Situated in the heartland, Missouri reflects the full range of American reality.

The state is highly urban yet deeply rural. It contains two bustling metropolises, numerous fastgrowing suburbs, and dozens of typically American small towns. Elsewhere lie tranquil swaths of open country where farmers still rise before dawn and the view consists mainly of rich cropland, trees, and sky.

Missouri sums up the best of the nation, in short.

And yet, Missouri also mirrors the country’s experience in more problematic ways.

The spread of the national economic downturn to Missouri, most immediately, has depressed tax collections and increased the demand for social services, resulting in a troublesome state and local fiscal moment. This has highlighted pocketbook concerns and underscored that the state must make the most of limited resources.

At the same time, Missourians, like many Americans, have many opinions about how their local communities are changing. They are divided—and sometimes ambivalent—in their views of whether their towns and neighborhoods are developing in ways that maintain the quality of life and character they cherish.

All of which explains the double focus of the following report by the Brookings Institution Center on Urban and Metropolitan Policy. Intended to speak to the simultaneous concern of Missourians for fiscal efficiency and communities of quality, "Growth in the Heartland: Challenges and Opportunities for Missouri" brings together for the first time a large body of new information about both the nature and costs of development patterns in the Show-Me State.

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As part of an ongoing cooperative agreement with the U.S. Food and Drug Administration (FDA), the Engelberg Center for Health Care Reform at Brookings has formed the Brookings Council on Antibacterial Drug Development (BCADD) to identify steps to address the major technical, regulatory, and financial barriers impeding antibacterial drug development. At the first meeting of the BCADD, stakeholders emphasized the importance of concentrating on discrete policy and program areas to revitalize the antibacterial drug development enterprise.

BCADD convened a diverse group of stakeholders, including FDA officials, industry and biotech representatives, payers, providers, clinicians, and academic researchers Wednesday, February 27, 2013, to discuss two of the economic challenges facing antibacterial drug development:

• Better understanding the potential role of incentives in drug discovery and development; and
• Identifying potential reimbursement models that can support both stewardship and expanded investment for antibacterial drug products.

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Editor's note: This article appears in the April 2015 issue of Global Forum. Click here to view the full publication.

Since passage of the Affordable Care Act in 2010, the last several years have seen a groundswell in physician payment and delivery reforms designed to achieve higher value health care through incentivizing higher quality care and lower overall costs. Accountable care models, for example, are achieving marked progress by realigning provider incentives toward greater risk-sharing and increased payments and shared savings with measured improvements in quality and cost containment. Medical homes are introducing greater care coordination and team-based care management, while the use of episode-based or bundled payments is removing perverse incentives that reward volume and intensity.

These reforms are coming just as the number of highly targeted, highly priced treatments continues to expand. The U.S. Food and Drug Administration (FDA) approved a decade-high 41 novel new drugs in 2014, many of them targeted therapies approved on the basis of increasingly sophisticated progress in genomics and the understanding of disease progression. In areas like oncology, such targeted treatments have grown as a percentage of global oncology market size from 11% in 2003 to 46% in 2013. New brand specialty drug spending in the U.S. is estimated to have been $7.5 billion in 2013, or 69% of total new drug spending. The growing prevalence of these drugs and their cost to the health system are setting the stage for significant flashpoints between industry, payers, and providers, seen most clearly in the debate over hepatitis C treatment costs that roiled stakeholder interactions for most of the past year. 

More of these targeted treatments are in the development pipeline, and a growing number of public policy efforts taking shape in 2015 are focused on accelerating their availability. The House of Representatives' 21st Century Cures Initiative, for example, has released a slew of legislative proposals aimed at promoting breakthrough innovation by increasing the efficiency of drug development and regulatory review. These efforts have significant downstream implications for the pace at which targeted and specialty therapies will become available, their associated costs, and the growing importance of demonstrating value in the postmarket setting.

As payers and providers continue their push toward increased value-based care, more innovative models for connecting such reforms to drug development are needed. Earlier collaboration with industry could enable more efficient identification of unmet need, opportunities to add value through drug development, and clearer input on the value proposition and evidentiary thresholds needed for coverage. Equally important will be unique public-private collaborations that invest in developing a better postmarket data infrastructure that can more effectively identify high value uses of new treatments and support achieving value through new payment reforms.

Stronger collaboration could also improve evidence development and the coverage determination process after a targeted  treatment has gained regulatory approval. Facilitated drug access programs like those proposed by the Medicare Administrative Contractor Palmetto GBA create access points for patients to receive targeted anti-cancer agents off-label while payers and industry gather important additional outcomes data in patient registries. More systematic and efficient use of policies like Medicare's Coverage with Evidence Development (CED), which allows for provisional coverage for promising technologies or treatments while evidence continues to be collected, could enable industry and payers to work together to learn about a medical product's performance in patient populations not typically represented in clinical studies. A CED-type model could be especially useful for certain specialty drugs: data collected as a condition of payment could help payers and providers develop evidence from actual practice to improve treatment algorithms, increase adherence, and improve outcomes. 

Finally, collaborations that support stronger postmarket data collection can also support novel drug payment models that further reward value. Bundled payments that include physician-administered drugs, for example, could encourage providers to increase quality while also incentivizing manufacturers to help promote evidence-based drug use and lower costs for uses that generate low value. Outcomes-based purchasing contracts that tie price paid to a medical product's performance could be another promising approach for high-expense treatment with clearly defined and feasibly measured outcomes.

