Where We Must Vaccinate

KARACHI/GANDHIDHAM-GUJARAT – With measles outbreaks currently spreading across Europe and the Midwestern United States, and meningitis infecting US college students, health experts are doing something they never thought they’d have to do in early 2017: reminding people in developed countries that vaccines save lives.

Perhaps vaccines are a victim of their own success: they work so well in protecting people against certain illnesses that many in the West have forgotten how devastating preventable diseases can be. With the recent outbreaks in the US and Europe, parents are being reminded that foregoing vaccinations for their children is a deadly gambit.

Sadly, in many other parts of the world, particularly South Asia, parents need no reminding that immunization saves lives. What they need is access to vaccines.

Preventable disease outbreaks, rare as they are in Western countries, are all too frequent occurrences in a region that is home to the world’s largest number of unvaccinated children. In the early 1980s, one of us almost lost our baby son to bacterial meningitis, because no vaccine was available in Pakistan at the time. The boy made a full recovery, but only because of an early diagnosis and care at a premier hospital, which is out of reach for many parents in Pakistan. The boy’s siblings were later vaccinated, too, but only after stocks of the vaccine were secured in the US and hand-carried back to Pakistan.

Fortunately, going to such lengths is largely unnecessary today. On average, 90% of children in South Asia now receive vaccines for preventable illnesses such as tetanus, influenza, diphtheria, and pertussis, and the number of infants protected against Hepatitis B has increased by nearly 60% in the last decade. Moreover, six countries in the region were declared polio-free in 2014, following extensive vaccination campaigns. Only those living in marginalized and remote areas remain unvaccinated for polio, typically owing to local hesitancy and refusals.

Collectively, these remarkable figures amount to a public health miracle. But too many children are still suffering needlessly. The just-concluded World Immunization Week (April 24-30) should spur us to redouble our efforts to vaccinate the millions of children in South Asia who remain unprotected from preventable illnesses.

Globally, more than 11 children under the age of five die every minute, many of them in South Asia, from preventable diseases. Despite the region’s progress, one in four children remain unprotected against diseases like measles and hepatitis, and the figures are even higher for major killers such as pneumonia and meningitis. As a result, the mortality rate for children in South Asia today is almost twice as high as it was in the US 50 years ago.

We have the tools to address these shortcomings and ensure that no child dies unnecessarily from an illness that vaccination could have prevented. To succeed, however, several obstacles must be overcome.

First, we must resolve systemic weaknesses in the region’s underdeveloped health systems, by improving training for health workers, ensuring proper storage and transportation of vaccines, and developing effective ways to deliver them. These improvements, together with more effective information sharing in the medical profession, are critical for better planning and accountability as well.

Second, we must actively confront the growing anti-vaccine lobby, which threatens to undo the gains made in recent years. These groups spread falsehoods about vaccine safety that can lead parents to leave their children unprotected. Foregoing vaccinations not only puts the health of individual children at risk; it also raises the likelihood of outbreaks that jeopardize the health of entire communities.

Finally, we must continue to encourage countries in the region to increase vaccine coverage rates, in particular with newer vaccines proven to protect against pneumonia and diarrhea, the two leading infectious killers of children.

Positive steps are already being taken to realize these goals. In Pakistan, for example, officials in Punjab province, hoping to protect one million children from a common form of diarrhea, recently introduced the rotavirus vaccine. Next door, India has vaccinated close to four million children since launching an initiative to expand the rotavirus vaccine’s coverage in ten states, and plans to reach 13 million children by the last quarter of 2017.

There is still much to do in both countries. In India, 13 million children annually are not reached with the rotavirus initiative; in Pakistan, five million children annually are not vaccinated. But, with help from Gavi, the Vaccine Alliance, more vaccines are being brought to the world’s poorest communities through funding, training, and delivery. Health officials everywhere can learn from and replicate the gains made in these two countries.

We are at a pivotal moment in the global vaccination drive. As pediatric professionals who have dedicated our lives to protecting children from preventable diseases, we believe it is within the world’s capacity to end this needless suffering. Vaccines are a proven tool for improving children’s health and development. Ensuring that children have access to them is an achievable public health goal behind which parents and pediatricians everywhere should unite.

Zulfiqar A. Bhutta is Founding Director of Aga Khan University’s Centre of Excellence in Women and Child Health in Karachi, Pakistan, Co-Director of SickKids Centre for Global Child Health, in Toronto, Canada, and President of the International Pediatric Association. Naveen Thacker is President of the Asia Pacific Pediatric Association and Coordinator of the International Pediatric Association, based in Gandhidham-Gujarat, India.

By Zulfiqar A. Bhutta and Naveen Thacker

Women in the Green Economy

LAGOS/STOCKHOLM – In Ghana, a group of enterprising women and young people is building bicycles out of an unlikely material: bamboo. Ten farmers grow the bamboo, and 25 builders craft it into environmentally friendly bikes that can be used on Ghana’s bumpy roads or exported overseas. Bernice Dapaah, the founder and CEO of Ghana Bamboo Bikes, plans to build two new factories soon, adding 50 more workers in communities with high unemployment.

Ghana Bamboo Bikes is just one example of the major role women can play in driving the transition toward sustainable economic growth and development. But such examples increasingly need to go together if we are to ensure a prosperous future on a healthy planet. The world needs more women climate leaders, whether around the tables where policy is made or at the helm of businesses, steering them toward sustainability.

