa until the latter part of the 19th century. Then what happened? Well, you could perhaps describe it to tonic water. Tonic water is water with quinine. But quinine is a natural preventative or curative to malaria, and when quinine was discovered and then mass-produced by the British and then by the other imperial powers, That enabled Europe to dominate Africa through military means. The Europeans were brutal vis a vis the Africans, but strangely polite and diplomatic among themselves. They sat down at the conference table at the famous Berlin Conference. Of 1884 and 1885 and said gentelemen, because of course was only gentelmen around the table, lets deivide africa in a very civilized way, civilized fro us without any civilaty vis a vis the fricans, and by 1914 you had a map of Africa that was divided in all of these arbitrary political divisions. This has left a legacy of wrong borders of high land lockedness of European domination over many of Africa’s natural resources. So that the resource earnings have been extracted and end up in tax havens around the world rather than the treasury coffers of Africa itself, the European powers did not provide education. Indeed there’s a documentary record showing we don’t want to educate the local population that would be a political Risk for us. And so when African governments achieved independence, often there were just a handful of people with a high school, much less a university, education. The infrastructure, physically, that the European powers left behind was also strangely deficient.

Have a look at, a comparison of the map of the Indian railway system, built largely during the British colonial period in India, with the map of Africa’s railway system built largely during the period of colonial rule. In India you see a full grid. And that was because a unified colonial power, Great Britain, created a unified infrastructure, partly to extract India’s natural resources, including its cotton. As inputs to the cotton mills of England. In Africa, where the conditions were harsher and more difficult and the political divisions existed, the European colonial powers did not sit down together after the conference in Berlin and say, Now let’s construct a railway network. They each one constructed just a line from their port to the diamond mine or to the gold mine or to the plantation, and so the rail systems in Africa is not a full grid, but is just spurs that go to a few locations. And this has much greater burden for Africa. When India had its agricultural revolutions, so-called Green Revolution of the 1960s, this railway line played a crucial role in bringing fertilizer into the interior and bringing grain from the interior to the national economy. But in Africa, the rail can’t sere that purpose it doesn’t exist. It still has to be built. Even in the 21st century. So the legacies of colonial rule in Africa have been very, very tough. This isn’t an explanation of everything My point, again and again, is, don’t take a single factor. You cannot blame it just on colonial rule. We’ve seen, you can’t blame it just on, quote, corruption, because in many parts of Africa, the levels of corruption are comparable to far richer countries. In other parts of the world. You can’t blame it just on culture, though culture matters. It matters for gender, it matters for fertility. It matters for commitment to education. You can’t blame it just on geography, but geography surely has player a role in the burden of disease, in the vulnerabilities of agriculture. Of the high transport costs. Differential diagnosis doesn’t necessarily give you a simple answer. Simple answers are often highly simplistic answers. We need accurate answers, and the differential diagnosis helps with accuracy. It identifies several of the challenges that need to be addressed, even though Africa And, other countries still stuck in poverty. May face added burdens. They also have the opportunities for technological breakthroughs. Unimaginable, until recently. Now, when you go, even to the remote African villages across the continent. Maybe with few exceptions, but as a general rule, mobile phone coverage is there, broadband is on the way, information technology, is already transforming these very low income villages very low income regions Bringing in knowledge, market information, data empowerment and the potential for breakthroughs in help, in education, in business development. In other words, when we make the differential diagnosis, we identified the political and the cultural and the geographic. Phenomenon when we identified that heritages of the colonial period and the shortfalls of the infastructure. We are not overcome by pessimism but we are motivated with an agenda. An agenda which is targeted. A specific, a balance of public and private investment At areas for social mobilization, public awareness, the role of parents to help their children to make breakthroughs as well, that is the key for sustainable development.

Lectures / Readings

Why Did Some Countries Advance While Others Remained in Poverty? IV

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

The Role of Politics

We’re making a differential diagnosis. A country is sick, it’s stuck in poverty, its economy is unstable it’s failing to achieve sustainable development. What ails that country? What kind of prescription should be applied?

And we’ve seen that there is no one answer to such a complicated challenge. And indeed several major categories of potential ills need to be examined. We need a kind of checklist. Is the problem a poverty trap, where government and society knows just what to do but can’t afford to do it so it needs financing? Is the problem physical geography, being landlocked? Being in a, in a tropical environment burdened by disease? Lacking the energy resources needed for development? Is the problem cultural? Perhaps discrimination against girls and women. Lack of attention to education. Lack of attention to reducing high fertility rates. Well, on that list we definitely need a politics checklist. We know that the role of government in economic development is crucial. Government is vital for building infrastructure for the roads, power transmission, the port services, that are vital for any economy to develop. Government is essential for human capital development, meaning the health, the education, the nutrition of the population. If the government isn’t performing, the schools will be miserable, health conditions will be poor, diseases will run out of control. What happens to a poor person on society poor family that can’t make ends meet?

The children in such a family, unless supported through government programs will lack access to vital things, proper health, proper nutrition, access to education, the ability to develop skills. So that that poor child will be able to escape from poverty. Government is vital to the rule of law. Of course, without government, there can be anarchy, violence and when government itself is massively corrupt, other institutions, the banking sector for example, is doomed to, to fail, to operate in a lawless environment. If contracts can’t be enforced, if courts aren’t working, then who can do business in a modern period. So when we see a country in crisis in addition to the checklist of culture, poverty, geography we want to look at the political situation. And we want to look at politics across several dimensions. We want to look at whether the government is managing properly the investment in infrastructure. Infrastructure cannot really be provided adequately by the private sector alone. A highway system, a rail system, the bridges, the ports require either public regulation or public financing or public ownership or some combination of all of those. China, which we know to be one of the fastest growing economies of the world, has excelled in the capacity of government at all levels, the national government, provincial governments, and local governments to undertake large scale infrastructure investments. Rapid rail intercity that now provides a tremendous transport system for the country. Urban metro systems in the major cities of China. Mass electrification, that has enabled China to support rapid industrialization. And so this is an example where the government has played its role, but there are many poor countries where the government has not been of the capacity, focus, or interest to undertake this kind of infrastructure spending adequately.

Government has to regulate key sectors of the economy. Finance is one of them. Unregulated banking systems tend to get into crises. Regulations that are allowed to lapse or that are not really pursued can end up in disaster. This, the whole world experienced in 2008 when the deregulation on Wall Street at the very epicenter of the world’s financial system, caused a massive financial crisis that also spread throughout all or the arteries and veins of international finance. Government dropped the ball. Because of the powerful financial lobbies in Washington who urge the deregulation of Wall Street, Wall Street got itself and all the rest of us in a lot of trouble. And when government fails, or when governments allow illegality or fraud in their banking systems one ends up also with financial panics. Corruption is a pervasive problem in government. There’s lots of money in business. Those businesses often want deregulation, dangerous for society but good in the short term for these businesses. Of course we don’t measure corruption all that well. A lot of it is under the table. They’re only corruption perceptions. We don’t even define corruption all that well. In the United States, it’s legal for business to give massive, indeed, unlimited campaign contributions to politicians. And so, what I would call corruption, is some times perfectly legal but it’s not classified as corruption. So when we look at a map, for example, of corruption perceptions as measured by surveys, in this case by Transparency International, we learn something but we don’t learn everything that we need to know about this problem of political failure.

One thing we see is that many poor countries, again look at tropical Africa, at some of the landlocked countries, corruption perceptions are quite high. But I’d also like you to uh,look at the fact that in many African countries, still very poor, where corruption is comparable to what you see in South America or China or India in perception. You have a lot of poverty, but not, evidently, corruption out of control. This underscores another point. Politics matters but it doesn’t explain everything. Geography, culture, poverty traps are also extremely important. Let’s not fall into the trap of single explanations. We don’t give aspirin for all fevers, or shouldn’t, and for the same reason we shouldn’t say that corruption is the cause of all economic crisis. We need that differential diagnosis. Now another major job of government is to resist poverty. Not only to help poor people meet their basic needs as a matter of basic social justice, but also to ensure that poverty doesn’t simply replicate itself generation after generation. A poor child growing up in a poor family faces many obstacles, of course. Maybe health and nutrition are worse. The neighborhood conditions, the environmental safety is likely to be worse. The schools in a poor neighborhood or poor region are likely to be much worse, dilapidated, per haps lacking teachers, perhaps very large class sizes, perhaps no books and materials, or computer rooms. Some very poor places don’t even have a roof over their schools, so the schools are conducted under a tree or in the open air.

So children growing up in poverty are likely, unless in some way given a boost, to be poor themselves as adults. And so poverty replicates itself from one generation to the next. Government has a major role here, to ensure a kind of equality of opportunity, to ensure that even children from poor families have the chance of social and economic mobility to rise to the middle class of their society. But that requires help. It requires public education, it requires access to early childhood development investments, a safe daycare for children, good nutrition programs, preschool. All demonstrated, time and again, to be tremendously powerful in enabling children, and especially children from poor households, to get that added step up. So that they have a good shot at prosperity and at joining the middle class of their societies. But governments differ a lot in their readiness and the quality of their response to this challenge of poverty. If you look within the high income world, the so-called group of the Organization of Economic Cooperation and Development, OECD. The 30 roughly countries in that group. There’s tremendous variation between governments that invest heavily in social areas in protection against poverty in provision of social services. And governments that invest relatively little. If you look at this graph of public social expenditures as a share of national income, you see at the high end countries like Sweden and Denmark. The social democracies in Scandinavia with very large investments. You see at the opposite end of the scale, the United States, Japan, Ireland with much lower levels of investment.

The consequences are that children in countries with lower levels of social expenditure have a much higher risk of growing up in poverty and a much greater chance of themselves ending up as leading poor households as adults. You see here the poverty rates across the OECD countries. Where are the poverty rates the lowest? These are poverty rates both shown for children in the bars and for the total population with the diamonds shown in this figure. What you can see is that the lowest poverty rates for children are in Denmark, Finland, Norway, Iceland, Sweden. Those social democracies in the Nordic region. Where are the very highest rates of children’s poverty? United States, Chile, Turkey countries that invest much less in social outlays. And just to demonstrate this relationship. If we plot in a scatter diagram, on the horizontal axis the social expenditures as a share of gross national product. And on the vertical axis the child poverty rate. We see a downward sloping line. We see countries that invest relatively little in social areas as a share of GNP having high child poverty rates, whereas counties like Finland, Denmark, and Sweden that invest high levels of national income in social areas having very low child poverty rates. In other words, politics matters. Even among high income, market economies there is a huge variation of those that attend to their poor and also thereby create conditions for social and economic mobility. And, those that more or less leave their poor to their fate. And, also, have the result that poverty replicates itself across generations. But I do have to be clear. In order to reduce child poverty, in order to be able to fund those higher levels of social expenditure as a share of national income, those governments that do so have to collect higher taxation. They say to their citizens, we can address problems of poverty. We can carry out our government functions, but that requires taxation to cover the bills of government so it can carry out that role. So if one looks at the share of taxes in GNP, once again it’s the Scandinavian countries at the very high end paying the bills In order to reduce child poverty, to make investments in education and in infrastructure and the environment. And it’s countries at the other end of the scale like the United States, which has a low tax to national income ratio, thereby invests much lower shares of national income in the social areas. And as a result has much higher inequalities of income, much higher rates of child poverty, and much lower rates of social and income mobility across generations. That’s a kind of scourge for societies when they become so divided. Remember that in sustainable development one of our pillars, one of our goals, is social inclusion, that everybody should have a chance. And in our differential diagnosis we need to focus on the role of government. Is it doing its job to make sure that a poor child has her chance, or his chance to get ahead? If government’s doing that, it provides a major boost for sustainable development.