Many of these ideas are not new, but as manufacturers, payers, providers, and patients move into an increasingly value-focused era of health care, it is clear that they must work together to find new ways to both promote development of promising new treatments while also making good on the promise of value-based health care reforms.

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The Risk Evaluation and Mitigation Strategies (REMS) program has become an important tool of the U.S. Food and Drug Administration (FDA) in ensuring that the benefits of a given medical product outweigh the associated risks, and has enabled FDA to approve a number of products that might not otherwise have been made available for patient use. Since the implementation of the REMS program, however, concerns have been raised regarding its impact on patient access to products and the associated burden on providers and health care systems. In an effort to address these concerns—and as part of its commitments under the Prescription Drug User Fee Act reauthorization of 2012—FDA has undertaken efforts to standardize and improve the effectiveness of REMS, and to better integrate REMS programs into the health system. As part of this broader initiative, the Agency is currently assessing the feasibility of integrating accredited continuing education (CE) programs and activities into REMS programs that have been developed for a single drug.

Under a cooperative agreement with the FDA, the Center for Health Policy held an expert workshop on May 18, titled “Incorporating Continuing Education into Single-Drug REMS: Exploring the Challenges and Opportunities”. This workshop provided an opportunity for pharmaceutical manufacturers, regulators, CE providers, accreditors, and other stakeholders to explore the ways that CE can be a valuable addition to the REMS toolkit, discuss potential barriers to the development and implementation of REMS-related CE for single products, and identify strategies for addressing those barriers.

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The Risk Evaluation and Mitigation Strategies (REMS) program has become an important tool of the U.S. Food and Drug Administration (FDA) in ensuring that the benefits of a given medical product outweigh the associated risks, and has enabled FDA to approve a number of products that might not otherwise have been made available for patient use. Since the implementation of the REMS program, however, concerns have been raised regarding its impact on patient access to products and the associated burden on providers and health care systems. In an effort to address these concerns—and as part of its commitments under the Prescription Drug User Fee Act reauthorization of 2012—FDA has undertaken efforts to standardize and improve the effectiveness of REMS, and to better integrate REMS programs into the health system. As part of this broader initiative, the Agency is currently assessing the feasibility of integrating accredited continuing education (CE) programs and activities into REMS programs that have been developed for a single drug.

Under a cooperative agreement with the FDA, the Center for Health Policy held an expert workshop on May 18 titled, “Incorporating Continuing Education into Single-Drug REMS: Exploring the Challenges and Opportunities”. This workshop provided an opportunity for pharmaceutical manufacturers, regulators, CE providers, accreditors, and other stakeholders to explore the ways that CE can be a valuable addition to the REMS toolkit, discuss potential barriers to the development and implementation of REMS-related CE for single products, and identify strategies for addressing those barriers.

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The Sentinel System is a state of the art active surveillance system relying on a distributed data network to rapidly scale analysis of health care data collected from over 178 million patients nationwide. Sentinel is an important safety surveillance tool used by the U.S. Food and Drug Administration (FDA), and its underlying distributed data infrastructure is increasingly being recognized to have the potential to support the needs of diverse stakeholders including other public health agencies, health systems, regulated industry, and the clinical research enterprise. Despite Sentinel’s importance in safety surveillance, patients are largely unaware of Sentinel’s public health mission and commitment to protecting patient privacy. Therefore, it is both timely and critical to identify opportunities to raise awareness and build trust for Sentinel safety surveillance among patients, consumers, and the general public.

On June 23, the Center for Health Policy at Brookings, in collaboration with the FDA, hosted an expert workshop to discuss opportunities to raise awareness of the Sentinel System through improved communication to patients and consumers. Participants, including Sentinel Data Partners, patient focused organizations (e.g., consumer advocacy groups), experts in patient privacy, ethics, and health literacy, and representatives from the FDA explored possible opportunities where each stakeholder might be uniquely positioned to engage with patients, and how these communications could be designed and delivered effectively. Discussions from this workshop resulted in recommendations including a set of guiding principles, potential tools, and strategies to improve awareness of the Sentinel System, but more broadly, safety surveillance activities led by the FDA.

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It has been hailed as the most significant discovery in biology since polymerase chain reaction allowed for the mass replication of DNA samples. CRISPR-Cas9 is an inexpensive and easy-to-use gene-editing method that promises applications ranging from medicine to industrial agriculture to biofuels. Currently, applications to treat leukemia, HIV, and cancer are under experimental development.¹ However, new technical solutions tend to be fraught with old problems, and in this case, ethical and legal questions loom large over the future.

Disagreements on ethics

The uptake of this method has been so fast that many scientists have started to worry about inadequate regulation of research and its unanticipated consequences.² Consider, for instance, the disagreement on research on human germ cells (eggs, sperm, or embryos) where an edited gene is passed onto offspring. Since the emergence of bioengineering applications in the 1970s, the scientific community has eschewed experiments to alter human germline and some governments have even banned them.³ The regulation regimes are expectedly not uniform: for instance, China bans the implantation of genetically modified embryos in women but not the research with embryos.

Last year, a group of Chinese researchers conducted gene-editing experiments on non-viable human zygotes (fertilized eggs) using CRISPR.⁴ News that these experiments were underway prompted a group of leading U.S. geneticists to meet in March 2015 in Napa, California, to begin a serious consideration of ethical and legal dimensions of CRISPR and called for a moratorium on research editing genes in human germline.⁵ Disregarding that call, the Chinese researchers published their results later in the year largely reporting a failure to precisely edit targeted genes without accidentally editing non-targets. CRISPR is not yet sufficiently precise.