When more women work, economies grow. According to the World Economic Forum, greater gender equality, which implies greater use of human capital, correlates positively with per capita GDP, competitiveness, and human development. Squandering that capital has the opposite effect: the United Nations Development Programme reports that gender inequality costs Sub-Saharan Africa, to name one example, $95 billion (or 6% of GDP) per year, on average.

Yet women around the world still face a massive gender gap in employment and wages. The proportion of women participating in the global labor force has hovered around 50% since 1990, compared to more than 75% for men. And, in most countries, the women who work earn, on average, only 60-75 cents for every dollar that men earn.

To support economic growth and development, we need to tap the potential of all workers, giving women opportunities not just to earn, but also to lead. Women need to be empowered, and their role in the economy transformed. What better moment to achieve this than now, when the world is pursuing another economic transformation, toward a green economy?

In fact, transforming women’s role in the economy could be even more urgent in the context of climate change. Traditional divisions of responsibility mean that men and women are often affected differently by climate change, particularly in developing countries.

Because men are more likely to perform wage labor or farm cash crops, a climate-driven event like drought may cost them their wages and force them to move to cities to find employment. Women, who are often responsible for growing local subsistence crops and taking care of their families, do not have that option.

Instead, women must find alternative means of securing food locally and of generating income to support their families, such as selling small assets or even withdrawing their children from school to help. The challenges women face are exacerbated in regions where women already spend hours each day fetching drinking water, and changing rainfall patterns could force women to travel even farther for it.

Against this background, it is crucial to empower women to seize the opportunity presented by the transition to a sustainable economy. Changes in four key areas could prove particularly valuable.

First, women need greater access to the financial system. In Sub-Saharan Africa, men are 30% more likely than women to have a bank account. To close this gap, we need to design loans and savings vehicles with more flexible requirements that work for women. This includes, for example, the expansion of microcredit – an approach that has already enabled women in many countries to become entrepreneurs.

Achieving this requires convincing still-skeptical creditors that women are dependable – and, indeed, valuable – clients, including by citing data on microcredit, which prove that women repay loans as reliably as men, if not more so. Once women gain access to the financial system, they can create and invest in small businesses, while feeling more secure about dipping into savings when confronted with emergencies.

Second, women need equal rights to land. Ownership of land – whether co-ownership, for a married woman, or sole ownership, for a single female head of household – not only improves economic security and productivity, but also boosts access to traditional finance. With a formal claim to the land they are farming, women are also more likely to invest in the fertility of the soil, contributing to more productive and sustainable land-use patterns.

Third, women need policies that support their active participation in the emerging green economy, including better education, skills training, and protections against workplace discrimination. Because the clean-energy industry is so new, it could help draw women into non-traditional higher-paid jobs like engineering.

Finally, women need to be empowered politically. If half the population doesn’t have a say in political decisions, the legitimacy of policymaking suffers. Women can play an important role as governments implement incentives and regulations that support the transition to a sustainable and inclusive economy.

Even without such support, women are already seizing the opportunity presented by this transition. Solar Sister is a social business that has created jobs for 2,500 women selling affordable solar lighting in Nigeria, Tanzania, and Uganda. Lumos, another solar solution, empowers women entrepreneurs in Nigeria.

But women still don’t comprise a large enough share of the workers in the clean-tech industry, and those who do work in that industry are generally low on the job ladder. Changing that – enabling all citizens to meet their economic potential – will require active efforts to promote women’s social and political inclusion.

Closing the gender gap is the right thing to do for women and the planet. It is also smart economics. Let’s not miss this opportunity.

Isabella Lövin is Deputy Prime Minister of Sweden. Ngozi Okonjo-Iweala, former Finance Minister of Nigeria and Managing Director of the World Bank, is currently Board Chair of Gavi, the Vaccine Alliance, and a member of the Global Commission on the Economy and Climate.

By Isabella Lövin and Ngozi Okonjo-Iweala

Mending Bangladesh’s Garment Industry

KUALA LUMPUR – Four years ago, the deadly collapse of the Rana Plaza garment factory in Bangladesh pulled back the curtain on the employment practices of the global apparel industry. We had hoped that the tragedy, which killed more than 1,100 workers – the deadliest accident in the industry’s history – would have brought meaningful change to a business long left to its own devices. Unfortunately, our research suggests the opposite has happened.

Media reports highlight the industry’s ongoing transgressions in Bangladesh, in particular the persistent reliance on child labor. In 2014, the British current-affairs program Exposure found evidence of children as young as 13 working in factories (often under harsh conditions) producing clothes for retailers in the United Kingdom. Another undercover report by CBS News interviewed a 12-year-old girl who obtained a factory job using a certificate that falsified her age. And journalists from The Australian Women’s Weekly found girls as young as ten stitching clothes for top Australian brands.

While the media reports are troubling, they do not provide the entire picture. How many minors and adolescent girls are employed overall in factory jobs? More important, should they be barred from such jobs entirely?

Access to factories is restricted, and most employees will not disclose their actual age in the workplace. Indeed, journalists often mask their identity to document abuses. We took a different approach to assess the prevalence of underage workers in the garment industry, and to determine the sector’s value to Bangladeshi society.

As part of a recent nationwide census, we collected data from thousands of mothers and girls in Bangladesh’s three industrial districts with the highest concentration of ready-made garment factories (particularly those operating outside the Export Processing Zones): Ashulia, Gazipur, and Narayanganj. The majority of the country’s female garment workers are concentrated in these areas. For comparison, we also carried out interviews in 58 urban areas where garment factories are not located.

