"There is growing consensus that populism constitutes a grave threat to liberal democracy, and to the liberal international order on which peace and prosperity have rested for the past two generations," writes Francis Fukuyama in the World Economic Forum. The fate of the global liberal order could be jeopardized due to rising populist powers and movements. Read the full article here. 

As global health assistance for developing countries dwindles, a Stanford student working on her PhD in health policy has developed a novel formula to help donors make more informed decisions about where their dollars should go.

Donors have typically relied predominately on gross national income (GNI) per capita to determine aid allocations. But using GNI is problematic because it effectively penalizes economic growth. It also fails to capture contextual nuances important to channeling aid effectively and efficiently.

So Tara Templin, a first-year Stanford PhD student specializing in health economics, and her Harvard colleague Annie Haakenstad, have developed a framework that estimates funding based on needed resources, expected spending and potential spending into 2030. They believe the more flexible model makes it adaptable for use by governments, donors and policymakers.

“We've observed development assistance for health growth attenuate over the last seven years,” said Templin, who was a research fellow at the Institute for Health Metrics and Evaluation before coming to Stanford. “There are difficult trade-offs, and this entails honing in on the specific challenges and countries most in need.”

Their research published in the journal Health Policy and Planning outlines how their “financing gaps framework” can be adapted to short- or long-run time frames, between or within countries.

“Depending on donor preferences, the framework can be deployed to incentivize local investments in health, ensuring the long-term sustainability of health systems in low- and middle-income countries, while also furnishing international support for progress toward global health goals,” write the authors, who also are Stephen Lim of the University of Washington, Jesse B. Bump of Harvard and Joseph Dieleman, also at the University of Washington.

The authors developed a case study of child health to test out their framework. It shows that priorities vary substantially when using their results as compared to focusing mainly on GNI per capita or child mortality.

The case study uses data from the Global Burden of Disease 2013 Study, Financing Global Health 2015, the WHO Global Health Observatory and National Health Accounts. Funding flows are anchored to progress toward the U.N. Sustainable Development Goals’ target for reductions in the death rates of children under 5. More than six million children die each year before their fifth birthday, so the United Nations set a goal to reduce under-5 mortality to at least 25 per 1,000 live births.

To build their child health case study, the authors relied on a 2015 study that estimated the average cost per child-life saved is $4,205 in low-income countries, $6,496 in lower-middle income countries and $10,016 in upper-middle countries.

The framework considers three concepts. First, expected government spending is constructed from national health accounts, which are standardized financial reports from countries around the world. Second, ability to pay is estimated by looking at countries with similar levels of economic development and looking at associations with country investment in the health sector. Lastly, needed investment considers a health target, the country’s current health burden, and average costs to save children’s lives in each country.

“Our focus is on the gap between the resources needed to reach critical health targets and domestic health spending,” the authors wrote. “We highlight two facets of domestic health resources—expected spending and potential spending—as critical. While donor preferences may vary, basing aid allocation on expected or existing spending levels incentivizes countries to spend less on health. We therefore propose the use of potential spending, which is a measure of a country’s ability to pay, as the domestic resource benchmark.”

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Instead of the gap between expected spending and need, their framework focuses on the gap between potential spending and the health resources needed to meet global health targets. In the framework, policymakers can choose which gap they want to target, since this decision can involve many factors.

“By focusing on that gap, donors can catalyze sustained domestic spending while also addressing the resource needs critical to reaching international health goals,” they wrote.

They then looked at 10 countries with the most need for additional child health resources. The gap between expected spending and potential spending was highest in Afghanistan, at 79 percent, and lowest in Cameroon, where expected spending exceeded potential spending.

“Fifty years ago, GNI was the best proxy for countries’ ability to finance their own development and health,” the authors wrote.

But today, more empirical data and technology are available, allowing donors to incorporate a broader set of health financing measures into their decision-making process.

“The flexible but targeted nature of our framework is critical in the current era of global health financing,” said Haakenstad, the lead author. “Our framework helps to ensure the poor and disadvantaged, the majority of which now reside in middle-income countries, are reached by development assistance and other public financing. This funding is critical to reducing death and disability and reaching global targets in health.”

The authors’ research was supported by the Welcome Trust (099114/Z/12/Z).

Our Leadership Academy for Development (LAD) recently visited Tunis, Tunisia in partnership with the Center for International Private Enterprise (CIPE) to conduct a workshop for a group of Tunisian business, government and civil society leaders. Read more here. 

"While it is folly to underestimate the severity of the crisis in Iran, it is no less dangerous to underestimate the regime’s capacity for brutality. There are hundreds of thousands of Revolutionary Guard and militia forces whose perks of power and privilege are tethered to the survival of the regime, and it is hard to imagine they would give up wealth and status beyond their wildest dreams without a fight." - writes Abbas Milani, Director of Iranian Studies and CDDRL affiliated faculty on latest protest in Iran. Read the article here.

On November 17, 2017, FSI and CISAC senior fellow Martha Crenshaw spoke to the United Nations about how civil wars affect terrorism. In response to her discussion, Politically Speaking published the following Q&A.

The international response to civil wars and conflicts involving armed or insurgent groups was the subject of discussion as the Department of Political Affairs recently hosted the contributors to a special issue of Dædalus, produced as part of the American Academy of Arts and Sciences’ Civil Wars, Violence, and International Responses project.

Martha Crenshaw, Senior Fellow at the Center for International Security and Cooperation (CISAC) at Stanford; Tanisha M. Fazal, Associate Professor of Political Science at the University of Minnesota; and Stathis Kalyvas, Arnold Wolfers Professor of Political Science at Yale, spoke about the evolving profile of armed groups, particularly those ostensibly motivated by religion. Following the 17 November discussion, Politically Speaking spoke to the researchers, whose work aims not only to contribute to current policy-making but also to contextualize current trends by building a larger conceptual understanding of the threats posed by the collapse of state authority associated with civil wars and insurgencies.

Politically Speaking: At the UN we often talk about the internationalization of civil wars, the mobilization of outside support, the involvement of foreign fighters and spillover effects. Can these phenomena be prevented?

Martha Crenshaw: It is not possible to contain civil wars within national boundaries or prevent linkages and spillovers, especially when conflicts involve parties motivated by transnational ideologies such as jihadism and its accompanying sectarianism. Outside actors, whether states or non-states, are drawn into or even instigate these conflicts because they have an affinity for local players and/or because they see support for specific factions as useful in pursuing their own self-interests and rivalries. Due particularly to the prevalence of social media and the ease of internet communication, civil wars in which jihadist or violent Islamist factions are fighting will attract volunteers and inspire individual terrorist attacks against the countries perceived as opposing the global Islamist cause, be they neighbors or physically distant from the battlefield. The difficulty of prevention in such complex scenarios does not mean, however, that nothing can be done.  It is essential not to approach the problem piecemeal; today’s complex and messy conflicts should be considered comprehensively as wholes that may be greater than the sum of their parts. Policies for countering terrorism, insurgency, and “violent extremism” should not be compartmentalized. For example, military efforts to quell violent oppositions may succeed in eliminating the threat on the ground but in the long run stimulate support for the cause and thus perpetuate or even widen the struggle. Military victories do not automatically create stable political orders or solve the political grievances and disputes that led to war in the first place.

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