CRISPR reignited an old debate on human germline research that is one of the central motivations (but surely not the only one) for an international summit on gene editing hosted by the U.S. National Academies of Sciences, the Chinese Academy of Sciences, and the U.K.'s Royal Society in December 2015. About 500 scientists as well as experts in the legal and ethical aspects of bioengineering attended.⁶ Rather than consensus, the meeting highlighted the significant contrasts among participants about the ethics of inquiry, and more generally, about the governance of science. Illustrative of these contrasts are the views of prominent geneticists Francis Collins, Director of the National Institutes of Health, and George Church, professor of genetics at Harvard. Collins argues that the “balance of the debate leans overwhelmingly against human germline engineering.” In turn, Church, while a signatory of the moratorium called by the Napa group, has nevertheless suggested reasons why CRISPR is shifting the balance in favor of lifting the ban on human germline experiments.⁷

The desire to speed up discovery of cures for heritable diseases is laudable. But tinkering with human germline is truly a human concern and cannot be presumed to be the exclusive jurisdictions of scientists, clinicians, or patients. All members of society have a stake in the evolution of CRISPR and must be part of the conversation about what kind of research should be permitted, what should be discouraged, and what disallowed. To relegate lay citizens to react to CRISPR applications—i.e. to vote with their wallets once applications hit the market—is to reduce their citizenship to consumer rights, and public participation to purchasing power.⁸ Yet, neither the NAS summit nor the earlier Napa meeting sought to solicit the perspectives of citizens, groups, and associations other than those already tuned in the CRISPR debates.⁹

The scientific community has a bond to the larger society in which it operates that in its most basic form is the bond of the scientist to her national community, is the notion that the scientist is a citizen of society before she is a denizen of science. This bond entails liberties and responsibilities that transcend the ethos and telos of science and, consequently, subordinates science to the social compact. It is worth recalling this old lesson from the history of science as we continue the public debate on gene editing. Scientists are free to hold specific moral views and prescriptions about the proper conduct of research and the ethical limits of that conduct, but they are not free to exclude the rest of society from weighing in on the debate with their own values and moral imaginations about what should be permitted and what should be banned in research. The governance of CRISPR is a question of collective choice that must be answered by means of democratic deliberation and, when irreconcilable differences arise, by the due process of democratic institutions.

Patent disputes

More heated than the ethical debate is the legal battle for key CRISPR patents that has embroiled prominent scientists involved in perfecting this method. The U.S. Patent and Trademark Office initiated a formal contestation process, called interference, in March 2016 to adjudicate the dispute. The process is likely to take years and appeals are expected to extend further in time. Challenges are also expected to patents filed internationally, including those filed with the European Patent Office.

To put this dispute in perspective, it is instructive to consider the history of CRISPR authored by one of the celebrities in gene science, Eric Lander.¹⁰ This article ignited a controversy because it understated the role of one of the parties to the patent dispute (Jennifer Doudna and Emmanuelle Charpentier), while casting the other party as truly culminating the development of this technology (Feng Zhang, who is affiliated to Lander’s Broad Institute). Some gene scientists accused Lander of tendentious inaccuracies and of trying to spin a story in a manner that favors the legal argument (and economic interest) of Zhang.

Ironically, the contentious article could be read as an argument against any particular claim to the CRISPR patents as it implicitly questions the fairness of granting exclusive rights to an invention. Lander tells the genesis of CRISPR that extends through a period of two decades and over various countries, where the protagonists are the many researchers who contributed to the cumulative knowledge in the ongoing development of the method. The very title of Lander’s piece, “The Heroes of CRISPR” highlights that the technology has not one but a plurality of authors.

A patent is a legal instrument that recognizes certain rights of the patent holder (individual, group, or organization) and at the same time denies those rights to everyone else, including those other contributors to the invention. Patent rights are thus arbitrary under the candle of history. I am not suggesting that the bureaucratic rules to grant a patent or to determine its validity are arbitrary; they have logical rationales anchored in practice and precedent. I am suggesting that in principle any exclusive assignation of rights that does not include the entire community responsible for the invention is arbitrary and thus unfair. The history of CRISPR highlights this old lesson from the history of technology: an invention does not belong to its patent holder, except in a court of law.

Some scientists may be willing to accept with resignation the unfair distribution of recognition granted by patents (or prizes like the Nobel) and find consolation in the fact that their contribution to science has real effects on people’s lives as it materializes in things like new therapies and drugs. Yet patents are also instrumental in distributing those real effects quite unevenly. Patents create monopolies that, selling their innovation at high prices, benefit only those who can afford them. The regular refrain to this charge is that without the promise of high profits, there would be no investments in innovation and no advances in life-saving medicine. What’s more, the biotech industry reminds us that start-ups will secure capital injections only if they have exclusive rights to the technologies they are developing. Yet, Editas Medicine, a biotech start-up that seeks to exploit commercial applications of CRISPR (Zhang is a stakeholder), was able to raise $94 million in its February 2016 initial public offering. That some of Editas’ key patents are disputed and were entering interference at USPTO was patently not a deterrent for those investors.

Towards a CRISPR democratic debate

Neither the governance of gene-editing research nor the management of CRISPR patents should be the exclusive responsibility of scientists. Yet, they do enjoy an advantage in public deliberations on gene editing that is derived from their technical competence and from the authority ascribed to them by society. They can use this advantage to close the public debate and monopolize its terms, or they could turn it into stewardship of a truly democratic debate about CRISPR.