Lectures / Readings

Why Did Some Countries Advance While Others Remained in Poverty? III

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

The Role of Culture: Demography, Education, Gender

We’re making a differential diagnosis of why countries get stuck with their bad economic performance. We’ve looked at, how poverty traps can hold poor countries in a grasp preventing them from making the basic investments to move forward. We’ve looked at how physical geography, the presence or lack of fossil fuels. That the proximity to or distance to the coast.

The nature of the climate system. Can shape economic development. Very often, people turn first to culture as the explanation, of why some places are ahead, and others behind. It’s often quite glib, because,rich people like to say, we’re rich because our culture is better, rather than to say, we’re rich because we have lots of energy resources, good coastal proximity, and a healthy climate. And rich people often like to blame poor people for their problems, say, well, they’re lazy, they’re not working very hard. And throughout history, places that were once poor and they became rich were known quote unquote as lazy places, during their period of poverty. And then once they became rich, their culture was used to explain their hard working ethos. So culture can be a bit of an optical illusion. A little bit to easy sometimes, as an attribution or a cause of a countries conditions. And we should remember that cultural phenomena, people’s beliefs and attitudes, their views towards appropriate roles in society. Change over time as well. SO culture isn’t a fixed monolit. I believe culture has a role, however, though not as big a role as sometimes thought. And we should focus on those atributtes of a societies values, its norms, Its attitudes. As ways that can be promotive or barriers to sustainable development. I want to focus on three. One is on demography and population. The second on education. And the third, regarding gender[1]. When we look at the population challenge, a good place to start is this world map of the fertility rate. The total fertility rate in a country, and you’ll recall Measures on average the number of children that a woman will have during her lifetime. It looks at the age-specific fertility rates for women in a society, and then says, if women age 20 to 25 on average have this many children, women age 25 to 30 have this many children, and so forth, Then on average over the course of a woman’s lifetime reproductive years, an average woman in this society would have this number of children. What the world map shows, is the tremendous variation in our world today in the total fertility rate. In many parts of the world, especially the high-income world today, fertility rates are below two.

That means that each woman, on average, is having fewer than two children. It means, since half the children are boys and half the children are girls, On average, each woman is having less than one daughter. Or, if you say, 10 women, in total would be having fewer than 10 daughters. You can see that when fertility rates are below two. So, that, on average, each mother is not replacing herself in the next generation with a daughter. Statistically speaking that the population would tend to, be stable or declining. When the total fertility rate is above two, then the population would tend over the longer term to increase. So, if in high-income world on this map we see total fertility rates below two. We also see in some of the worlds poorest countries in notably in Africa and in parts of South Asia, total fertility rates above four and many rural areas in low income tropical Africa we have total fertility rates above six.

That is a pooe household would, on average, the woman would be having six or more children. This tremendously effects economic development because with very large populations of young children, poor families Have a very difficult time providing the basics for all of their children, maybe just the eldest son is able to go to school and the girls are married at a young age or working the fields about proper education and that means that in the next generation those young girls will grow up without the literacy and the skills that they need. To help their own lives their own children and the national economy to be productive. So countries that had made, a transition from high fertility rate to low fertility rates, have tended to have an advantage in economic development. Countries that have still today very high fertility rates tend to have much lower economic growth. To a certain extent, this is a matter of income itself. It’s not really a matter of culture. Poorer families, living on farms tend to have more kids. And have less access to family planning to contraception, the girls don’t have access to schools and don’t go to school and are married young and begin having children at a very young age, but to some extent at least fertility rates also reflect culture, lets look at one example of a society that move rapidly, From high fertility rates to much lower fertiliity rates.

That’s China. They did that by and large through a government policy known as the One Child Policy. And while it’s been very controversial, notice the implications of this policy. What has happened, in a very short period of time. Family size has come down rapidly and parents have invested intensively in their one or sometimes two children. And so that within one generation, the levels of education, health, nutrition of Chinese young population has soared. This played an enormous role in China’s very rapid economic development. So some places by virture of culture, politics, of history, have still very high fertility rates. Other places have made a rapid transition. To lower fertility rates. And the record shows very clearly that those countries experience faster economic growth, better health for the children, and higher educational attainments. Over time this fertility rate shapes the population dynamics. Whether the population is rising or declining in overall size, and the age distribution of the population shown here by the age population pyramid so called, what these pyramids show, are the numbers of boys and girls or men and women at various ages,uh showing the age structure of the population If you look at Japan’s population, for example, in 1950 when fertility rates were still rather high, The number of children at the bottom of the pyramid was much larger than the number of their parents, and far larger than the number of the grandparents. By 2005, the shape of that pyramid had changed considerably.

Japan had reduced its fertility rates. Partly as a result of culture, partly as a result of economic development, partly as a result of public policy. And so now the number of children were actually fewer than the number of parents because the fertility rate had come down below two. And the whole age structure, therefore, wasn’t a broad pyramid with a big, big base of young children. But was now much more similar in numbers of population at all ages. By the middle of this century, because of the continuing low fertility rate, the population age structure will be an inverted pyramid. Few children, many more older people. And that’s how the transition occurs when fertility rates come down. Most of today’s very poor countries have that big base pyramid. Huge numbers of very young children to be supported. How are they going to be educated? How are they going to get the healthcare and the nutrition that they need? Only if today’s high fertility countries are able, through matters of public policy, cultural attitudes, and so forth to help reduce those fertility rates. And the best way is through the voluntary choices of, households who decide to reduce the number of children so that they can invest more per child and help raise healthy and better educated children, unless that happens, then the problems of the large numbers of children outnumbering their parents will continue to make very difficult the economic development of the poor countries. Another cultural phenomenon involved attitudes towards education. Some poor societies even in a state of great poverty, by tradition, by culture, focused a huge amount of effort and attention on literacy. Korea is one such country. Korea even when it was impoverished in the middle of the last century had a very high literacy rate, and there was always great attention in Korea’s modern history to broad based literacy. Well that’s a cultural attitude as well as a government policy. And it’s done very well for Korea since the middle of the century and the terrible Korean war that took place and devastated so much of Korea. In South Korea, we’ve seen some of the most successful economic development every attained, some of the fastest economic growth And with a rather widespread prosperity. A huge part of that has been facilitated by this continuing commitment to broad based, high quality education. And indeed this shows up in international test scores. What you’re looking at here are the rankings on International testing, in science and math. Where is Korea? Right at the top. It’s not the richest country in the world, but it is right at the top ranks number one or number two, definitely in almost every, test and cateogry, within the top few countries in educational performance. This reflects not only public investments in education, but it reflects parental support for their children, urging their children to excellence. It reflects a culture that has long strongly valued education, and thereby made it possible for Korea to become a world leader in technology. And one of the fastest growing countries in the world. A third cultural attitude, that deeply influences patterns of economic development, are attitudes towards women. Do women have rights? Are women participating in the labor force? Do women face massive discrimination? So, gender equality or inequality also has, political aspects, but culture plays a significant role. Once again, as with fertility and as with education, there are big differences around the world. In attitudes towards gender equality in attitudes towards women, even in the physical safety of women from violence. One can see the many, many ways that this influences economic development. There’s probably not a society in the world where women still do not face at least some discrimination. It took Tremendous political effort, social mobilization, and a lot of courage of women to break through this discrimination even in places today that we view as close to gender equality if not fully there. But there are many parts of the world of course where women still face profound, profound barriers. To their economic participation, to their political particiiaption to hteir role in society. What are the consequences of that? A society that tries to run on half its brain power on half its human capabilities, block the role of women. In problem solving, in economic leadership, in a political role. A country that’s running on only half its human resources is bound to fall behind countries that are empowering all of their citizens, women and girls as well as men and boys. Countries where young girls may have one of two years of schooling, but then because lack of interest, lack of budget, lack of family attention and effort, are forced to drop out of school, marry young, start having children young, do not have the productivity to participate in a modern economy.

Face a tremendous amount of poverty and suffering themselves. And by dint of that are likely to be raising children in poverty as well. Now, this is an area where there have been huge changes, fortunately, in the right direction. Over the last 30 years but by no means uniformed. Look at this wonderful picture of the rowandan parliament, it may surprise you to know that rowanda’s parliament is not only more than half omen, but has the highest porportion of women in it’s parliament in comparison with the rest of the world. And women’s participation in politics has soared in Rwanda and it is rising in other parts of the world, though still with the huge inequalities and still a tendency towards men dominating. Political power. In Rwanda you can see the wonderful benefits of this turn towards women’s empowerment. and Rwanda has made astounding progress in reducing child mortality. It’s making big progress in improving education. Social conditions have improved dramatically. And while there are many factors that are contributing to Rwanda escaping the poverty trap, the role of women in the parliament in my opinion has played a significant role, Not only are, these women powerful role models for young girls in Rwanda, and I think Rwanda’s success. In light of this experience is a very powerful nessage for countries that are still lagging behind. Don’t try to develop with only half of your citizenry. Take the lesson that a country that is mobilizing all of its citizens, its girls, women, as well as its. Boys and men, is a country that’s going to have more success in the 21st century

[1]http://www.theguardian.com/global-development/ng-interactive/2014/feb/04/womens-rights-country-by-country-interactive

Bilhetes

Why Did Some Countries Advance While Others Remained in Poverty? II

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

The Role of Physical Geography: Transport, Energy, Disease, Crops

Poor countries and even poor people are often blamed for their plight. You’d better do something better. It’s your culture. It’s your bad government. It’s your corruption. Well, sometimes those factors play a role but, often poor countries remain poor in part, because they live in very difficult places on the planet. Physical geography is one of the seven main categories for a good differential diagnosis.

Of economic development. Though it’s one that strangely is often overlooked by economic practitioners. I’m not exactly sure why that is because when in fact you’re standing at 14,000 feet above sea level on the Bolivian altiplano, and wondering. Why this country’s having some problems. It pretty much strikes you in the face looking at those gorgeous mountains surrounding you and, and the snow capped peaks that, while its natural beauty is absolutely superlative. The costs of doing business there could be pretty high. And, indeed, when you look carefully at how geography effects the diffusion of economic growth. You find that it’s very powerful, and that it gives very strong indications of how today’s poor countries should focus their attention, their resources, and their problem solving. Because a lot of it involves overcoming these physical difficulties. Look again at the map we’ve seen now several times of the gross domestic product per person on the planet.

Remember how income per capita. At the very low levels, in tropical Africa for example, and South Asia, in a, a few other parts of the world is concentrated geographically. That’s not an accident. Those places have difficulties in terms of physical geography That have impeded the development of those regions. It meant that as the concentric waves ripples coming out from the epicenter of global growth have spread throughout the world they often haven’t reached these remaining poor places.

This is a map of the world’s large urban areas. And, we can see the cities populations above one million and, and the mega cities above five million shown in this map. And, while you find large cities in most parts of the world. Take a close look and notice the high proportion of cities along the coasts of the continents. And for those that are in the interior of the continents, very often they are along major rivers so that they have At least a water borne trade, the kind that Adam Smith talked about more than 200 years ago, as being the low cost kind of trade, and that is one of the major reasons large cities have developed and grown where they have. Being on the coast. Being near ports, being near major rivers, has been the key to a vibrant economy with a division of labor that promotes productivity, and that allows for economic growth because of access not only for. Exports to world markets at competitive costs.