During our research, we identified 3,367 women and girls in the survey areas who reported being employed in the apparel industry. Of them, 3% were between the ages of ten and 13, and 11% were 14-17 years old. Of the 861 girls below the age of 18 who were engaged in any kind of work, 28% said they worked in the garment industry.

Based on this evidence, it would appear that Bangladesh’s garment factories are using child labor (particularly that of young girls) more pervasively than even the most sensational media reports suggest. But for us, the real question is whether this practice should be eradicated or reformed.

Global brands relying on cheap labor have promised eradication. In 1992, about 10% of the garment sector’s workforce was below the age of 14. The following year, after the introduction of the Child Labor Deterrence Act in the United States – the so-called Harkin Bill, which barred US imports of products made with child labor – some 50,000 underage workers were removed from the factory floor. Meanwhile, the Bangladesh Garment Manufacturers and Exporters Association has pledged to phase out child labor and put children back in school – female school enrollment is typically lower in areas of high garment-industry employment than in other areas – upholding a 2010 law prohibiting employment of children under 14.

Clearly, our data suggest that the industry’s promises have yet to be fulfilled (though the government of Bangladesh claims that there currently is “no child labor” in garment processing units).

But that may not be entirely bad for underage female workers in Bangladesh. Thanks to pressure on garment manufacturers in the wake of the Rana Plaza disaster, the industry’s minimum wage was increased 77%, to $68 a month. This has made it more attractive for young girls to take up paid employment in the sector, which, paradoxically, does have some social benefit.

The majority of young girls who are working in Bangladesh are from poor families. Even in garment manufacturing areas, relatively better-off families rarely send their daughters to work in factories. Although recent initiatives have lowered the cost of schooling for girls (through cash stipends and the elimination of school fees), many young women still drop out of secondary school, even without the opportunity to engage in paid work. That often leaves girls with one option: marriage. And in a country where minimum marriage-age laws are rarely implemented, earning a paycheck is the best way to avoid a premature wedding day.

In such a situation, when many young girls must choose between factory work and marrying young, banning factory employment for girls under 18 would do more harm than good. To help young girls avoid this choice, and to reduce the presence of minors and young girls in factories, requires greater emphasis on poverty reduction in rural areas.

Bangladesh’s garment industry is expected to quadruple in size over the next two decades, attracting millions more female workers, young and old, to the production floor. According to our estimates, one of every ten of these new employees will be between 10-17 years of age.

Consumers around the world reject clothing stitched by child labor, which is commendable. Children under 18 should be in school and learning important life skills, not working long hours under difficult conditions. But the lessons from the 2013 tragedy at Rana Plaza are more complicated than much of the international media make them out to be. The garment industry does need to reform; but, for the time being, if women and girls are not to suffer needlessly again, promising to eradicate child labor may not be the right answer.

M Niaz Asadullah is Professor of Development Economics at the University of Malaya, in Kuala Lumpur, Research Fellow at the IZA Institute of Labor Economics, and Visiting Fellow at the Center on Skills, Knowledge, and Organization Performance (SKOPE) at the University of Oxford. Zaki Wahhaj is a senior lecturer at the University of Kent.

By M Niaz Asadullah and Zaki Wahhaj

Theresa May’s Pyrrhic Victory

LONDON – The British election called by Prime Minister Theresa May for June 8 will transform the outlook for Britain’s politics and its relationship with Europe, but not necessarily in the way that a vastly increased majority for May’s Conservative Party might seem to imply. The scorched-earth defeat that Conservative Euroskeptics expect to inflict on Britain’s internationalist and progressive forces was symbolized by the Daily Mail headline on May’s election announcement: “Crush the Saboteurs.” But June’s resounding victory could ultimately lead to an even more stunning reversal, like Napoleon’s hubristic march on Moscow after he had destroyed all opposition in Western Europe.

Britain’s pro-European progressive forces could still snatch victory from the jaws of defeat for three related reasons. First, by bringing forward the British election, May has effectively extended the deadline for Britain’s withdrawal from the European Union from 2019 until 2022. The early election makes it inevitable that Britain will formally leave the EU in March 2019, because May will no longer face even the theoretical possibility of parliamentary opposition. But it also allows Britain to accept a long transition period after the 2019 departure deadline, so that businesses and administrative systems can adjust to whatever terms are agreed by then.

British business lobbies, as well as the government officials tasked with implementation, have been pressing for this transition period to be as long as possible. The EU, however, has insisted that during the transition period all of the current obligations of EU membership must continue, including budget contributions, free movement of labor, and enforcement of EU legal judgments.

Until the election was called, it seemed almost impossible to reconcile the business community’s need for a long transition period with the insistence of Conservative Euroskeptics on a complete and immediate break with the EU. A crushing election victory will give May the necessary authority to negotiate a long transition, despite the objections of anti-EU extremists, and will persuade more moderate Euroskeptics that, with Brexit now guaranteed, the precise timing of various EU obligations is less important.

As a result, although Britain will formally cease to be an EU member by March 2019, very little will change in Britain’s economy or way of life by the time of the next general election in 2022. In this sense, May’s decision to call an early election is a setback for extreme Euroskeptics, who might otherwise have forced her to break completely with Europe by March 2019.

This relates to a second reason why the imminent triumph for British Euroskeptics may end up a pyrrhic victory. Whereas the early election will delay economic changes, it will greatly accelerate the transformation of British politics.

Britain’s main opposition Labour Party has been in its death throes since 2015, but could survive in its present zombie condition until a general election was called. Because the next election was expected in 2020, it was possible that some unforeseen development in the three years might allow Labour to revive. By bringing the election forward, May has brought forward Labour’s disintegration as well, and virtually eliminated the possibility of its revival.