The latter choice can benefit from three steps. A first step would be openness: a public willingness to consider and internalize public values that are not easily reconciled with research values. A second step would be self-restraint: publicly affirming a self-imposed ban on research with human germline and discouraging research practices that are contrary to received norms of prudence. A third useful step would be a public service orientation in the use of patents: scientists should pressure their universities, who hold title to their inventions, to preserve some degree of influence over research commercialization so that the dissemination and access to innovations is consonant with the noble aspirations of science and the public service mission of the university. Openness, self-restraint, and an orientation to service from scientists will go a long way to make of CRISPR a true servant of society and an instrument of democracy.

Other reading: See media coverage compiled by the National Academies of Sciences.

¹Nature: an authoritative and accessible primer. A more technical description of applications in Hsu, P. D. et al. 2014. Cell, 157(6): 1262–1278.

³More about ethical concerns on gene editing here: http://www.geneticsandsociety.org/article.php?id=8711

⁴Liang, P. et al. 2015. Protein & Cell, 6, 363–372

⁵Science: A prudent path forward for genomic engineering and germline gene modification.

⁶Nature: NAS Gene Editing Summit.

⁷While Collins and Church participated in the summit, their views quoted here are from StatNews.com: A debate: Should we edit the human germline. See also Sciencenews.org: Editing human germline cells sparks ethics debate.

⁸Hurlbut, J. B. 2015. Limits of Responsibility, Hastings Center Report, 45(5): 11-14.

⁹This point is forcefully made by Sheila Jasanoff and colleagues: CRISPR Democracy, 2015 Issues in S&T, 22(1).

¹⁰Lander, E. 2016. The Heroes of CRISPR. Cell, 164(1-2): 18-28.

Despite the undeniable benefits of education to society, the educational needs, particularly in the world’s poorest countries, remain strikingly great. There are more than 67 million children not enrolled in primary school around the world, millions of children who are enrolled in school but not really learning, and too few young people are advancing to secondary school (van der Gaag and Adams 2010). Consider, for instance, the number of children unable to read a single word of connected text at the end of grade two: more than 90 percent in Mali, more than 50 percent in Uganda, and nearly 33 percent in Honduras (USAID n.d.).

With more young people of age 12 to 24 years today than ever before who are passing through the global education system and looking for opportunities for economic and civic participation, the education community is at a crossroads. Of the 1.5 billion young people in this age group, 1.3 billion live in developing countries (World Bank 2007). The global community set the goal of achieving universal primary education by 2015 and has failed to mobilize the resources necessary, as UNESCO estimates that $16.2 billion in external resources will be need to reach this goal.

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Results from this report were presented at an April 6 Center on Universal Education event at the Brookings Institution.

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INTRODUCTION

In August, 2010 the government of Kenya adopted a new constitution. This followed a referendum in which an overwhelming majority of Kenyans voted for change. The decisive impetus for reform came from the widespread violence and political crisis that followed the 2007 election. While claims of electoral fraud provided the immediate catalyst for violence, the deeper causes were to be found in the interaction of a highly centralized ‘winner-take-all’ political system with deep social disparities based in part on group identity (Hanson 2008).

Provisions for equity figure prominently in the new constitution. Backed by a bill of rights that opens the door to legal enforcement, citizenship rights have been strengthened in many areas,including access to basic services. ‘Equitable sharing’ has been introduced as a guiding principle for public spending. National and devolved governments are now constitutionally required to redress social disparities, target disadvantaged areas and provide affirmative action for marginalized groups.

Translating these provisions into tangible outcomes will not be straightforward. Equity is a principle that would be readily endorsed by most policymakers in Kenya and Kenya’s citizens have provided their own endorsement through the referendum. However, there is an ongoing debate over what the commitment to equity means in practice, as well as over the pace and direction of reform. Much of that debate has centered on the constitutional injunction requiring ‘equitable sharing’ in public spending.

On most measures of human development, Kenya registers average outcomes considerably above those for sub-Saharan Africa as a region. Yet the national average masks extreme disparities—and the benefits of increased prosperity have been unequally shared.

There are compelling grounds for a strengthened focus on equity in Kenya. In recent years, the country has maintained a respectable, if less than spectacular, record on economic growth. Social indicators are also on an upward trend. On most measures of human development, Kenya registers average outcomes considerably above those for sub-Saharan Africa as a region. Yet the national average masks extreme disparities—and the benefits of increased prosperity have been unequally shared. Some regions and social groups face levels of deprivation that rank alongside the worst in Africa. Moreover, the deep fault lines running through society are widely perceived as a source of injustice and potential political instability.

High levels of inequality in Kenya raise wider concerns. There has been a tendency in domestic debates to see ‘equitable sharing’ as a guiding principle for social justice, rather than as a condition for accelerated growth and enhanced economic efficiency. Yet international evidence strongly suggests that extreme inequality—especially in opportunities for education— is profoundly damaging for economic growth. It follows that redistributive public spending has the potential to support growth.

The current paper focuses on a group of 12 counties located in Kenya’s Arid and Semi-Arid Lands (ASALs). They are among the most disadvantaged in the country. Most are characterized by high levels of income poverty, chronic food insecurity and acute deprivation across a wide range of social indicators.

Nowhere is the deprivation starker than in education. The ASAL counties account for a disproportionately large share of Kenya’s out-of-school children, pointing to problems in access and school retention. Gender disparities in education are among the widest in the country. Learning outcomes for the small number of children who get through primary school are for the most part abysmal, even by the generally low national average standards.