But also for the ability to buy inputs from the rest of the world. And bring them for processing or for local use. Now if we identify the major ports of the world. And then ask about the proximity of the world’s populations. To those ports we learn some very interesting things. Have a look at this map where each dot each black dot is a major port, and one can then look at the distribution of worlds population within each country. And ask how far is that population from the nearest port? If it’s a landlocked country, there’s an added problem. There is a nearest port, but the nearest port, by definition is in someone elses country, so not only do you have to go over land to reach that seaport, you have to cross a political border as well. And that can be a major hindrance, In the map that you’re looking at countries are shaded according to the average distance of their populations, from the closest port to each part of that country and then averaged over the country.

You can see that the places in Western Europe, in the United Kingdom, in the Arabian peninsula along the Eastern coast, the United Arab Emirates, Oman. These are places almost by definition right at the port, and these are countries that are advantaged, by very low cost transport conditions. England with the, it’s many rivers, with it’s coastal access and London as a city on the Thames able to engage in great international trade, was made possible because it has the advantage of a great river and great access to world trade. But the large continental countries, take Russia, shown in red here, meaning that it’s populations are very far from the closest port, have a big disadvantage. And Russia did not develop a lot of trading cities. There’s St. Petersburg up in the Baltics. But For most of Russia, the cities are land based and face huge over land transport conditions. Have a look at Africa. Almost the entire center of tropical Africa is in red. Not surprising. Most of the countries shown there are landlocked countries. Africa has the largest number of landlocked countries in the world. And it means, for those countries, populations are far from the ports and politically far from the ports as well. Because of the problem of crossing a political boundry even to get to the nearest port. Turns out, that countries abilities to engage in international trade and, thereby, to be part of the wave of global growth Is strongly related to the evidence shown in this picture. The countries that have proximate access to international trade have tended to grow better, faster, and earlier and those that are landlocked and far from the ports have tended, with some important exceptions, to be laggards in the process of economic development. Now the next map shows yet another crucial aspect of physical geography. We know that energy is at the core of the ability to engage in every economic activity, whether it’s farming, industry, services, transport. Home conveniences, energy is vital. And we know indeed that the steam engine really represented the whole take off of the industrial revolution, because for the first time in human history humanity could use coal.

And thereafter fossil fuels more generally; coal, oil, and natural gas. As a major source of the energy for the world economy. That gave it profound impetus to modern economic growth. But the distribution of these fossil fuels that have been so important for the world economy over two centuries, is highly varied. Some parts of the world are blessed with massive deposits. Other places in the world have almost none. In the 19th century, coal was king. We did not yet have in the economy, even the internal combustion engine in the automobile using, oil. And so coal was absolutely central for industry through the steam engine. For transport through rail. And steamships and so forth. But look at the map. Who has coal and who doesn’t have coal? Well, England of course has it. Western Europe has lots of coal. The United States, Russia, Africa. Very little coal, almost none in tropical Africa. That’s no accident of, politics or culture. That’s a matter of deep geology. When the coal was formed through tens of millions of years.

The African continent was in the wrong place with the wrong climate and the wrong conditions to generate coal over the earth’s history. And the result is, that when the steam engine was developed in the late 18th century, Africa had no local coal that it could use. And even when countries tried in Africa, such as Egypt and North Africa. In the middle of the 19th century to develop industry based on imported coal. The costs were just too high of transport to be able to make a go of it. So the deposits of resources, a pure accident of geography and geology can make a huge difference. The next picture I’d like you to look at is another map of the world, huh, this doesn’t look like a map of the world at all, this is not the shape of the planet as we know it, it is the shape of the planet if each country is given the size of its oil reserves. And what you see here of course, right at the center of the map is Saudi Arabia, with it’s massive reserves of petroleum. And you see, other large countries on this world map, which doesn’t look like a world map. Iraq, Kuwait, Iran, Venezuela, is major world reserves.

The United States show up there. It’s used up a lot of its historical legacy of reserves. Where’s Africa? It barely shows up on the map. Because only a few places in Africa Nigeria and Angola, and now a few finds in other parts of Africa have given Africa the home based potential. Of petroleum. And one, one measures these reserves relative to the national populations. Of course, the differences are even more vast. Some countries have massive reserves per capita. A country like Kuwait. That leads to huge income per capita. Other countries, like Mali or Niger or Chad, have populations with no oil to speak of or just tiny amounts. And they have suffered from the absence of traditional fossil fuel energies of any kind. They have something up their sleeve now with modern technology, lots of sunshine, so solar power could be a great breakthrough in the age of sustainable development for many countries that were unlucky in the sense of not having the fossil fuels to give them the local energy resources for development. There’s another aspect to geography that makes a huge difference, and that is climate. Not surprising because we all need food and water to survive, to thrive, and climate has a huge effect Not only on the quality of our lives, but on the ability to grow food for our sustenance. You’re looking at a climate map of the world. I find this map quite beautiful. The colors, the variation around the world, it’s quite complicated. Because climate scientists have created many climate classification systems. And the Koppen-Geiger system that’s shown in this map is one that I prefer. The pink and the red areas are the warm tropical areas. They have very distinctive challenges in food production and in disease burden. Where many diseases, such as malaria thrive. The beige areas of the world are the dry ones or where water is scare or in the desert areas basically non-existent and dry regions have the very particular problem. Of growing food and they have particular vulnerabilities of extreme poverty by the difficulties of food production. The light green and the dark green areas are the temperate zones in this climate system. They tend to have winters and summers, and most of them have pretty plentiful water throughout the year, though the particular kind of temperate climate varies. Most of the high income economies of the world traditionally have been in these temperate zones. Food production, dairy production, timber, other parts of agriculture have been favored in the temperate zones. And since modern economic growth began in a temperate zone economy in England. It naturally spread to other tempered zone locations like most of the United States. Like Australia, Argentina, Uruguay, Chile, and so on. So climate has made a big deal difference and in the next map you’ll see one of the reasons why climate Is so powerful. Not only for food production, but for the location of disease burden. Malaria is a disease that in the rich world, we may read about, but don’t experience firsthand, except on visits to tropical locations. And that is because of the physical environment. Its a disease that is only transmitted when temperatures are above about 65 degrees fahrenheit. In cooler climates you dont get maleria transmission. And in the very warm places that are warm all year round, such as tropical Africa, you can have very high, year round malaria transmission. Well, we know, as we’re reminded of a child being attended for malaria that repeated bouts of malaria not only claim Vast numbers of lives, still hundreds of thousands every year. But, they debilitate societies unless the disease is controlled. Children don’t finish schooling, if they survive, they may have long-term difficulties and liabilities as a result. And so, In this way, we see that climate has very subtle and often very insidious ways of holding back economic development. There’s good news of course disease like malaria and many other tropical disease can be brought under control. But it’s an extra challenge and extra expense, it’s one of those things that needs to be targeted. If we are to succeed insustainable development, geography is not deterministic, it’s not true that a difficult geography prevents development. But, geography conditions economic development and unless we understand it, focus on it. And target the problems that can result, countries can get stuck. If we pay attention to the lessons of geography, however, we can help spring countries now stuck in poverty, from the poverty trap, and enable them too to get on to the path of economic development

Lectures / Readings

Why Did Some Countries Advance While Others Remained in Poverty? I

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

The Idea of Clinical Economics

We’ve seen how modern economic growth diffused through the world. It started in England. It spread out [COUGH] like the ripples of waves on a lake surface. But, why did it go to particular places? Geography matters a lot, proximity to already rich markets matters. The conditions of the natural environment, the government policies all matter. I’d like to take a deeper dive today into this question. What happens within individual countries that determine whether that country gets on a path of rapid economic growth and development, or whether it remains mired in poverty.