When the Labour Party collapses after its defeat in June, a realignment of progressive British politics will become almost certain. This realignment, uniting disillusioned Labour politicians and voters with Liberal Democrats, Greens, and perhaps Scottish and Welsh nationalists, is likely to produce an opposition that is much more effective than May currently faces, even if it has fewer parliamentary seats.

By the time of the next general election, most likely in 2022, Britain’s internationalist and progressive political forces will have had five years to prepare themselves to oppose May’s conservatism and English nationalism. By that time, the Conservatives will have been in power for three parliaments and 12 years. That is about how long it has typically taken Britain’s political pendulum to swing between right and left.

Moreover, owing to the extended transition period for Brexit made possible by the early election, it will only be around 2022 that the full consequences of terminating EU membership come into view, together with the contradictions in the Brexit coalition between libertarian free traders and socially conservative nationalists and protectionists. Meanwhile, efforts to negotiate free-trade agreements with the US and China will have revealed the weakness of Britain’s bargaining position. As a result, public opinion about the wisdom of Brexit could shift substantially by 2022. In any case, the changing relationship with Europe will be the core issue around which Britain’s socially liberal and internationalist political forces can coalesce after their defeat.

Suppose that, in the meantime, the EU continues its economic recovery. Suppose further that, after the French and German elections this year, a stronger Franco-German partnership drives the eurozone toward the closer political integration that is obviously needed for the single currency to succeed, whereas Denmark, Sweden, and Poland make clear that they have no intention of ever joining the euro. By 2022, British voters could well decide that re-joining a twin-track European Union is much more attractive than pleading for a junior partnership with the US, not to mention China. That is the third reason why Britain’s Conservative Euroskeptics could end up regretting their imminent electoral triumph.

Whatever happens, the decisive battle in the war for Britain’s long-term future will not be this year’s easy victory for May. It will be the clash, five years from now, between nationalist conservatism and a new outward-looking progressive opposition. Anatole Kaletsky is Chief Economist and Co-Chairman of Gavekal Dragonomics and the author of Capitalism 4.0, The Birth of a New Economy.

By Anatole Kaletsky

A Big Bond for Africa

LAGOS – The countries of Sub-Saharan Africa have reached a critical juncture. Strained by a collapse in commodity prices and China’s economic slowdown, the region’s growth slipped to 3.4% in 2015 – nearly 50% lower than the average rate over the previous 15 years. The estimated growth rate for 2016 is lower than the population growth rate of about 2%, implying a per capita contraction in GDP.

Sustained economic growth is essential to maintain progress on reducing poverty, infant mortality, disease, and malnutrition. It is also the only way to create sufficient good jobs for Africa’s burgeoning youth population – the fastest growing in the world. As Gerd Müller, Germany’s development minister, noted at a recent press conference, “If the youth of Africa can’t find work or a future in their own countries, it won’t be hundreds of thousands, but millions that make their way to Europe.”

One way to sustain growth and create jobs would be to collaborate on planning and implementing a massive increase in infrastructure investment across Africa. Public infrastructure is particularly important. This includes highways, bridges, and railways linking rural producers in landlocked countries to Africa’s urban consumers and external markets; mass transit and Internet infrastructure to accommodate greater commercial activity; and electricity transmission lines integrating privately financed power plants and grids.

Major regional projects are also needed to knit together Sub-Saharan Africa’s many tiny economies. This is the only way to create the economies of scale needed to increase the export potential of African agriculture and industry, as well as to reduce domestic prices of food and manufactured goods.

While governments in Africa are spending more on public infrastructure themselves, outside finance is still required, especially for regional projects, which are rarely a top priority for national governments. Yet aid from Africa’s traditionally generous foreign donors, including the United States and Europe, is now set to shrink, owing to political and economic constraints.

But there may be a solution that helps Africa recover its growth in a way that Western leaders and their constituents find acceptable. We call it the “Big Bond” – a strategy for leveraging foreign aid funds in international capital markets to generate financing for massive infrastructure investment.

Specifically, donors would borrow against future aid flows in capital markets. That way, they could exploit current low interest rates at home, as they generate new resources. With 30-year US Treasury rates of about 3%, donors would have to securitize only about $5 billion to raise $100 billion. That money could come from the $35 billion in annual official development assistance (ODA) to Africa (which totals about $50 billion) that takes the form of pure grants.

Donors would pass on the interest cost to African countries, reducing their own fiscal costs. For African countries, the terms would be better than those provided by Eurobonds. In fact, as audacious as it may sound, passing on the interest costs to recipient countries could actually bolster their debt sustainability.

According to a study of eight countries by the African Development Bank’s Policy Innovation Lab, a 3% interest rate in US dollar terms would be lower than the marginal cost of commercial borrowings undertaken by several African countries over the last five years. Moreover, far longer maturities and grace periods, compared to market finance, would ease growing pressure on foreign-exchange reserves.

Frontloading aid in this way is not new. Doing so in the early 2000s to finance vaccines saved millions of lives in the developing world. Big Bond resources, managed by the African Development Bank, could be used to help guarantee financing for major regional infrastructure projects that have long been stuck on the back burner, such as the East Africa Railway connecting Tanzania, Rwanda, and Burundi, and a highway stretching from Nigeria to Côte d’Ivoire. Such projects could also be co-financed by private investors.