Unequal public spending patterns have played no small part in creating the disparities that separate the ASAL counties from the rest of Kenya—and ‘equitable sharing’ could play a role in closing the gap. But what would a more equitable approach to public spending look like in practice?

This paper addresses that question. It looks in some detail at education for two reasons. First, good quality education is itself a powerful motor of enhanced equity. It has the potential to equip children and youth with the skills and competencies that they need to break out of cycles of poverty and to participate more fully in national prosperity. If Kenya is to embark on a more equitable pattern of development, there are strong grounds for prioritizing the creation of more equal opportunities in education. Second, the education sector illustrates many of the wider challenges and debates that Kenya’s policymakers will have to address as they seek to translate constitutional provisions into public spending strategies. In particular, it highlights the importance of weighting for indicators that reflect need in designing formulae for budget allocations.

Our broad conclusion is that, while Kenya clearly needs to avoid public spending reforms that jeopardize service delivery in wealthier counties, redistributive measures are justified on the grounds of efficiency and equity.

The paper is organized as follows. Part 1 provides an overview of the approach to equity enshrined in the constitution. While the spirit of the constitution is unequivocal, the letter is open to a vast array of interpretations. We briefly explore the implications of a range of approaches. Our broad conclusion is that, while Kenya clearly needs to avoid public spending reforms that jeopardize service delivery in wealthier counties, redistributive measures are justified on the grounds of efficiency and equity. Although this paper focuses principally on basic services, we caution against approaches that treat equity as a matter of social sector financing to the exclusion of growth-oriented productive investment.

Part 2 provides an analysis of some key indicators on poverty, health and nutrition. Drawing on household expenditure data, the report locates the 12 ASAL counties in the national league table for the incidence and depth of poverty. Data on health outcomes and access to basic services provide another indicator of the state of human development. While there are some marked variations across counties and indicators, most of the 12 counties register levels of deprivation in poverty and basic health far in excess of those found in other areas.

Part 3 shifts the focus to education. Over the past decade, Kenya has made considerable progress in improving access to basic education. Enrollment rates in primary education have increased sharply since the elimination of school fees in 2003. Transition rates to secondary school are also rising. The record on learning achievement is less impressive. While Kenya lacks a comprehensive national learning assessment, survey evidence points to systemic problems in education quality. In both access and learning, children in the ASAL counties—especially female children—are at a considerable disadvantage. After setting out the national picture, the paper explores the distinctive problems facing these counties.

In Part 4 we look beyond Kenya to wider international experience. Many countries have grappled with the challenge of reducing disparities between less-favored and more-favored regions. There are no blueprints on offer. However, there are some useful lessons and guidelines that may be of some relevance to the policy debate in Kenya. The experience of South Africa may be particularly instructive given the weight attached to equity in the post-apartheid constitution.

Part 5 of the paper explores a range of approaches to financial allocations. Converting constitutional principle into operational practice will require the development of formulae-based approaches. From an equitable financing perspective there is no perfect model. Any formula that is adopted will involve trade-offs between different goals. Policymakers have to determine what weight to attach to different dimensions of equity (for example, gender, income, education and health), the time frame for achieving stated policy goals, and whether to frame targets in terms of outcomes or inputs. These questions go beyond devolved financing. The Kenyan constitution is unequivocal in stipulating that the ‘equitable sharing’ provision applies to all public spending. We therefore undertake a series of formula-based exercises illustrating the allocation patterns that would emerge under different formulae, with specific reference to the 12 ASAL focus counties and to education.

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Ghana attained middle-income status after rebasing its National Accounts, pushing per capita gross domestic product (GDP) of the country above $1,000 in 2007. After recovering from economic recession in 1984 on account of the Bretton Woods sponsored economic reform introduced at that time, Ghana’s growth has been remarkably strong, with its lowest economic growth of 3.3 percent recorded in 1994. The country’s growth rate reached its peak of 15 percent in 2011 on the back of the commencement of commercial production of oil, making it one of the fastest growing economies globally during that year. This has translated into increased per capita income, which reached a high of about $1,900 in 2013.

The concern, however, has been the ability of the country to sustain this growth momentum given the level and quality of education and skills, and, more importantly, the failure of this strong growth performance to be translated into the creation of productive and decent jobs, improved incomes and livelihoods. The structure of the economy remains highly informal, with a shift in the country’s national output composition from agriculture to low-value service activities in the informal sector. The commencement of commercial production of oil raised the share of the industrial sector in national output. However, the continuous decline in manufacturing value added undermines Ghana’s economic transformation effort to promote high and secure incomes and improve the livelihoods of the people.

Structural change towards higher value added sectors, and upgrading of technologies in existing sectors, is expected to allow for better conditions of work, better jobs, and higher wages. But the low level and quality of human resources not only diverts the economy from its structural transformation path of development but also makes it difficult for the benefits of growth to be spread through the creation of gainful and productive employment. Thus, productive structural economic transformation hinges on the level and quality of education and labor skills. A highly skilled, innovative and knowledgeable workforce constitutes a key ingredient in the process of structural economic transformation, and as productive sectors apply more complex production technologies and research and development activities increase the demand for education and skills. However, the observed weak human capital base does not provide a strong foundation for structural economic transformation of Ghana.

Ghana’s employment growth lags behind economic growth, with an estimated employment elasticity of output of 0.47, suggesting that every 1 percent of annual economic growth yields 0.47 percent growth of total employment.