There are lots of reasons that, or good explanations for why some countries advance and others get stuck. But what’s true is that those good reasons don’t all apply to all places. The real art of economic development is to make good judgement what’s happening in this particular place. Not on average, but if there’s a country that is facing an economic crisis, if your country is stuck in poverty, Or stuck in instability. What needs to be done here and now. How do we make a diagnosis? Well, I, I was lucky, in, in, my own work and thinking about this because I got to watch close up a wonderful diagnostician. Do her work. Thats my wife. Shes a clinical pediatrician, and when she sees a young child with a fever, she doesn’t say oh that’s it I know what that is all fevers are the same. Of course she does something completely different. Her training and knowledge and experience shows her as a trained medical doctor that there could be a thousand reasons for that fever. And in order to give a good prescription there has to be a good diagnosis. And what the doctors call it is differential diagnosis. Well I’ve come to the view that in economic development, and in sustainable development more generally, we also need to have a clinical approach. In my book The End of Poverty, I called it clinical economics[1]. And I said the world of a good practicing clinical economist is to make a differential diagnosis just like a good medical doctor. And the fact of the matter is that as medical doctors go through their checklist what could be the cause of that fever. Is that an infection, is it something more serious. And they look at the evidence, they look at the lab results, they do the interviews, they try to understand from the parents and from the child, what’s happening. And then they draw a rich diagnosis. So to we as. The practitioners of sustainable development need to make such a differential diagnosis. On my checklist, as I presented it in the end of poverty, I suggested seven items on that checklist. Each with many categories to work through. What could cause a country to be stuck in poverty or stuck without economic growth? Let me mention the seven. First, could be what I call a poverty trap. Second, it could be bad economic policies, governments just making terrible mistakes. Choosing the wrong kind of strategy, closing the borders when international trade would make more sense, going for central planning under communism when a market system would be much more propitious for economic development. A third it could be that the government is broken in some manner, and most often, it’s bankrupt. Many governments around the world, and throughout history, have gotten into a fiscal mess. They’ve spent too much, they’ve taxed too little, they’ve got into wars that they shouldn’t have done and couldn’t afford, and ended up with a massive fiscal crisis. A fourth is physical geography. Maybe the country is stuck. Because it’s landlocked, high in the mountains, facing a terrible disease burden. Malaria for example. You might say, well if it’s geography, what can you do about it? You can’t change your geography. But the fact of the matter is you can change the consequences of your geography. If a country is landlocked, it needs to think about transport, and the kinds of industries that it’s promoting. If it has a heavy disease burden like malaria because of its tropical environment, it has to think about specific disease control. So while geography might not change, the results of geography are often subject to the human resolution. A fifth kind of failure could be ru, the lack of rule of law, massive corruption. That corruption[2], when it gets out of hand, can completely frustrate the normal processes of governance and therefore of economic development. A sixth. Problem could be cultural barriers. In fact, it’s very often said, if a country isn’t performing well, something’s wrong with the culturee. More often than not, I think that’s glib and simplistic, but sometimes cultural factors can really make a difference. And last. It’s geopolitics. By geopolitics, I mean a country’s relations with it’s neighbors, with it’s foes, with it’s allies. Because countries can suffer geopolitically. Of course, countries that fell under imperial domination in the middle of the 19th century and were under colonial rule for a century or more. Our powerful examples of what geopolitics can do to frustrate economic development. Clearly these seven factors and the many sub-factors that would fall under each of these categories does not necessarily apply in any particular condition. It’s a checklist for a diagnosis to ask what in particular counts in this particular place from the point of view of the strategy of economic development or of sustainable development more generally. In my own experience of more than 25 years of working with countries all over the world, It’s really struck me how different parts of the world in different counties in different times have extremely different conditions that they need to confront to get out of the rut, and the idea of always prescribing the same medicine, for a doctor it would be a disaster, the same is true. A foreign economy. I worked in Bolivia in the middle of the 1980s. That country had a hyperinflation. Prices were rising thousands of percent per year. When you did the differential diagnosis you could see that the government was broke. The government was printing money to pay its bills. And therefore what was required most of all was to get the budget under control in short order so that this fever of hyperinflation could be broken. That involved in part cancelling some of the debts that Bolivia’s government owed to international banks. That was part of the solution. Maybe in other countries, that wouldn’t have been necessary but in Bolivia’s case, it was. 1989, when Poland was in the transition from communism to a market economy, the great challenge was to allow supply and demand, markets and trade to work once again. Because the central planning mechanism had collapsed. When I began working in Africa, in the middle of the 1990s, the conditions obviously were completely different, from those of Poland, or Bolivia earlier, indeed other parts of the world. Africa was in the midst of a massive AIDS pandemic. It was in the midst of a massive resurgence of Malaria. Many places were so poor, that the most basic infrastructure, grows. Power, water, and sanitation did not even exist. I’ve found some. Economic officials from international institutions prescribing exactly the same medicine that, that they had said was needed in Poland or in other places. And it amazed me. Do a differential diagnosis and you see the problems in Tanzania or Ghana or Mali are completely different. From those in Poland. Do expect that these conditions will differ across history within a country, and certainly at any time across countries of the world. Now, one of those possible diagnoses is a poverty trap. Since we want to focus on the poorest of the poor to help. The poorest places get out of poverty. It’s important for us to focus on this particular case. It does not apply to most parts of the world. The idea of a poverty trap is rather straightforward, even if it’s sometimes overlooked. The idea is that any. Economy in the 21st century needs certain basics in order to be able to achieve economic development. It needs the basics of roads, of ports for trade, of electricity. Of safe water and sanitation for the people of access to basic health care so that the population is not burdened massively by disease and of education for children. Pretty basic list, and most of the world is able to secure that. But the poorest of the poor countries often cannot. Because the amount of finance that’s needed just for those very basic goods could be out of reach of the government. Let me give you an example. Suppose that you look at the basic cost not of, of fancy systems for health and education, roads and power. But of a very rudimentary system to help a poor country get started in economic development. Say that the cost of that, when you add it up, is $200 per person per year. Consider a poor country, say, $500 per capita as we’ve seen in the case of Malawi, for example. The budget for Malawi might collect 20% of the national income for public provision of goods and services and investment in infrastructure. Well, 20% of $500 per capita means that the government would be collection $100 per person per year. But we just said that the minimum needs are $200.00 per person per year. So the government of Malawi may be staffed with wonderful people and they know just what to do, they’ve made a great differential diagnosis, they even have plans on the shelf for schools, for clinics, for roads, for power, for water and sanitation. But how are they going to pay for it? They are trapped in poverty. Because they know what to do, they know the investments that need to be made, but they don’t have the money for it. There are two ways to break the poverty trap. One way is to borrow that extra money, and then have the economic growth that results. Help to pay off in the future. If global capital markets worked well, that would be a remedy. But private markets and public lenders say, well, that’s a poor country. That’s too much of a credit risk. We can’t lend to it, even if our loans would trigger the development that would allow them to repay. So the capital market solution doesn’t work all that well. The alternative is to get a boost of help. A short term boost, sometimes called aid or sometimes called official development assistance. So that a country like Malawi can fight Malaria, or build the classrooms for it’s kids. This is a pretty proven method and it really works. During the last dozen years or so as the world has been organized to help countries in extreme poverty fight extreme poverty. There have been special institutions set up like the Global Fund to fight AIDS, TB, and Malaria. And when money is put into that fight, you get tremendous results. Alas, even though the evidence is strong that it’s possible to break a poverty trap by that kind of target investment, and there are some positive results along the way. We haven’t quite succeeded yet in the world accomplishing that, in part because the concepts of what’s needed, the diagnostics of how to do it, and then the institutions to offer the finance are not fully in place. This remains one of the great challenges of sustainable development.

[1] http://en.wikipedia.org/wiki/The_End_of_Poverty

[2] http://www.transparency.org/cpi2013/results/

Bilhetes

Espaço Patrimonial na era da Reprodução Tecnica

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

Monumentos Expo

Lectures / Readings

Human Rights and Gender Equality V

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

Gender Inequity

Social inclusion is a challenge across groups racial groups, ethnic groups, linguistic groups. It’s a challenge across classes, especially when market forces and politics combine to widen the gap between the rich and the poor. And it is from time immemorial been a challenge, across the gender. Because from traditional societies until today in most parts of the world, women have faced massive barriers to their effective participation in the economy. To careers, to earning a living. To the right to own and inherit property, or to start businesses. Often this discrimination has been, legally imprinted, it’s in the books, in other words. Often it has been cultural barriers. Fortunately, this is changing and changing fast in many parts of the world. indeed, my own experience working in poor villages, in remote areas that are known to be traditional patriarchal communities where the men are in charge. Even in such places, one can observe dramatic social change before one’s eyes, where villages that, up until recent years, never contemplated that a young girl would complete a primary education and go on to secondary school are now actively pursuing, when given the opportunity, the education of their girls, not only through secondary school, but of young women into higher education, and then coming back as leaders of communities. And this in places with the reputation of being highly discriminatory in practice. So, we’re in an environment of flux, where age old practices of discrimination against girls and women are changing. Where ideas are changing, where economic demands are changing. And where economic possibilities for girls and women are changing in the right direction. Our purpose in sustainable development is to help that process to help insure that societies make all opportunities open to girls and, and to women and thereby dramatically to improve their economic performance. Often this is a key step out of poverty. Often it’s a key step to overall sustainable development because when girls are educated, when women are empowered, many very important and powerful and wonderful things happen in society. That help not only the economic development and social equality, but also the environmental sustainability. And of course, the quality of governance in society. All of the aspects of sustainable development. The Millennium development goals, took on gender equality in a quite strong and direct way, MDG3, says that the goal was to promote gender equality, and empower women. And the specific target attached to that is in the education sector. To eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015. And this should be measured by the enrollment rates and the completion rates of girls compared to boys, and primary secondary and higher ducation. Let me emphasize the many many gains that will be achieved by honoring and fulfilling MDG3. First, of course is human rights. This is a basic question of human rights. Back in the Universal Declaration of Human Rights and in the International Covenant on Economic Social and Cultural Rights, as well as the International Covenant on Civil and Political rights. The rights of, girls and women are protected, absolutely as clearly and strongly as the, the rights of, boys and men. Gender equality is at the core of universal human rights from the very start. But the economic gains the practical implications of this, are enormously strong as well. And that’s why Jeremy Bentham, with his Utilitarian philosophy of the greatest good for the greatest number, would be the first champion of gender equality. Because, Jeremy Bentham’s utilitarian calculation would be very very clear that, it can’t work for society, as a whole to try to operate on half its brain power, half its human potential, half its investments in skills, training, and know-how. So the returns to investing in girls and women from a, quote unquote human capital point on view, the productivity of women in any sector of the economy, whether they’re farmers or workers in industry or workers, workers in the service sector. Of course, is greatly enhanced, as it is for men by more education, better literacy, numeracy,and advanced skills. But when investing in women, there’s a, an added dimension that is extremely important. Women are biologically and socially the main caregivers of children in the family. Of course, that’s a, a bit of a social phenomenon, but it’s also a very real phenomenon naturally, because the health of the mother in pregnancy, for example, is absolutely pivotal for the well being throughout the lifetime of of, of the child. We’re learning how intrauterine development, what happens to the, the fetus during pregnancy, can create the conditions for health or ill health throughout the, the entire subsequent, life. So if a mother faces discrimination, if she’s not eating properly, if she is not literate and able to secure access to antenatal care for example, the consequences can be devastating for the child. Of course, the mother then by best health practice, will be the exclusive provider of nutrition for the newborn for the first 6 months in breast feeding. And will play an important role of breast feeding and a complementary feeding basis, for another year or year and a half after that. Say for, the period from 6 months to 2 years. And so the mother’s health, her well-being, her knowledge of how to take care of the child is absolutely essential to the well being of the next generation. Invest in a girl, you’re investing in a mother. Investing in a mother, you’re investing in a child’s wellbeing in the next generation. You are thereby having a fundamental role in intergenerational social mobility. And so that’s an added, decisive reason why gender equality is so essential, and why gender discrimination, discrimination against girls and women, has such a pernicious effect on societies, causing one of the most profound reasons why they may remain stuck in extreme poverty. We’ve also noted that, as the woman is empowered with more skills, as she is therefore enabled to enter the labor force, earn a decent income. It will be very much expected on a variety of reasons for the mother to have fewer children. To have a voluntary, rather quick reduction of the total fertility rate. One thing is that the woman herself will be empowered within the household. Sometimes, there’s a difference of opinion between the the, the mother and the father about how many children. The father says, as many as possible. The mother says, I’d rather have fewer, but in many traditional societies, the mother’s voice is very weak, in that negotiation if it even is a negotiation. But more importantly, both the husband and the wife very often agree completely, that if the mother is with skills, with education, especially, able to be in the labor force earning a decent income, then the opportunity cost of having more children is very, very high. The time taken out to raise the child may be very expensive in terms of lost income, and then it’s not a difference between the father and the mother, but rather an, an alliance of views that say, better to have fewer children, to invest more in the health, nutrition and education of that smaller family, and we’ve seen for so many reasons why that’s a better deal for the children themselves, and a better deal for the society in accelerating the end of extreme poverty. And in combining the economic development with the social inclusion in that next generation. We have new tools very good ones, and ever-improving tools to assess the state of gender inequality, and to make comparisons across societies in ways that can give good direction and impetus to societies to to do better.

The United Nations development program beginning in 2010, has began to construct a Gender Inequality Index, which is a, a very handy and useful tool, like its Human Development Index, the Gender Inequality Index combines several different dimensions on a weighted average basis to give a Quantified Assessment of gender inequality that can be compared across countries. In this index, there are 3 different categories that are included. First, reproductive health. If mothers face very adverse conditions in, reproduction, then this is scored as a high degree of gender inequality. Two sub-categories to reproductive health, one is the maternal mortality rate. That is the rate at which mothers die in child birth or pregnancy, more generally. And the second is the adolescent fertility rate. The rate at which adolescent girls are bearing children. An indication of girls being forced out of their education into early marriage, and early child bearing. The second big category in the gender inequality index is, empowerment. And this is measured 2 ways in the index. One is by the share of total parliamentary seats, held by women. And the second is by the enrollment rates of women in higher education. In the third big category, of the gender inequality index is the measure of inequality of labor market participation. In some societies till today, women are simply not allowed to work in many sectors of the economy. This is especially true in the Middle East. Where women even very educated women, can’t work with men alongside them, or, are not allowed to work at all in particular sectors of the economy. In other places, labor force participation by women is very, very high. Public Policy plays a role here, not only in barring or allowing women to participate in particular sectors, but also in facilitating that participation. In Scandinavian countries, for example, with the social democratic ethos and the social welfare state. Every woman is afforded the right to have access for their child, in a quality daycare, financed by the state. And that enables mothers, even poor mothers who might otherwise not be able to afford the child care, to leave the children with the high confidence in a, a very safe preschool environment, and often a preschool environment which does an excellent job of helping to prepare that young child for primary school education. Well, the result of putting together these 3 factors of reproductive health, of empowerment, and labor force participation, gives us a world map that you see in, in front of you. And the color code, as always, gives us an indication of the relative rankings of, of countries. What you can see is that, again, not surprisingly, because we’ve seen it again and again, northern Europe, and especially Scandinavia, Sweden, and Norway, Denmark, stand right at the top of, of the world league tables, in having the lowest gender inequality. A strong representation of women in parliament, very high labor force participation, excellent coverage of reproductive health services. Then you have many countries that are a bit in the middle of the pack, still high. But not as high as Scandinavia. My own country, the United States is an example of that where conditions are relatively good on a global basis, and this is after decades of improvements of the legal status and the social status of women in the society and in the labor force. And then there are countries that are clearly places where girls and women continue to face a tremendous amount of discrimination. And you see this in West Africa, where the index scores are low.