Moreover, the Big Bond could help to reinvigorate the relationship between donors and African countries. And, as it supports investments with important country-level benefits, it could serve as an incentive for African countries to pursue reforms that increase their absorptive capacity, in terms of choosing and executing public infrastructure investments.

The Big Bond approach represents a much-needed update to the ODA framework – one that supports higher and more sustainable growth in recipient countries, while lowering the burden on donor countries. At a time when aid is under political pressure, perhaps such a bold approach to maximizing the efficiency of donor resources is exactly what the world needs.

Nancy Birdsall is President Emeritus and a senior fellow at the Center for Global Development. Ngozi Okonjo-Iweala, a former finance minister of Nigeria and managing director of the World Bank, is a distinguished visiting fellow at the Center for Global Development.

By Nancy Birdsall & Ngozi Okonjo-Iweala,

Fixing Fixed-Investment Incentives

LONDON – Back in February, I noted that the global economy at the end of 2016 was in a stronger cyclical position than most people had expected, given the political upheavals of the previous 12 months. That upward momentum carried through to the first quarter of 2017. According to the latest “nowcast”-type indicators, world GDP growth is exceeding 4% – perhaps the strongest performance seen since before the 2008 financial crisis.

Still, some observers – and not just chronic pessimists – have countered that the evidence remains anecdotal, and that it is impossible to predict how long the current economic moment will last. Indeed, there have been other periods in the long post-2008 recovery when growth returned, only to peter out quickly and become sluggish again.

To bolster long-term economic growth, business investment will have to increase. Unfortunately, this is easier said than done. In Western economies in particular, non-residential fixed investment is precisely the factor that was missing in previous, short-lived cycles of acceleration.

No one can say for sure why non-residential business investment has failed to recover in recent years. But I suspect that the slightly pessimistic conventional wisdom on this question is wrong.

The conventional argument asserts that wary CEOs have come to see long-term risks as “just not worth it.” The many uncertainties they face include concerns about excessive regulation, burdensome corporate taxation, high debt levels, erratic policymaking, the political backlash against globalization, and doubts that consumer spending outside (or even within) the United States will last.

A less pessimistic view holds that, after 2008, it became inevitable that the global economy would unhitch itself from the US consumer engine and adjust to the rise of emerging consumer economies, not least China. When that happens, we can all live happily ever after.

I tend to side with this less pessimistic crowd. As I pointed out in March, China’s economy did surprisingly well in the first quarter of 2017, and that seems to be the case in the second quarter as well. In fact, China’s latest monthly data show signs of economic acceleration, especially in consumption. And it was evident in the first-quarter data that Chinese consumers are becoming an increasingly important driver of economic growth.

When confronted with the numbers, pessimists respond by insisting that China’s recent strong economic performance is only temporary – a product of yet more unsustainable stimulus. And even if growth does last, they argue, the Chinese authorities will not allow Western businesses – or even Chinese businesses, according to ultra-pessimists – to benefit from it. But whether or not the pessimists turn out to be right about China, it is odd that business investment remains tepid even during times when the engine of global growth is located elsewhere, such as in the US or Europe (Germany in particular).

During my time as the head of the British government’s Review on Antimicrobial Resistance, I had to develop a better understanding of the pharmaceutical industry, and I learned that there is something to be said for microeconomic forces – and for basic common sense.

Consider the future, which always has been uncertain and always will be. And yet the biggest economic busts have happened when businesses were not uncertain enough – when they were sure that the future would be rosy. An overabundance of certainty might explain the 2000-2001 dot-com bubble, and many others.

But if, thanks to the increased availability of so much information (including different viewpoints and opinions), we now know that the future is always uncertain, the behavior of Western businesses (and many in the emerging world) is eminently logical, especially given the current workings of the financial system. Why would business leaders invest in an uncertain world, rather than paying dividends to demanding (but generally risk-averse) investors, or buying back some of their companies’ own shares (thereby improving the price/earnings ratio and, better yet, increasing their own remuneration)?

At the end of the day, the CEOs and the most aggressive investors are all happy with this approach. Unfortunately, the same cannot be said for the company’s employees, past and present, who reap no benefits in their paychecks or pensions (which are actually being eroded by the low yields on government bonds across Western countries).

It is past time for our elected governments to change the rules of the game. For starters, that means updating the tax code to make debt issuance far less attractive, especially when the proceeds are being used to buy back shares. At a minimum, it should be harder to buy back shares than to issue true dividend payments. That way, at least all shareholders, not just senior-executive insiders, will benefit.

Furthermore, those same executives should not be remunerated on the basis of short-term price-to-equity targets. More investors should be demanding that the incentives change to reflect true measures of long-term performance.

To its credit, the Norwegian Sovereign Wealth Fund recently spoke out in favor of such changes. Other large institutional investors and policymakers should follow suit, to give the corporate world a nudge. If we change the incentives, we just might finally see business investment make a comeback.

Jim O’Neill, a former chairman of Goldman Sachs Asset Management and former Commercial Secretary to the UK Treasury, is Honorary Professor of Economics at Manchester University and former Chairman of the British government’s Review on Antimicrobial Resistance.

By Jim O’Neill

Uniting Against Malaria

LOMÉ/GABORONE – As African women leading influential and impact-driven organizations – the Ecobank Foundation and the African Leaders Malaria Alliance (ALMA) – we are passionate about building a prosperous, inclusive, and sustainable African economy. But achieving that goal requires accelerating progress toward eradicating the diseases that continue to deplete our communities of their most valuable resource: healthy people. One such disease is malaria.