There is also widespread concern about the quality of the country’s growth in terms of employment and inequality, as well as general improvement in the livelihood of the people (see Alagidede et al. 2013; Aryeetey et al. 2014; Baah-Boateng 2013). A key indicator for measuring the extent to which macroeconomic growth results in gains in the welfare of the citizenry is the quality of jobs that the economy generates. Ghana’s employment growth lags behind economic growth, with an estimated employment elasticity of output of 0.47 (see Baah-Boateng 2013), suggesting that every 1 percent of annual economic growth yields 0.47 percent growth of total employment. Besides the slow rate of job creation is the dominance of vulnerable employment and the working poverty rate in the labor market. In 2010, 7 out of 10 jobs were estimated to be vulnerable while only 1 out of 5 jobs could be considered as productive jobs that meet the standard of decent work (Baah-Boateng and Ewusi 2013). Workers in vulnerable employment tend to lack formal work arrangements as well as elements associated with decent employment such as adequate social security and recourse to effective social dialogue mechanisms (Sparreboom and Baah-Boateng 2011). The working poverty rate remains a challenge with one out of every five persons employed belonging to poor households.

The article seeks to provide an analytical assessment of Ghana’s economic growth as one of Africa’s growth giants over a period of more than two decades and the implication for labour market and livelihood outcomes. Growth of labor productivity at the national and sectoral level is examined, as well as the sectoral contribution to aggregate productivity growth. The article also analyses the effect of growth on employment and the employment-poverty linkage in terms of elasticity within the growth-employment-poverty nexus in Ghana. It also delves into a discussion of the constraints on growth and productive employment from both demand and supply perspectives, and identifies skills gaps and the opportunities offered in the country, which has experienced strong growth performance. The article has five sections, with an overview of Ghana’s economic growth performance in Section 2, after this introductory section. This is followed by an overview of the developments in the labor market, specifically in the area of employment, unemployment, poverty, and inequality in Ghana in Section 3. The growth-employment-poverty linkage analysis is carried out in Section 4 followed by a discussion of constraints to growth and employment generation in Section 5. Section 6 provides a summary and conclusion, with some policy suggestions for the future.

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Editor’s Note: The following is a transcript of the House of Representatives’ Special Select Committee hearing on the Benghazi scandal, taking place in a parallel universe not very far away. It is satire, obviously, but perhaps only because of an almost random quirk of fate.

Representative Trey Gowdy: I would like to call this hearing to order. We are gathered today to get to the bottom of the horrific events of March 18 to 25, 2011, when over 100,000 inhabitants of Benghazi were cruelly killed in the worst act of genocide since Rwanda. Libya has since descended into a catastrophic civil war on a par with Syria, and yet Colonel Gadhafi is still in power. Worse, the situation has exacerbated extremism and threatens to spur Islamic terrorism throughout the region. The recent intervention of Russian forces in the Libyan civil war ensures that any chance the United States had of ending Gadhafi’s cruel tyranny has been missed. 

This was the greatest moral and strategic failure of U.S. foreign policy in 20 years. And yet there has been little or no accountability. Former U.N. Ambassador Susan Rice was even promoted to Secretary of State, while former National Security Council staffer Samantha Power stepped down, apparently in quiet protest at the president and Secretary Hillary Clinton’s weak and morally vacuous policy. Ms. Power's new sequel "A Problem From Hell" has now been made into the Oscar-winning movie "Hotel Benghazi." This scandal, this moral failing is now seared into the conscience of our nation.

This Special Select Committee was stood up 18 months ago and has been working diligently since that day to build on the work of multiple other congressional inquiries to get at the truth of this national shame. We know that the Obama administration had intelligence about the risk of genocide in Benghazi but it decided not to act. Indeed, the entire world knew. The questions we want answered are: What did the administration know about the approaching genocide? And when did it know it? 

We are joined by former Secretary of State Hillary Clinton. Madam Secretary, we appreciate you taking time off from the campaign trail. I understand you have a short statement. 

Secretary Hillary Clinton: Thank you, Representative Gowdy. This is my fourth time appearing before the U.S. Congress on this issue; 37 members of my staff and family have appeared, and my dog is currently fighting a subpoena. So I will keep this brief.

While we deeply regret the Benghazi genocide, we must remember that we had incomplete information about Colonel Gadhafi's intentions. We were faced with a difficult choice: Should we intervene to stop an uncertain atrocity, committing U.S. troops to an uncertain mission with no exit plan and no vital national interest? Or should we try to shape events without the use of U.S. forces, using the many other tools at our disposal? 

We decided that U.S. military intervention was not prudent. We were worried about a failed state and losing U.S. personnel on the ground. The administration instead sought to mobilize the international community to prevent any genocide and ultimately to bring Gadhafi and his henchmen to justice at the International Criminal Court. 

We continued throughout my tenure as secretary of state—and until this day—to work to bring the civil war to an end and to help the moderate Libyan opposition to overthrow the regime. 

We made some tough calls and we must acknowledge that we were not always right. Knowing what we know now, I wish that we had acted more forcefully. Indeed, I was personally in favor of a no-fly zone to protect Libyan civilians. But hindsight is twenty-twenty and the president decided to stay out. 

Representative Gowdy: Madam Secretary, with all due respect, Gadhafi's intention was quite clear. Just days before the slaughter he said, and I quote: “All of these germs, rats and scumbags, they are not Libyans.” He told them "It's over…We are coming tonight…We will find you in your closets, ” adding: “We will show no mercy.” U.S. NGOs on the ground provided detailed information of troop movements. What more evidence did you need of imminent war crime? Why did you not act? Isn’t the role of the secretary of state to persuade the president? 