And you see it especially in the places where the inequality ranks the highest. This is in the Middle East and in West Asia. Typically societies, Islamic societies where women are not allowed to have an economic role where strict separation by gender is often enforced. As in many aspects of Saudi society. And where women’s participation in the political process is extremely low. so, this gender inequality index is rather vivid, in highlighting on a multidimensional basis, where progress has been high, and where progress is still very much needed if society is to reap the benefits of gender equality. We can see in more detailed way, the underlying factors in this index. Shown here is the participation rate by women in parliament. We know that in much of the world women are not well represented. This is true in a lot of Africa. It’s true in the Middle East. It’s true in large parts of Asia. At the other extreme, again, is the very high representation in northern Europe, and especially in Scandinavia. Remember that Rwanda is a remarkably exciting exception, to the general trends because there’s very very high women’s, representation in the parliament. More than 50%, the very highest in the world. And I think, causally a factor in Rwanda’s, large strides in social progress and social indicators in recent years. The next picture shows the labor force participation, differences across the world. The highest rates of labor force participation again are in the Scandinavian countries with all of the support of the social welfare system.

The lowest rates are in the Middle East and North Africa, and Western Asia.and, and in South Asia as well, where women are not in the labor force, either for legal or for cultural reasons that anywhere close to the rates in other countries. These are tremendous lost opportunities. I’ve worked in a number of countries in this region. Often households are quite poor. The woman is quite skilled, maybe even with a college education, but not in the labor force, because of the prevailing ideas within the family, that it’s not right for the woman to be out of the house, for example. And I find it a bit frustrating, to see the family and the children suffering poverty, even when the opportunities are there, the skills are there.

And with both the legal and social empowerment, the women would definitely find opportunities and a very gainful employment. Even in the high income countries where labor force participation has remained higher or has become higher, I should say, because it’s reflected a lot of social change over the last half century, there are still some significant gaps in the earnings of men and women. Women may take time out from the labor market, during child bearing and raising young children and this can cause them to suffer a strong loss of earnings, companies may discriminate saying we’re not going to invest in, in the skills or the promotion of women because we think they’re going to leave to raise families or simply because of social norms. And I’ve been shocked, I have to say, by sometimes what I’ve heard from CEOs in some parts of the world who just assume, them being, they being men, that women do not have a place in top management. But there is progress, and it’s important progress.

In education, and, I think, with the good impetus of the Millennium Development Goals, there has been a narrowing of the gap at the primary level, the gap has nearly been closed, or has been closed in most parts of the world. Girls in primary school age are in school, they are completing school, they have comparable enrollments to boys. In some parts of the world, the girls have overtaken boys at secondary and tertiary level. This is an exciting development. Sometimes I’m wondering what’s happening to those young men, because they’re dropping out, the girls are staying in university. Latin America, which had a tradition and, and a reputation as a Makismos Society male-oriented is a place where girls have really done very, very well at secondary and tertiary education. And the gaps have been narrowed or fully closed or more, more than cloth closed, in recent years. And this is a, a very exciting development.

What can be done? What should be done when gender inequality is high and society is bearing the heavy cost of that? It’s clear that as always, a multidimensional process needs to be deployed because some of these barriers are legal, some are cultural, some are a matter of tradition and inertia.

Legal reform is often remaining a very important factor. Can women run businesses? Can they own property? Can they inherit property? Shockingly, the answer is often no, still today in the 21st Century.

Women’s representation in politics. Sometimes it’s a matter of women running for office and this becoming a normal practice. Some societies have, added quotas, that say that certain proportion of the votes on a proportional representation list of a party, must be taken by women. And this can have a very powerful effect of changing ideas, changing norms, and changing policies when the women are represented.

Government financial support for families, for maternity leave, for child care, play a huge practical role in the places that have had most success, especially in the Scandinavian context. The rest to the world needs to learn from that example. Early childhood development activities where government ensures childcare, preschool, health and nutrition programs for young children, obviously for boys as well as girls, is a big help for gender equality, because otherwise, the mothers are the caregivers, the mothers that don’t then have the opportunities either to provide the care that their young children need, or to be able to rejoin the labor market.

And finally it bears emphasizing that around the world till today, women face a terrible, terrible unspoken burden of violence. Whether it’s rape and and the kind of violence that once in a while gets reported, or it’s husbands beating wives and we know that this is a part of the real world around the world, UNICEF and other UN agencies have undertaken heroic efforts to bring this kind of violence against women and girls to light. To help advocate and press for changes of laws, and when the laws are on the books but the enforcement is not, to press for proper enforcement, and public leadership so that these laws are taken seriously, and they are enforced. In many traditional societies women were the property of their husbands and the property to beat if that’s how they saw fit. This inhuman approach that is a most fundamental denial of human rights has got to come to an end. It is a core part of gender equality. It is a continuing reality that must be brought to a close.

Lectures / Readings

Human Rights and Gender Equality IV

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

Forces of Widening Inequalities

Social inclusion means prosperity that is widely shared and we’ve noted that large groups in society, because of the forces of history. Cultural exclusion, violence have entered the 21^st century in situations that are often extraordinarily difficult and challenging. We know that women in many parts of the world continue to face. Major barriers to their economic participation, their prosperity, their ability to prosper. Young girls have faced the difficulties of achieving and gaining access to the education. The health that they need for their own well-being as future adults and future citizens in their country. We know also that economic forces putting aside for the moment gender and ethnic divisions. Are also playing a role in widening inequality and undermining social inclusion in many parts of the world. I’d like to focus for a few minutes on the economic and political drivers that are causing larger and larger class differentiation within societies.

We have at least three fundamental forces that have been playing a role in widening economic inequalities in the United States, in many European countries, and in many of the emerging economies. Around the world. One is the rising gap between high-skilled and low-skilled workers that has resulted from forces of globalization. A second phenomenon is changing technology that is having a differential effect on different Income groups, different classes within society. And the third force is the political system often amplifying the widening inequalities caused by globalization and by technological change. So. Perhaps the useful starting point to understand these changes is a frequently viewed graph. This case for the United States, but one would find similar though perhaps not as stark conditions like this in other places in the world. This is a graph of the premium in income, the extra income, that is earned by college graduates in the United States, relative to high school graduates. So take the population, the labor force that has a four year college degree or higher, could include those with an advanced degree. Look at the earnings of that group. And then compare it with those that have a high school diploma, but not more. And this is what we observe in the case of the United States, from 1973 until the recent decade. What you observe is that for all of this period, having a higher degree, not surprisingly, means more income.

In 1973, a college grad had a 30% premium relative to a holder of a high school diploma as the top level of educational attainment. That actually dipped. During the 1970s so that that premium fell to under 25%. But then from roughly 1979 onward, we see in this graph, that the college wage premium, as it’s called has soared. And has increased to around 45% wage premium compared with a high school degree holder. It’s interesting that, that increase started around 1979, because that’s also a period when many powerful forces of globalization linking together the high-income world and the emerging economies really started to develop.

So this is a, a puzzle for us. Why did the Gap between those with higher education and those with a high school diploma suddenly widen. What happened? And, I would argue that the three forces that I mentioned, globalization, technological change, and politics have all played an important role. How would globalization work? Well, consider the US suddenly, becoming a trading partner with countries like Mexico or Korea, or Taiwan. Remember those Asian Tigers. Which were the first of the emerging economies in Asia to achieve rapid, economic growth by dint of their export-oriented strategy relative to the U.S. and European market. Or consider the fact that soon after, 1979 China opened its economy to international trade. And opened its border regions in particular to host foreign Companies that would locate in China to produce goods, some of our favorite electronics products for example, to be assembled in China and then reexported to the US and Europe. This kind of globalization is economic integration. Made possible by improvements in technology such as mobile phones, and computer assisted design and manufacturing. Containerization and radically lower transport costs, suddenly put US workers and Chinese workers into the same labor market. Now, the Chinese workers at the time made much less than $1 per hour whereas American workers might have been earning $10 to $20 an hour. And yet suddenly both sets of workers would have the same technologies at their disposal.

The Chinese workers, after all, would be working in factories using the very machinery, the specifications, often literally the same companies, as the American workers. And so suddenly, the relatively low-skilled Chinese workers, may, maybe with a. A high school education would be using machinery to put together electronics products. Or to cut and sew apparel. Or to make plastic objects, extrusion objects and components of vehicles. That American workers had been employed to do up to that point. This joining of the labor market through the internationalization of the production technologies and the role of multinational companies in bridging. Between the high wage US market and the low wage emerging economies, transformed the labor market globally. In the US, there began a quite significant decline of jobs in traditional manufacturing sectors. The apparel sector, for example, was displaced. Whether to Mexico or the Caribbean, or Honduras, or to East Asian low-wage sites. The electronics assembly industry which used to be part of an integrated electronics operation. Was separated from the R&D base or the the production of the semiconductors themselves so that the relatively lower skill part of the work of assembling. The mother boards of electronics, devices, and household appliances. Could be moved to China, or moved to Vietnam, or to places where the wages were a tenth or a twentieth or a fiftieth of those that might prevail in the U.S. Suddenly the downward pressure on the wages, especially of the relatively lower-skilled workers in the United States. With their High School diplomas suddenly facing competition from abroad became intense. And I think that’s why 1979 is this turnaround time. Deng Xiaoping came to power in China in 1978, threw the Chinese economy into openness and market institutions. And while that took a process of three decades subsequently to build China as the great workshop of the world.

The dynamics of an integrated global market began to really play a powerful role at that point. And we know in the United States that. The US just about time of 1979 had the peak of its employment in the manufacturing sector, around 19 million workers. And from 1979 onward there has been a significant decline. Of manufacturing sector employment. A loss of jobs. Partly a displacement to lower wage economies. For those low wage economies, a huge benefit. A key part of the rapid economic growth that is lifting people from abject poverty. By no means a bad thing. But with a real impact, in the high wage labor markets, putting downward pressure on the wages of the relatively lower skilled workers. Now even if it weren’t for globalization, another force certainly is at play. And that is the information revolution, and all that it signifies. Meaning a progressive automation of many production processes, another force leading to higher productivity, but fewer jobs of the traditional sort. In many key sectors. So put China out of mind from the US perspective for a moment. And just think about how technological change has re-made the shop floor of major manufacturing sectors. Automobiles probably being among the most dramatic. I’ve toured many automobile factories. Some absolutely stunning and amazing. One in Japan of Toyota where we entered a very, very large assembly line completely clean. Completely quiet. And almost no workers around. Vehicles were going their merry way until you looked closely, no drivers. Because the vehicles were being directed automatically to deliver components from one place to another. And the whole assembly line all the way down this large cavernous hall. Robots. Very clever. Very sophisticated seemingly tireless robots with the great precision. Reaching into a basket, taking a component, putting it just where it should be on the automobile chassis coming down the assembly line. Next automobile, often of a different make, and the robot knowing through, of course, its programming. To put that component in a somewhat different place on the chassis of a somewhat different vehicle. All remarkably automated. The robotics are one of the most visible, remarkable aspects of the information technology revolution and the computerization revolution. That we are enjoying in the 21^st century. It’s raising productivity dramatically it is of course lowering the costs of many, many goods and services. That kind of automation even when it’s not literally a robot handling a physical product. But is simply a computer making massive payrolls or processing orders that thousands of clerks might have done in an earlier day, is part of a modern high productivity economy. But, just like the off-shoring of jobs. It’s taking a toll on workers who used to do exactly that kind of labor. And so technology also drives income differences across countries. And we are seeing the combination of globalization and technological change, in an intertwined way, putting a special pressure on lower skilled workers. We can’t even separate these two phenomena with any precision, though you can image economists have written hundreds of articles, I’ve added a few myself. To the debates how much is globalization, how much is technological change. Well since globalization itself is enabled by the same technological change making a clear difference between the two is not possible analytically. But what is discernible is the fact that this rising wage premium has absolutely come from both of these phenomena. Now, I’ve stressed that there is a third factor that is part of this story, and that is politics. And this is extremely important for us to understand.