To be sure, Africa has lately made significant progress in combating malaria. From 2010 to 2015, as part of the global Millennium Development Goals, the continent reduced the malaria incidence rate (the number of new infections) by 21% and malaria deaths by 31%.

But malaria remains a serious threat to the wellbeing of millions of Africans. In 2015, an estimated 212 million people contracted malaria worldwide, with 47% of cases concentrated in just six African countries. An estimated 429,000 people – mostly children under five years of age – died from malaria that year, with 92% of those deaths occurring in Africa and 40% occurring in just two countries, Nigeria and the Democratic Republic of Congo. There is, therefore, an urgent need to accelerate progress – and end malaria for good.

This is both a moral and economic imperative. Preventable illnesses and deaths limit the ability of communities to contribute to Africa’s much-needed economic transformation. In many African countries, malaria reduces GDP growth by one percentage point per year. The effort to end malaria can therefore not be separated from the effort to ensure prosperity across Africa.

The Copenhagen Consensus think tank estimates that every dollar invested in ending malaria yields $36 in economic returns. To reap these benefits, African countries must increase domestic-resource mobilization substantially. Africa’s private sector, in particular, has a crucial role to play in developing innovative solutions that address malaria’s growing resistance to existing drugs, as well as mosquitoes’ growing resistance to insecticides. Moreover, the private sector can help to address inefficiencies in supply-chain management and logistics, thereby facilitating distribution of insecticides and long-lasting insecticidal nets.

Of course, even with private-sector investment, progress toward eradicating malaria in Africa will be uneven, not least because different countries are at different points on the path. Senegal – where the share of malaria-related outpatient visits fell from 36% in 2001 to just 3.3% last year – is now on track to achieve so-called pre-elimination by 2020. Meanwhile, other African countries – such as Angola and Somalia – are struggling to make any progress at all, as indicated in the ALMA scorecard for accountability and action.

No single African country can reliably eliminate malaria so long as the disease remains rampant among its neighbors. Malaria does not, after all, respect borders. That is why it is vital for African governments to work together, using every tool at their disposal, to achieve comprehensive malaria control, pre-elimination, and, ultimately, elimination.

ALMA – a coalition of 49 African heads of state and government working to eliminate malaria by 2030 – aims to advance precisely such cooperation, by focusing on accountability and action at the national, regional, and global levels. ALMA provides management tools, such as the scorecard for accountability and action, that help to track progress, identify obstacles and bottlenecks, and advance solutions. These tools are versatile and adaptable throughout the continent. Where needed, ALMA has provided support to address challenges directly with countries, in cooperation with partners, or through results-based management structures.

The Ecobank Foundation is also doing its part: its investment of both cash and in-kind services and training have enhanced the impact of the Global Fund partnership in Africa. By helping to strengthen the financial-management capabilities of grant recipients in Nigeria, Senegal, and South Sudan, the foundation is unlocking funding for health programs in those countries – and is now expanding its support to Chad and Zambia.

And there is more. Through its digital financial platform, the Ecobank Foundation is leveraging its presence to bring in new funding for the fight against malaria. And it is raising awareness as well, among its own staff and other stakeholders, of how to support malaria prevention, including through mosquito nets and a clean environment.

The goal of eradicating malaria in our lifetime may sound ambitious, but it is achievable. Together, Africa’s governments and private sector can produce the investment and action needed to stop the disease for good – and ensure greater prosperity across the continent. Julie Essiam is Chief Executive Officer of the Ecobank Foundation. Joy Phumaphi is Executive Secretary of the African Leaders Malaria Alliance.

By Julie Essiam and Joy Phumaphi

New Life for the SDR?

WASHINGTON, DC – The rise of anti-globalization political movements and the threat of trade protectionism have led some people to wonder whether a stronger multilateral core for the world economy would reduce the risk of damaging fragmentation. After all, lest we forget, the current arrangements – as pressured as they are – reflected our post-World War II forebears’ strong desire to minimize the risk of “beggar-thy-neighbor” national policies, which had crippled growth, prosperity, and global stability in the 1930s.

Similar considerations fueled the launch, nearly 50 years ago, of the International Monetary Fund’s Special Drawing Right as the precursor to a global currency. And with renewed interest in the stability of the international monetary system, some are asking – including within the IMF – whether revamping the SDR could be part of an effective effort to re-energize multilateralism.

The original impetus for the SDR included concerns about a national currency’s ability to reconcile the need for global liquidity provision with confidence in its role as the world’s reserve currency – what economists call the “Triffin dilemma.” By creating an international currency that would be managed by the IMF, member countries sought to underpin and enhance the international monetary system with a non-national official reserve asset.

Legal and practical factors, as well as some countries’ political resistance to delegating economic governance to multilateral institutions, have prevented the SDR from meeting its creators’ modest expectations, let alone the grand role of a truly global reserve currency that anchors the cooperative functioning of a growth-oriented global economy. Information and other market failures have added to the challenges, as have weak institutional infrastructure and inadequate branding. The result is a substantial gap between the SDR’s potential and its performance.

That gap has meant missed opportunities for the global economy – particularly in terms of asset-liability management, responsive liquidity, adjustment between deficit and surplus countries – and thus a gap between actual and potential growth. With the SDR providing a stronger glue at the international monetary system’s core, prudential currency diversification could have been made easier, the need for costly and inefficient self-insurance could have been reduced, and the provision of liquidity could have been made less pro-cyclical.

So, do today’s anti-globalization winds – caused in part by poor global policy coordination in the context of too many years of low and insufficiently inclusive growth – create scope for enhancing the SDR’s role and potential contributions?