If something went wrong, I would be the first to say war is unpredictable and involves risk. I am confident the Congress would have fully supported you.

Secretary Clinton: Congressman, with all due respect, Congress at the time steadfastly opposed our intervention. Had we acted and had the aftermath been messy—as we fully expected—I have no doubt that you would be calling me here to account for that, noting that our own assessments showed we had no capacity to bring stability to Libya. What if we had lost U.S. military personnel or diplomats? What if a U.S. overthrow of the Gadhafi regime merely led to more and different chaos and violence, as we saw in Iraq?

Representative Gowdy: Madam Secretary, the greater shame is clearly inaction in the face of a moral imperative. I can assure you, and I feel confident I speak for all of my colleagues, that had you acted, we would have had your back, come what may. If something went wrong, I would be the first to say war is unpredictable and involves risk. I am confident the Congress would have fully supported you. 

Secretary Clinton: Thank you Congressman, but you will excuse me if I still have some doubts on that score. I guess we’ll never know. 

On Thursday, when former Secretary of State Hillary Rodham Clinton appears before the Senate Benghazi Committee for a new round of hearings, reporters with vivid historical imaginations will be pining for an epic battle. Melodramatic journalists may recall the 1950-1951 Kefauver Committee investigating organized crime, which introduced politicized television dramas to millions of Americans. They may evoke the 1954 Army-McCarthy hearings, when the aristocratic Boston lawyer Joseph Welch cold-cocked the anti-communist Senator Joe McCarthy by asking: “Have you no sense of decency, sir, at long last? Have you left no sense of decency?” They will yearn for the constitutional grandeur of the 1973 Senate Watergate hearings, which exposed Richard Nixon’s corruption. Alas, most likely, we will endure yet another round of the 1990s’ tawdry Clinton follies, which diminished both parties and helped trigger our current political depression.

Although Hillary Clinton often performs well under pressure and probably has rehearsed a dramatic soundbite or two to rile her partisan base, these hearings are bad news for her campaign. The email server scandal has gotten more traction than the Clintonites would have expected. It stirs fears that both Hillary and Bill Clinton are so convinced of their own goodness, their own idealism, their own contributions to the public good, that they exempt themselves from the rules ordinary Americans must follow. The scandal also reminds many of the Clintons’ moral blindspot, their ethical sloppiness that led them into the cozy, overlapping, ambiguities, and occasional lies behind the Whitewater mess, the Travelgate coverup, the Paula Jones sexual harassment, the Monica Lewinsky obstruction of justice, and a host of lesser Clinton catastrophes.

Many Americans had Clinton fatigue by 2000, despite Clinton’s record high approval ratings. And with our Canadian neighbors just having voted in Justin Trudeau due to Stephen Harper fatigue, Hillary Clinton should remember that American voters want a fresh start after enduring a decade and a half of terrorist fears and economic woes, preceded by a scadal-plagued, hyper-partisan period of peace and prosperity in the 1990s.

Democrats also should worry that Hillary Clinton’s best defense is pretty offensive. She will play the partisan card. In the final question of the Democratic debate, Anderson Cooper asked “Which enemy are you most proud of?” Hillary Clinton answered: “Well, in addition to the NRA, the health insurance companies, the drug companies, the Iranians. Probably the Republicans.” In his presidential announcement-esque I’m-not-running speech Vice President Joe Biden pointedly said: “I don’t think we should look at Republicans as our enemies.” How does a candidate who compares Republicans to Iranians woo centrist voters in crucial swing states? And you can imagine the general campaign commercials asking: How does a president who demonizes her rivals work with them after Election Day?

Republicans should not be too cocky about these hearings either. The male senators pounding away at millions of American women’s best chance at a female president should beware the Anita Hill effect. During the 1991 fight over the sexual harassment allegations during Clarence Thomas’s Supreme Court nomination hearings, hostile senators interrogating Thomas’s female accuser looked like bullies who, in the parlance of the time, “just didn’t get it.” For the last six years, the Democrats have cleverly cast the Republicans as the party of no. In the 1990s, the Clintons cleverly cast the Republicans as a party of Ken Starrs, prosecutorial prigs abusing congressional and federal powers to subvert the political process and undermine the Constitution.

Moreover, Hillary Clinton’s defense during the last set of hearings more accurately reflects the public mood. Four brave Americans died. Their Islamist terrorist murderers are the guilty ones, not whatever mistaken spin the Obama administration may or may not have put on it subsequently.

Since the 1990s, gotcha journalism and politics have ruined politicians’ reputations and soured Americans on politics. Unlike the Watergate scandal, which produced heroes defending the Constitution like Judge John Sirica and Senator Sam Ervin, the Clinton scandals, and especially the Monica Lewinsky debacle, tarnished everyone involved. Journalists and Republicans looked like bullies, invading people’s privacy, treating personal indiscretions as high crimes not even misdemeanors. Feminists and Democrats sounded like hypocrites, excusing sexual harassment and the White House as a hostile workplace for women as long as the perpetrator was a pro-choice liberal. The people’s business suffered. In post Watergate America, the Pig-Pen-like cloud shrouding the Clintons, and their supporters’ “everybody does it” defense, had once naïve Americans now cynically grumbling, “they’re all guilty of something.”