Market forces alone would widen inequalities. The wage premium is a real phenomenon coming from the combination of globalization and technological change. What you see in this picture of the income levels by a more detailed classification of educational attainment. Showing that those with an advanced degree have had the biggest gains of earnings. Those with the bachelor degree next. Those with some college, high school, and no diploma basically flat, or even declining income levels, but something more has been at play. When that market inequality starts, starts to rise, politics then enters the scene. In some political systems, government forces would lean against this by saying, well lower skilled workers are facing a problem. They need some extra help. Maybe some new job training. Maybe a cut in their taxes. Maybe added family benefits. High-skilled workers are receiving a bonanza, both because of technological change and because of globalization. And maybe they should receive fewer benefits or pay higher taxes. And in that way, government would, as we say, lean against the wind. If market forces are tending to widen inequality, political forces would tend to narrow it. But in some places, and my own country, the United States is definitely one, political forces amplified the market forces, took a widening inequality, and made it even more. Of a steeply widening inequality as a result of politics, rather than helping the poor and perhaps taxing the rich to do so. In the Unites States, the poor lost even more of their social support as government cut back. And the rich gained government support as their taxes were reduced. Rather extraordinary. And one can even date this, I’ve argued, though some disagree with me, to a specific political event and that starts in my opinion on January 20th, 1981. When Ronald Reagan became President of the United States. And came into office reflecting various political forces which said, that they should implement the libertarian philosophy. Get government out of things. And reduce taxes, reduce social support. The libertarian view does not agree with the basic needs philosophy that everybody’s needs should be represented. The libertarian philosophy more takes the point of view that government should not play a role, that taxes should be cut. That’s argued both on a philosophical base that freedom and liberty are the number one goal. It’s argued on a pragmatic base that, that will free up the dynamism of the entrepreneurs in society and through a kind of trickle-down effect, make everybody better off. But whatever it’s argued in the US, starting in 1981, and really continuing since that time, the rich and powerful have had advantages of politics. Their taxes have been cut. Their even as their wealth has soared they have faced a diminishing share of their income being paid in taxes. Various restraints on their behavior, whether it’s cultural norms that say don’t take so much money or whether it’s practical limitations of how companies operate, have been relaxed. Deregulation in the financial markets for example, enabling the top management of the financial system to pay itself mega bonuses and massive compensation. And so in addition to the market forces suddenly in the United States as well starting in the 1980’s, the incomes, the total compensation package of the. Top management of the big companies, and especially on Wall Street and in the financial companies, began to soar. And so the United States faced not only downward pressures on the low-wage workers, but upward pressures at the very top, what became known in the American. Political parlance as the top 1%, though sometimes it’s even a fraction of that top 1%. The income levels soared, and this is illustrated in a graph showing the ratio of compensation of Chief Executive Officers, CEOs in American companies to average workers. What you see is that that ratio was maybe 10 or 20 times higher in the 1970s, but suddenly, the compensation packages went out of sight. The regulatory constraints, the cultural norms were, went in the direction of saying pay the top everything, let them take huge amounts. And suddenly, these CEOs were earning hundreds of times the income of the workers. And the result is shown in a curve that illustrates the income share taken by the top 1%. Of America’s richest households, the blue curve. And what you see is over the course of a century, the income share was between 15 and 20% up to the time of 1929 when the great depression started. The new deal era of the United States came in, government cracked down on a lot of abuses in the financial sector, for example. And the income share at the top went down sharply. Tax rates faced by the top went up sharply. The income share of the top 1% was around 10% of total income between 1940 and the late 1970s. Still pretty good. 1% of the households taking 10% of the total household income. But then the curve starts straight up and it’s not just market forces doing that because this isn’t observed in this extreme way in almost any other country in the world. It’s politics amplifying the market forces. Reducing the taxes paid at the top as President Reagan did. And as was subsequently confirmed by later administrations. Reducing the political constraints and the regulatory constraints on top managers to take home big take home pay. Suddenly the top income share in the US, the top 1% were taking home 20% of the total household income. And whats quite remarkable is the top of the top of the top, the top 1% of the 1% that is the top .01 % of US households around 12,000 in total because they are, are around a 120 million households. So 1% of those is about 1.2 million households, and 1% of that is about 12,000 households. They are now taking home 5% of the total income of American households, and so the inequality at the top, aided by the political process, also soared. And, in this sense we could say that the challenge of social inclusion is very well illustrated in the US context, though the story up until today is not a very satisfactory one for many, many Americans. On the one hand, market forces have amplified the inequalities. On the other hand, the political system not only did not come to the rescue of the poor, but reacted in a quite stark way. Coming to the backing of the rich. Pulling away some of the social support of the poor. Taking the libertarian view that the Government’s not going to address the issues of inequality. Making it harder rather than easier for society to meet its basic needs. Setting up an even bigger challenge for social inclusion as one of the key pillars of sustainable development. We will look at what can be done in this context because there are ways to reestablish social mobility and social inclusion. But the the political system has to participate in that if those methods of achieving social inclusion are to be effective.

Lectures / Readings

Human Rights and Gender Equality III

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

Divided Societies

Social inclusion aims for broad prosperity. For fighting discrimination, for equal protection under the laws, for enabling everybody to meet basic needs. And for social mobility to ensure that a child born in any part of the country in any part of the income distribution to any class or ethnicity or race has a chance. And through hard work, education, always a bit of luck mixed in, to achieve a good standard of living, and economic success in society. Of course, none of our societies achieves uniform equality. And nobody would want that. People differ by luck, tastes, work effort, and, naturally, this would show up in variations in economic outcomes and wealth.

People expect such differences to an extent, but societies, of course, can have differences far beyond anything that would emerge from normal differences between individuals and luck and circumstance and, for whatever reason, when inequalities are very, very large ethics and human rights would tell us that governments have some responsibility to look after those left behind. And many would think that helping to narrow the big gaps is part of our moral or ethical responsibility. We’ve already looked at the actual situation and how varied it is around the world.

We’ve looked at this map of the Gini Coefficient. Remembering that the Gini Coefficient is a measure of income inequality that varies between zero and one. Zero would be a society where everyone has exactly the same income. One would be a society where everybody but one has zero income and one person has all the income that is complete inequality and the Gini varies between those ranges, of course. And what we saw is really some notable and important systematic differences across regions of the world in the extent of inequality, and therefore in the extent of social inclusion or exclusion. On the whole, the Americas, as I noted earlier, with the notable exception of Canada, the Americas is a relatively unequal part of the world. Western Europe is a relatively equal part of the world. Northern Europe, especially the Scandinavian countries, Norway, Sweden, Finland, Denmark or the Nordic countries, I should say. Those countries Iceland included are among the most equal places in the world and the Scandinavian countries, specifically of Norway, Sweden and Denmark are right at the top of the list of indicators of social inclusion and at the bottom of the list with the lowest value of the Gini Coefficient. When we look at this map, we should think history, because standing behind this is a long history, a legacy, that has led to certain kind of inequality that I want to focus on for a few minutes. This is inequality across groups rather than inequality of individuals alone or inequality of households alone. The inequality that we see varying across the world in this map of the Gini Coefficient reflects the fact that whole groups within society, defined according to race or, in some places, according to ethnicity or linguistic group, or tribe have very different life chances from other groups in the same society. And so, the map, while also reflecting normal variation across individual households, also reflects the interaction of different groups within society. Take the case of the Western hemisphere with, again, Canada being a notable exception, for a reason that will become clear in just a moment. The Americas were, from the time of the first arrival of human beings to the Americas, probably around 13,000 years before the present, or thereabouts. To the year, and we can date it to October 12, 1492, the arrival of Columbus in the island of Hispaniola. The Americans by and large had almost no contact with the old world population. Maybe there was a tiny bit of contact in very short period. When Icelanders arrived in the coast of Canada and the northeast of the United States for a brief sojourn but without long term settlement.

The only long term settlement from that long period of 13,000 years before the present to the arrival of Columbus in October 1492 was by Americans, whom we now call Native Americans, that arrived fairly early on in migration from Asia after the last Glacial Period. And then settled throughout the Americas and the Caribbean in and, and established civilizations that developed completely independently of what was taking place in Asia, in Europe, and in Africa, until that connection was made once again with the arrival of the Europeans. The Europeans arrived with two huge advantages. One is they had more powerful weapons. The second is they had pathogens that to had developed the Old World to which the conquerors came already immune or protected. And those pathogens spread throughout the unprotected Native American populations leading to massive, massive set of epidemics and a massive dying off of Native American populations. Well, you know the history, the Americas became a kind of conquest society where European conquerors, and especially the Spanish Conquistadoras came and conquered a large part of the Americas, and generally ruled, and often ruled violently, over the indigenous populations. They added one more crucial element to the history of the Americas starting in the sixteenth century, and that was to bring in African slave labor, especially to the tropical and subtropical regions of the Americas, such as the Caribbean, the American South, northeast of Brazil. Not to Canada.

That’s one of the reasons why Canada is different. It never had a large slave population brought into Canada. And what emerged, of course, was a very complicated society of groups. A small European, dominant group, which ruled by force and power and the backing of empire, empires in Europe. A an indigenous population that was often broken by disease, by poverty, by forced labor. Essentially a kind of slavery or serfdom that was imposed in many places. And by the horrific institution of slavery itself based on the importation of African slaves into the Americas. And over time that three categories became more complicated of course, through a mixing of the three populations. So mulatto, or so called mixed populations of African slaves, European conquerors, indigenous populations, and so forth also developed across many societies. From the sixteenth century onward, those groups had completely different situations in their society, politically, socially and economically. And vast inequalities of wealth developed often with this small European population own, owning all of the, the good land in the country with the native inhabitants pushed, pushed, pushed into smaller and smaller land areas deprived of traditional land holdings. All of this is to say that the history of the Americas was a violent and conflictual one that created an extensive inequality, rather shocking by the standards of many, many other parts of the world. And that legacy of inequality continued past the sixteenth century, seventeenth century, eighteenth century, until the present day.