Addressing this question, were it to gain traction, would involve a focus on an ecosystem of SDR use, with the composite currency – which last year added the Chinese renminbi to the British pound, euro, Japanese yen, and US dollar – potentially benefiting from a virtuous cycle. Specifically, the SDR’s three roles – an official reserve asset, a currency used more broadly in financial activity, and a numeraire – could ensure greater official liquidity, expand the range of new assets used around the world in public and private transactions, and boost its use as a unit of account.

Of course, given the advanced economies’ embrace of more inward-looking, populist, and nationalist politics, a “big bang” approach to reinvigorating the SDR is highly unlikely. Even an incremental approach, starting with practical low-hanging fruit that does not require amendments to the IMF’s Articles of Agreement, would face political challenges. But it would be worth considering.

Areas of focus would include using the SDR for some bond issuance and trade transactions, developing market infrastructure (including payments and settlement mechanisms), improving valuation methodologies, and gradually developing a yield curve for SDR-denominated loans and bonds. This would also help to leverage the inter-connectedness of the SDR’s roles, in order to reach critical mass quickly and have a foundation for further incremental gains.

For the effort to succeed, the IMF’s approach would need to evolve – just like it did on country-specific issues.

When I joined the IMF in the early 1980s, discussions with non-government counterparts, whether on country or policy work, were discouraged. The situation today is very different. Broader national engagement – with NGOs, local media, and a broad set of politicians – is now viewed as an integral part of effective country advice and program implementation, as well as being essential for the Fund’s “surveillance” function under its Article of Agreements.

A similar pivot is needed if the IMF is to deliver better on the supra-national issues that are now migrating up its policy agenda. Specifically, the Fund would need to complement its traditional core constituency of governments and other multilateral institutions (particularly the World Bank) with systemically influential sub-national and private counterparts. The resulting public-private partnerships would enhance issuance, the development of market infrastructure, and liquidity provision for the SDR.

While it is not easy to combine developmental and commercial activities, the implications for global growth and stability of not doing so suggest that it is an effort that should be explored. Moreover, the IMF could start small, focusing on interactions with other official multilateral and regional institutions, sovereign wealth funds, and multinational financial companies – all anchored by an active coalition of the willing among the G20.

In an ideal world, the SDR would have evolved into more of a reserve currency during the era of accelerated trade and financial globalization. In the world as it is today, the international monetary system faces two options: fragmentation, with all the risks and opportunity costs that this implies, or an incremental approach to bolstering the global economy’s resilience and potential growth, based on bottom-up partnerships that facilitate systemic progress.

Mohamed A. El-Erian, Chief Economic Adviser at Allianz, was Chairman of US President Barack Obama’s Global Development Council and is the author of The Only Game in Town: Central Banks, Instability, and Avoiding the Next Collapse.

By Mohamed A. El-Erian

Enlisting Women in Africa’s Health Fight

BRAZZAVILLE– Neglected Tropical Diseases (NTDs) disproportionately affect women and girls. Female genital schistosomiasis (FGS) alone causes severe pain, bleeding, and lesions in more than 16 million women and girls in Sub-Saharan Africa.

Beyond causing widespread physical suffering, NTDs have a severe long-term socioeconomic impact on millions of women and girls. Women who have been scarred or disfigured from diseases such as FGS and lymphatic filariasis are often stigmatized to the point that they are unable to marry or are abandoned by their spouses. And even though disfigurement and social stigma are not lethal conditions, they can cause or exacerbate psychological disorders and limit the opportunities women and girls have.

Since 2000, enough pharmaceuticals for five billion preventive treatments against NTDs have been donated. And many people now recognize that controlling, and eventually eliminating, NTDs will be essential for achieving the Sustainable Development Goals, which apply to such diverse areas as nutrition, education, health, water, sanitation and hygiene, and economic growth. Because the SDGs are based on the principle of “leaving no one behind,” they cannot be considered a success until they have been met everywhere, and for all people – including women and girls.

SDG 5, in particular, calls for the world to “achieve gender equality and empower all women and girls” by 2030. Gender equity applies to both sexes, but special attention is needed to improve conditions for women and girls. In Africa, women are often disenfranchised, even though they account for more than half of the continent’s population. To ensure that they are not forgotten, we need to improve our understanding of how gendered power relationships operate, and address those social dynamics head on.

Because women and girls in their childbearing years suffer disproportionately from the health and social effects of NTDs, it is critically important that they be included in any large-scale health-policy interventions that are proposed. And, beyond making women the focus of NTD programs, we should acknowledge that they will play a central role in advancing the sustainable development agenda.

We need to empower women and girls to promote and lead social-mobilization efforts in Africa. Women are front-line partners for public-health advocates who are working to make essential medicines available across the continent. Moreover, women can help to control NTD vectors at the source, by ensuring that all members of their community are complying with anti-NTD drug distribution and treatment programs.

Ongoing efforts to control and eliminate NTDs in Africa have made some progress. But the time has come to develop more innovative policy tools. We urgently need integrated, inter-programmatic, and inter-sectoral approaches that address NTDs’ social, economic, and etiological dynamics. And we will need the full participation of the most vulnerable communities. Without that, no program aimed at ultimately eradicating NTDs can succeed.

This year marks the fifth anniversary of the World Health Organization’s Roadmap to eliminate NTDs, and of the London Declaration on Neglected Tropical Diseases. It is encouraging to see that the international community is recognizing not only the disproportionate burden that NTDs place on women, but also the essential role that women play in controlling and eradicating these diseases.