Slavery was eliminated, thank goodness, in the nineteenth century, usually by law in the United States, by, only by war, a violent war fought to end slavery. A very rare exception, because usually slavery was ended peacefully, but not in the United States, where the, the hold of White Southern land owners was so powerful that they resisted with a full force and a very violent war to try to protect slavery. And slavery was only ended in 1865, one of the last places in the world. And only two decades later, later in Brazil, so this is a phenomenon that comes into the twentieth century. And, of course, the descendants of slaves arrive to the twentieth century. And until the end of the twentieth century and into the early twenty-first century, often with massive liabilities of poverty and difficulties of poor health, lack of rights facing massive social discrimination. I emphasize all of this because you look at the dark red of the Americas in the Gini map, and you have to remember the history behind this, of a whole region of the world essentially settled by conquest, and then a long legacy that results from that. So, when we think about the forces of inequality today, we need to keep a broad perspective. This is the holistic approach that I like to emphasize. Inter-generational dynamics plays a huge role. Even when slavery ends, the legacy of slavery continues. Even when the massive brutality against Native Americans in the United States, essentially a genocide, or the brutality against the so-called First Nations in Canada ends by law, the legacy of poverty and poor health in discrimination, in property holdings and so forth continues thereafter. Social discrimination continues. Racial discrimination. Ethic discrimination. Of course, the gender discrimination which I will turn to shortly. Regional differences persist. Sometimes for only geographical physical reasons climate distance, transport, landlockedness, sometimes for the historical reasons of how various regions fell under imperial domination, for example. As a backdrop, there’s also the individual differences. We should not forget that. There will be variations in effort, variations in capacities, variations in luck, which will create a level of inequality in any society. And then finally, public policies shape these inequalities. Does the state meet basic needs? Does the state truly ensure education for all children? Is the educational quality that is accessed by the poor up to the job of providing a base for social mobility, or is the education access by the poor so poor that the poor get stuck in an inter-generational cycle of poverty? All over the world, the indigenous populations, meaning populations that were the first arrivals in a particular location maybe arriving in, in a location even 10, 20, 30,000 years ago and then subsequently facing later migrations like the Native Americans facing the inflow of Europeans after Columbus’s arrival. You see, whether it’s in the U.S. with the Native Americans, Canada with the First Nations, Australia with its Aboriginal population, New Zealand with its Maori population, Malaysia with its Orang Asli population, and the name given to various indigenous tribes, a rather remarkable consistency of major social discrimination, a remarkable extent of poverty social, cultural exclusion. And usually a legacy of rather brutal state policy as well. State policy that uprooted populations, that pushed populations into forest regions or mountain regions or desert regions as enclaves. One of the big mistakes that we make, often by the way in naivete is to see a an indigenous group inhabiting a very fragile environment. For example, an extreme dry region of a country. And you read the tour book and it says that the tradition of such and such tribe is life in this near-desert region. And, very often, that’s a nonsense to say that’s a cultural phenomenon, or a tradition. More typically what’s happened is that that group has faced massive dislocation and displacement and so, maybe this group was in the most fertile lands before, but then when the later waves of migration came and more powerful successor rulers in the region came, these discriminated groups were physically pushed into isolated areas in the forests, in the mountains, in the deserts. And then, to justify that in a naive way the life in those extremely difficult regions is described as the cultural tradition of the group in question. The poverty rates of indigenous populations is very, very high around the world, and it’s not a small part of the overall global extreme poverty. Nobody has a precise count of indigenous populations, but I think it’s probably right to say that it’s around 400 million people, adding up indigenous populations around the world. At least, that’s an estimate that is often given and that means that it’s nearly 6% of the world’s population. And since many of those 400 million live in extreme poverty and abject social exclusion, it’s not a small part of the overall numbers living in extreme poverty. You’re looking here at a graph of the poverty rates in some relatively poor countries in the Americas, Bolivia, Ecuador, Guatemala, Mexico and Peru. What you can see is that, in each case, the poverty rates among the indigenous populations, are higher than the poverty rates among the non-indigenous. And if one were to show the African-American population’s poverty rates as well, those would be much, much higher too. And, so, this is an example of how the indigenous populations in the Americas face continuing challenges which are long, long legacies of political military and cultural discrimination. And many, many acts of violence. This map of ethno-linguistic groups highlights another point for us. Which is that around the world, there are significant differences in the extent of ethnic diversity. Ethnic diversity sometimes measured along linguistic lines. And a map like this gives an indication of what’s called ethno-linguistic fractionalization. It asks how likely is it that two people selected at random within a population within a country belong to the same ethnic group or the same tribe as it might be called in some contexts. You can see that Africa, for example is just a maze of ethno-linguistic fractionalization. And the differences of tribes in Africa, and the fact that when one tribe comes to power, it may discriminate heatedly against others is part of the political and social reality that has made social inclusion so difficult. You see in the Amazon region the high degree of ethno-linguistic fractionalization as well. All of this is to emphasize that when we consider the challenges of social inequality and the application of human rights to those challenges, we will have to address this at several different ways, in several different dimensions. One is a class dimension. What to do to help poor people and especially poor children in poor households to achieve social mobility and the escape from poverty. Another dimension, which I’m going to discuss at greater length, is gender differences. The systematic discrimination against women and against girls in virtually all parts of the world, but here I’ve emphasized the inequalities across groups and how power structures, colonial history, discrimination systematically against indigenous populations has played a role. We need to be aware of that group-level discrimination as well if we’re going to be accurate and effective in overcoming social exclusion and achieving that major killer of inclusive growth that is at the core of sustainable development.

Lectures / Readings

Human Rights and Gender Equality II

23/04/2015 Pedro Pereira Leite Deixe o seu comentário

Major UN Covenants and Declarations

Economic rights that define the right of individuals to meet basic needs. Social rights the right to live in secure families and communities. And cultural rights, the right to participate in one’s culture. And that human rights approach while not universally subscribed to by each person on the planet, has been found compelling across the world by individuals, by activists, by many different kinds of groups, by most governments. And it has become enshrined in a very important way in international law and in the norms of the international political and diplomatic system under the United Nations. When the United Nations was formed at the end of World War Two, one of the first great steps of the United Nations a few years after its founding in 1948 at the urging of Eleanor Roosevelt, the former first lady of the United States and a great champion of human rights, was the adoption by the member states of the United Nations of the Universal Declaration of Human Rights. It is a wonderful, remarkable document. A very powerful one that was adopted in the wake of World War Two at a time of hope and also remembrance of the devastation of World War Two and the idea that by meeting the basic rights and needs of all people in the world one would not only ensure their dignity improve their economic well being, but also help to prevent another global war and global disaster. The Universal Declaration is in essence the moral charter of the United Nations. The UN has it’s legal charter which defines it’s institutions, it’s functioning, the selection of the Secretary General, the operations of the security counsel and the General Assembly. It is itself an extremely important document of international law and practice. But the Universal Declaration of Human Rights is the moral s, heart and soul of the United Nations. And when the UN takes actions in the area of economic development or protecting the environment, or protecting refugees or addressing natural disasters almost always it’s to the Universal Declaration of Human Rights that the eyes are drawn and that the attention is placed. Because that provides an inspiration and a guidance that continues more than half a century later. Well over half a century after the adoption of the Universal Declaration. Coming out of the Universal Declaration were two more detailed international covenants that also helped to implement The Universal Declaration. One is the International Covenant on Political and Civil Rights, the other is the International Covenant on Economic, Social, and Cultural Rights. So between those two covenants, one covers the five main areas of human rights. Most of the governments subscribed to both of those covenants. Interestingly, the United States did not subscribe to the International Covenant on Economic, Social and Political rights and it’s interesting to know why. While many, many Americans including myself certainly agree with the International covenant on Economic, Social and Cultural Rights, the libertarian streak in the United States which goes back to the founding of the U.S. as it broke away from from Great Britain. The libertarian streak which takes the view that government’s main role is to provide defense, security and and private property, but not to do more than that because of the risks to liberty. That libertarian streak in part of American politics we don’t want to guarantee or to underpin or to encourage the idea of economic rights because economic rights means economic responsibilities to, especially for the rich. And the libertarians say, don’t go there, let markets, let individuals transact. It’s not the role of the state in their view to implement an ethical framework beyond that of the protection of the individual and, and private property. So the US did not sign that, though most of the world’s governments did. Later on, that was in 1966 when those two international covenants were adopted the UN has adopted many more specific ambitious goals around meeting the basic needs. The most important by far we’ve noted have been the Millennium Development Goals adopted in the year 2000. And I’ll note in just a few minutes that those two took their inspiration from the Universal Declaration and from the international covenants, because the Millennium Development Goals were taken from the start as a way to implement, in essence, the human rights to a decent economic life helping the poor to break free at the poverty trap. Let’s go back to the 1948 Universal Declaration that is so important and it is a very moving document which I hope will continue to be honored, respected, read embraced and improved upon in the 21st century. So in 1948 the governments of the world agreed to the following. They said the General Assembly, Proclaims this Universal Declaration of Human Rights as a common standard of achievement for all peoples and all nations, to the end that every individual and every organ of society, keeping this declaration constantly in mind, shall strive by teaching and education to promote respect for these rights and freedoms and by progressive measures, the progressive realization of the rights, national and international, to secure their universal and effective recognition and observance, both among the peoples of Member States themselves and among the peoples of territories under their jurisdiction. So that is the preamble more or less to the Universal Declaration. Saying that all of the Member States should strive to teach, advocate and honour and progressively achieve all of the rights of the Declaration itself. Well there are many rights and it’s a a document that bears study. But I wanted to highlight just a few of them. Article 22 calls for the right to social security. In other words, to a guaranteed base so that human dignity and the most basic needs of water, shelter, clothing and so forth can be met. Article 23 of the Universal Declaration calls for the right to work, to a livelihood, to be able for individuals to support themselves and their families. Article 24 calls for the right to rest and leisure so that one can’t demand work of around the clock and in burdensome and crushing ways. Article 25 says that there is universal right to a standard of living adequate for the health and well-being of the individual himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widow, widowhood, old age or other lack of livelihood in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance. What a remarkable bold statement. How unmet that remains today we know with more than one billion people still living in extreme poverty. These goals even according to the founders of the Universal Declaration would not be achieved instantly. They would only be realized progressively. But progressive might mean time is time is up. Time to meet these needs and we know as we’ve discussed, that meeting the basic needs of all is within reach. The end of poverty in its extreme form is itself within reach in our generation. Article 26 says that everyone has a right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. A merit good should apply to everyone in the world. And Article 28 I find very, very interesting, it says that everyone is entitled to a social

and international order in which the rights and freedoms set forth in this Declaration can be fully realized. In other words, this is not just an empty statement of wishes. This is a call for a political order and a social order in which these rights can be progressively realized. And I think that this is a key point. One could still by cynical and say, doesn’t matter, it’s just words on a page. Governments don’t have to do this. But it really does say more than that, and the effects are more powerful than, just the cynical view that they can easily be discarded. What the document is saying is that only do individuals have rights, but individuals in our collectivity in our nations,and in a grouping of nations at the United Nations, also has the right to a system of government, a system of taxation and spending and delivery of services in which the rights and freedoms set forth in the Declaration can be fully realized. To implement this Universal Declaration, of course, is mainly the responsibilities of each society, but the international covenants which came in 1966 are more detailed documents that describe more specifically the various rights and more specifically how they are to be realized.