Now that an ever-growing international partnership has emerged, we have a unique opportunity to put an end to these debilitating diseases once and for all. In 2016, the WHO Regional Office for Africa launched the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN), which provides African countries with technical assistance and fundraising tools to fight the five NTDs that can be preempted with preventive chemotherapy: onchocerciasis, lymphatic filariasis, schistosomiasis, soil-transmitted helminthiasis, and trachoma.

ESPEN is an effort to bring together governments, the global public-health community, and other stakeholders. Our goal is to strengthen partnerships that are designed specifically to eliminate NTDs. Toward that end, ESPEN is actively supporting national-level anti-NTD programs that have been established to break the cycle of poverty that NTDs cause and sustain.

As the WHO works toward achieving the SDGs, we will continue to foster participatory approaches that include the most vulnerable populations – especially women and girls – in the fight against disease. Ultimately, the only way to ensure long-term success is to empower those who are most affected. MatshidisoMoeti is Regional Director for Africa at the World Health Organization.

By MatshidisoMoeti

Will Health Care Be Disrupted?

LEXINGTON, MASSACHUSETTS – Although intelligent machines are increasingly operating complex manufacturing systems and replacing humans on factory floors, they have not made significant inroads in health care. The sector’s most advanced machines, from ultra-high-resolution imaging instruments to surgical robots, are still fully controlled by humans.

But as robotic and artificial-intelligence (AI) systems become more advanced, will they eventually render doctors and nurses obsolete, with patients consulting a computer instead? The short answer is: not anytime soon. Health-care professionals will certainly become increasingly dependent on machines; but technology will augment, not replace, their abilities, and doctors will remain in charge of medical practices.

In his 2009 book The Innovator’s Prescription, Harvard Business School’s Clayton Christensen identified a spectrum of medical practices that range between “intuitive” and “precision.” Intuitive medicine describes when a doctor interprets a patient’s symptoms to arrive at a diagnosis and prescribe a treatment, the efficacy of which is often uncertain. Precision medicine – which should not be confused with personalized medicine – describes a rules-based process by which standardized treatments with predictable outcomes are applied to known health conditions.

According to Christensen, most of the medicine practiced today is closer to the intuitive side of the spectrum, and only a few diseases, primarily infections, can be treated using precision medicine. In fact, at the moment, the concept of precision medicine is incorrectly applied to improve only the outcomes of intuitive medicine, instead of identifying the causal mechanisms of diseases. As long as this is true, human know-how and engagement will remain integral to health care.

Treating unspecific symptoms without a prescribed roadmap requires effective decision-making and trust, which is a significant hurdle for machines. After millions of years of evolution, humans have developed a capacity for contextual intuition that enables trained doctors to make sensible and timely decisions in uncertain, data-scarce environments. Even the most sophisticated AI systems that we have today would need to be improved significantly in order to mimic this ability.

Communicating with patients poses an even greater challenge for machines. Explaining the many nuances of a mysterious disease such as cancer requires emotional intelligence and the ability to build trust with patients by delivering information effectively. Doctors also must exhibit cultural humility, so that they can take into account a patient’s social background when administering care. For the foreseeable future, machines probably will not be able to match humans in helping chronically ill patients whose prognosis remains uncertain.

Still, despite intelligent machines’ limitations, they will continue to play a bigger role in health care, even in the realm of intuitive medicine. Owing to their superior analytic power, machines are already providing more data upon which physicians base their diagnostic and treatment decisions. Machines are increasingly monitoring patients as well, helping to prevent human errors in hospitals and pharmacies. Soon, many more ancillary functions such as admissions, scheduling, and discharges will be automated.

But, again, until the scope of precision medicine surpasses that of intuitive medicine, health-care professionals will continue to make medical decisions and interpret the data. So, what are the prospects for such a shift?

Up until the mid-nineteenth century, bacterial and viral diseases were treated through intuitive medicine, because nobody had isolated the cause of patients’ symptoms. Then, Louis Pasteur and other scientists developed the germ theory, microscopes improved, and scientists began to identify the sizes and shapes of microbes.

Over the past century, our scientific understanding of germs has improved so much that every virus and bacteria can now be quickly diagnosed and isolated. This has enabled health-care professionals to switch from practicing intuitive medicine to precision medicine, where they can apply standardized processes that predictably cure diseases. With simple and inexpensive methods, we have eradicated deadly diseases such as polio and smallpox.More recently, researchers discoveredan Ebola vaccine that provides 100% protection against the virus.

One day, when we have gained a similar level of understanding of the biochemistry and physiology of the human body, precision medicine will be applied to all disease categories. We will be able to determine every disease’s cause and progression precisely, and machines will operate with more autonomy, within a standardized environment, to provide the exact treatment that every patient needs.

Just as rules-based processes have laid the groundwork for self-driving vehicles, rules-based precision medicine will steadily increase the importance of automated super-machines in health care. It already feels routine to be prescribed antibiotics for an infection. Eventually, patients will have the same confidence in machines to administer their care; and as our understanding of diseases improves, personal interactions will become less necessary.

We shouldn’t expect machines to replace health-care professionals for some time, but new technologies will continue to be introduced into the sector’s evolving landscape, and we should welcome them. Practicing more precision medicine than intuitive medicine will make health care simpler, more accessible, and less expensive. By understanding patients’ diseases precisely, we can push medicine one step closer to its ultimate goal: patient-centered care of the finest quality. Spencer Nam is a senior research fellow at the Clayton Christensen Institute for Disruptive Innovation.

By Spencer Nam

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