The International Covenant on Civil and Political Rights focuses naturally on the rights of citizenship and the protection from abuses of the state. And let me just mention a few of the key points of the civil and political rights that are defined in the International Covenant on Civil and Political Rights. Article 6, for example, says that the right to life is protected by law. Government cannot willfully end without a due process, take a life. And of course, in many countries of the world capital punishment has been made illegal and has been eliminated long ago. Yet we do know that governments continue to kill their people that is not realizing the rights of this covenant. Article 7 says that no one can be subjected to torture. Here again we know that governments have violated this willfully. The United States itself engaged in water boarding so called after 9/11 until that was discontinued by the Obama Administration. Or at least we hope and and it was said by the administration that it has been discontinued. But torture, of course, remains a terrible scourge practiced in many parts of the world. Article 8 says that nobody can be held in slavery. And while slavery is illegal throughout the world, we know that there is human trafficking and that people are held in slavery though illegally. Governments have the responsibility to fight to resist that and to free people that are held against their will. Article 9 says that there’s a right to liberty and security of individuals, that government cannot violate the liberty and security of their citizens. Article 16 says there’s a right of citizenship defined as the recognition of all persons before the law. Article 18 declares the freedom of thought. Article 24, the protection of children. And Article 26, the equal protection of the law from discriminatory application. So you can see that these are rights that are not realized to the extent that they need to be. But our rights that are widely accepted, widely regarded, at least on paper, that’s a start and in application, but to be realized and to, to to be struggled for.

Now the companion to the civil and political rights, are the economic, social and cultural rights adopted at the same time in the complimentary international covenant. And let me mention some of those economic and social and cultural rights. And again, as in the Universal Declaration[2], Article 6 calls for the right to work. Article 7 for just and favorable conditions of work decent remuneration and safe working environment. Article 8 declares the right of individuals to form and to join trade unions. Article 9 as in the Universal Declaration, the right to social security. Article 11, the right to an adequate standard of living, to be able to meet basic needs. Article 12, very interesting and very important, very relevant for the Millennium Development Goals and for the sustainable development goals that will follow is the highest attainable, the right to I should say, the highest attainable standard of physical and mental health. Very interesting. At first one can’t grant the right to health, per se. People are ill they may suffer from conditions that are not preventable or treatable. So the standard is the highest attainable level of health. Importantly, physical health and mental health, because we know that mental illness is a terrible scourge for individuals and quantitatively a very heavy burden on societies around the world. Article 13, the right to education. And Article 15, the right to take part in cultural lives. And again as in the original Universal Declaration the Covenant on Economic, Social and Cultural Rights realizes this isn’t all at once. This is a framework, it’s a moral and ethical framework, it is a commitment. And the way that it is defined, is that each state party to this covenant undertakes steps individually, and through international assistance and cooperation, and to the maximum extent of its available resources to, to honor these rights and then quote, with a view to achieving progressively the full realization of the rights recognized in this covenant. So, this is a call on us. It’s to turn values into practice. And while cynics may say, so what, practice shows differently. These values do reach the heart. They do move governments. They can make a big difference, and I think this has been nowhere more clear than in the Millennium Development Goal effort. Initiated in September 2000, you’ll recall, by the world leaders gathered at the United Nations, and providing a motivation to meet these basic needs in health, in education, in gender equality, in at least a minimum standard of living. And when the MBG’s were launched in September 2000 in the Millennium Declaration which framed them and which looked to the Universal Declaration of Human Rights, the government said, we will spare no effort to free our fellow men, women, and children from the abject and dehumanizing conditions of extreme poverty to which more than a billion of them are currently subjected. We are committed to making the right to development a reality for everyone, and to freeing the entire human race from want. Human rights at the core of this development agenda, a motivation, a set of legal agreements and a moral heart of the United Nations, and of the sustainable development efforts in the years ahead.

[1]

Values underpin sustainable development, and one kind of value approach is the human rights approach. The idea that every human being on the planet within any political system has human rights, and human rights of five sorts as I have mentioned. Civil rights as citizens. Political rights to participate in governance. Economic rights that define the right of individuals to meet basic needs. Social rights the right to live in secure families and communities. And cultural rights, the right to participate in one’s culture. And that human rights approach while not universally subscribed to by each person on the planet, has been found compelling across the world by individuals, by activists, by many different kinds of groups, by most governments. And it has become enshrined in a very important way in international law and in the norms of the international political and diplomatic system under the United Nations. When the United Nations was formed at the end of World War Two, one of the first great steps of the United Nations a few years after its founding in 1948 at the urging of Eleanor Roosevelt, the former first lady of the United States and a great champion of human rights, was the adoption by the member states of the United Nations of the Universal Declaration of Human Rights. It is a wonderful, remarkable document. A very powerful one that was adopted in the wake of World War Two at a time of hope and also remembrance of the devastation of World War Two and the idea that by meeting the basic rights and needs of all people in the world one would not only ensure their dignity improve their economic well being, but also help to prevent another global war and global disaster. The Universal Declaration is in essence the moral charter of the United Nations. The UN has it’s legal charter which defines it’s institutions, it’s functioning, the selection of the Secretary General, the operations of the security counsel and the General Assembly. It is itself an extremely important document of international law and practice. But the Universal Declaration of Human Rights is the moral s, heart and soul of the United Nations. And when the UN takes actions in the area of economic development or protecting the environment, or protecting refugees or addressing natural disasters almost always it’s to the Universal Declaration of Human Rights that the eyes are drawn and that the attention is placed. Because that provides an inspiration and a guidance that continues more than half a century later. Well over half a century after the adoption of the Universal Declaration. Coming out of the Universal Declaration were two more detailed international covenants that also helped to implement The Universal Declaration. One is the International Covenant on Political and Civil Rights, the other is the International Covenant on Economic, Social, and Cultural Rights. So between those two covenants, one covers the five main areas of human rights. Most of the governments subscribed to both of those covenants. Interestingly, the United States did not subscribe to the International Covenant on Economic, Social and Political rights and it’s interesting to know why. While many, many Americans including myself certainly agree with the International covenant on Economic, Social and Cultural Rights, the libertarian streak in the United States which goes back to the founding of the U.S. as it broke away from from Great Britain. The libertarian streak which takes the view that government’s main role is to provide defense, security and and private property, but not to do more than that because of the risks to liberty. That libertarian streak in part of American politics we don’t want to guarantee or to underpin or to encourage the idea of economic rights because economic rights means economic responsibilities to, especially for the rich. And the libertarians say, don’t go there, let markets, let individuals transact. It’s not the role of the state in their view to implement an ethical framework beyond that of the protection of the individual and, and private property. So the US did not sign that, though most of the world’s governments did. Later on, that was in 1966 when those two international covenants were adopted the UN has adopted many more specific ambitious goals around meeting the basic needs. The most important by far we’ve noted have been the Millennium Development Goals adopted in the year 2000. And I’ll note in just a few minutes that those two took their inspiration from the Universal Declaration and from the international covenants, because the Millennium Development Goals were taken from the start as a way to implement, in essence, the human rights to a decent economic life helping the poor to break free at the poverty trap. Let’s go back to the 1948 Universal Declaration that is so important and it is a very moving document which I hope will continue to be honored, respected, read embraced and improved upon in the 21st century. So in 1948 the governments of the world agreed to the following. They said the General Assembly, Proclaims this Universal Declaration of Human Rights as a common standard of achievement for all peoples and all nations, to the end that every individual and every organ of society, keeping this declaration constantly in mind, shall strive by teaching and education to promote respect for these rights and freedoms and by progressive measures, the progressive realization of the rights, national and international, to secure their universal and effective recognition and observance, both among the peoples of Member States themselves and among the peoples of territories under their jurisdiction. So that is the preamble more or less to the Universal Declaration. Saying that all of the Member States should strive to teach, advocate and honour and progressively achieve all of the rights of the Declaration itself. Well there are many rights and it’s a a document that bears study. But I wanted to highlight just a few of them. Article 22 calls for the right to social security. In other words, to a guaranteed base so that human dignity and the most basic needs of water, shelter, clothing and so forth can be met. Article 23 of the Universal Declaration calls for the right to work, to a livelihood, to be able for individuals to support themselves and their families. Article 24 calls for the right to rest and leisure so that one can’t demand work of around the clock and in burdensome and crushing ways. Article 25 says that there is universal right to a standard of living adequate for the health and well-being of the individual himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widow, widowhood, old age or other lack of livelihood in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance. What a remarkable bold statement. How unmet that remains today we know with more than one billion people still living in extreme poverty. These goals even according to the founders of the Universal Declaration would not be achieved instantly. They would only be realized progressively. But progressive might mean time is time is up. Time to meet these needs and we know as we’ve discussed, that meeting the basic needs of all is within reach. The end of poverty in its extreme form is itself within reach in our generation. Article 26 says that everyone has a right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. A merit good should apply to everyone in the world. And Article 28 I find very, very interesting, it says that everyone is entitled to a social

Now the companion to the civil and political rights, are the economic, social and cultural rights adopted at the same time in the complimentary international covenant. And let me mention some of those economic and social and cultural rights. And again, as in the Universal Declaration, Article 6 calls for the right to work. Article 7 for just and favorable conditions of work decent remuneration and safe working environment. Article 8 declares the right of individuals to form and to join trade unions. Article 9 as in the Universal Declaration, the right to social security. Article 11, the right to an adequate standard of living, to be able to meet basic needs. Article 12, very interesting and very important, very relevant for the Millennium Development Goals and for the sustainable development goals that will follow is the highest attainable, the right to I should say, the highest attainable standard of physical and mental health. Very interesting. At first one can’t grant the right to health, per se. People are ill they may suffer from conditions that are not preventable or treatable. So the standard is the highest attainable level of health. Importantly, physical health and mental health, because we know that mental illness is a terrible scourge for individuals and quantitatively a very heavy burden on societies around the world. Article 13, the right to education. And Article 15, the right to take part in cultural lives. And again as in the original Universal Declaration the Covenant on Economic, Social and Cultural Rights realizes this isn’t all at once. This is a framework, it’s a moral and ethical framework, it is a commitment. And the way that it is defined, is that each state party to this covenant undertakes steps individually, and through international assistance and cooperation, and to the maximum extent of its available resources to, to honor these rights and then quote, with a view to achieving progressively the full realization of the rights recognized in this covenant. So, this is a call on us. It’s to turn values into practice. And while cynics may say, so what, practice shows differently. These values do reach the heart. They do move governments. They can make a big difference, and I think this has been nowhere more clear than in the Millennium Development Goal effort. Initiated in September 2000, you’ll recall, by the world leaders gathered at the United Nations, and providing a motivation to meet these basic needs in health, in education, in gender equality, in at least a minimum standard of living. And when the MBG’s were launched in September 2000 in the Millennium Declaration which framed them and which looked to the Universal Declaration of Human Rights, the government said, we will spare no effort to free our fellow men, women, and children from the abject and dehumanizing conditions of extreme poverty to which more than a billion of them are currently subjected. We are committed to making the right to development a reality for everyone, and to freeing the entire human race from want. Human rights at the core of this development agenda, a motivation, a set of legal agreements and a moral heart of the United Nations, and of the sustainable development efforts in the years ahead.

Global Heritages

Arquivo diário: 23/04/2015

Universal Health Coverage V

Universal Health Coverage IV

Universal Health Coverage III

Universal Health Coverage II

Universal Health Coverage I

Why Did Some Countries Advance While Others Remained in Poverty? V

Why Did Some Countries Advance While Others Remained in Poverty? IV

Why Did Some Countries Advance While Others Remained in Poverty? III

Why Did Some Countries Advance While Others Remained in Poverty? II

Why Did Some Countries Advance While Others Remained in Poverty? I

Espaço Patrimonial na era da Reprodução Tecnica

Human Rights and Gender Equality III

Human Rights and Gender Equality II

The inclusion of community knowdlege on territorial development