Inevitably, after the Thursday hearings, too many Republicans and Democrats will assess the results based on quickie polls suggesting who “won” or “lost” the exchange, and whether Hillary Clinton’s popularity rises or falls. Washington should start tracking a different set of poll results. Back in the 1950s and the 1960s, the vast majority of Americans trusted their government. The most recent Gallup poll has only 19 percent of Americans surveyed agreeing that “you can trust government to do what is right.” Those metrics suggested that both Democrats and Republicans, all the presidential candidates, the president, Congress, and the Supreme Court, have disappointed the American people. A healthy democracy needs citizens with more faith in their government, we don’t need more recriminations, the criminalizing of politics, or more partisan clashes. Perhaps it is time for Senate Republicans to join Democrats in creating a bipartsan committee to investigate that problem, and begin by inviting all presidential candidates to testify about what they will do to make Americans believe in Washington again.

"At the end of the day, we need to remember that Daesh is more a product of the civil wars than it is a cause of them. And the way that we’re behaving is we’re treating it as the cause.  And the problem is that in places like Syria, in Iraq, potentially in Libya, we are mounting these military campaigns to destroy Daesh and we’re not doing anything about the underlying civil wars.  And the real danger there is—we have a brilliant military and they may very well succeed in destroying Daesh—but if we haven’t dealt with the underlying civil wars, we’ll have Son of Daesh a year later." – Ken Pollack

“Part of the problem is how we want the U.S. to be more engaged and more involved and what that requires in practice. We have to be honest about a different kind of American role in the Middle East. It means committing considerable economic and political resources to this region of the world that a lot of Americans are quite frankly sick of… There is this aspect of nation-building that is in part what we have to do in the Middle East, help these countries rebuild, but we can’t do that on the cheap. We can’t do that with this relatively hands off approach.” – Shadi Hamid

In this episode of “Intersections,” Kenneth Pollack, senior fellow in the Center for Middle East Policy and Shadi Hamid, senior fellow in the Project on U.S. Relations with the Islamic World and author of "Islamic Exceptionalism: How the Struggle over Islam is Reshaping the World," discuss the current state of upheaval in the Middle East, the Arab Spring, and the political durability of Islamist movements in the region. They also explain their ideas on how and why the United States should change its approach to the Middle East and areas of potential improvement for U.S. foreign policy in the region. 

Show Notes

Fight or flight: America’s choice in the Middle East

Security and public order

Islamists on Islamism today

Temptations of Power: Islamists & Illiberal Democracy in a New Middle East

Ending the Middle East’s civil wars

A Rage for Order: The Middle East in turmoil, from Tahrir Square to ISIS

Building a better Syrian opposition army: How and why

With thanks to audio engineer and producer Zack Kulzer, Mark Hoelscher, Carisa Nietsche, Sara Abdel-Rahim, Eric Abalahin, Fred Dews and Richard Fawal.

Subscribe to the Intersections on iTunes, and send feedback email to intersections@brookings.edu.

Editor's Note: This piece originally appeared in Foreign Policy.

The killing of Nasir al-Wuhayshi, reportedly via U.S. drone strike, is not just another notch in the belt of America’s long campaign against al-Qaida and its allies. Wuhayshi was one of al-Qaida’s top remaining leaders, and he is the highest-level death the organization has suffered since Osama bin Laden was killed in 2011. Wuhayshi headed al-Qaida’s most active affiliate, the Yemen-based al-Qaida in the Arabian Peninsula (AQAP), and was the designated successor of al-Qaida leader Ayman al-Zawahiri. His killing adds one more element of uncertainty to the turbulence in Yemen and may set AQAP on a new path. Which path, however, remains an open question.

Wuhayshi helped transform AQAP from a fractious organization on the edge of defeat to one that menaces both Yemen and the United States. A decade ago, Yemen’s jihadi movement seemed near defeat. In the aftermath of 9/11, the Yemeni government rounded up jihadis and imprisoned Wuhayshi, and it was Saudi Arabia, not Yemen, that was the focus of jihadis in the Arabian Peninsula. In 2003, al-Qaida sponsored the original AQAP’s uprising against the Saudi government. Several years later, most of AQAP’s Saudi members were dead or in jail, and its remnants had fled to Yemen. There, they mixed with Yemeni jihadis, including important figures like Wuhayshi, who had escaped from Yemen’s jails in 2006. In 2009, two regional Islamist groups merged and formally anointed themselves AQAP, basing their operations in Yemen and trying to unseat the government. As Osama bin Laden’s former secretary, Wuhayshi became the group’s leader and embraced al-Qaida’s emphasis on attacking Western targets.

The group made fitful progress, at times taking territory but often losing it quickly after alienating locals and proving vulnerable to government counterattacks. But when the government of Yemeni President Ali Abdullah Saleh fell in 2012 during the Arab Spring, AQAP tried to step into the void. Saleh’s successor, Abed Rabbo Mansour Hadi, pursued AQAP vigorously, but his weak government was unable to score any lasting successes.

In addition to its prowess in Yemen, AQAP has long been al-Qaida’s most active affiliate when it comes to taking on the West. The organization was behind the 2009 Christmas Day attempt to down a U.S. airliner over Detroit, a near-miss only foiled by the bomber’s incompetence and the quick thinking of the plane’s passengers. AQAP tried again in 2010, this time attempting to down U.S. cargo planes. The organization also attacked Western targets in Yemen, and puts out Inspire, a stylish English-language online publication that is one of al-Qaida’s more effective attempts to influence Western jihadis.

These AQAP efforts to attack the United States and the West, in general, led to a greater U.S. focus on Yemen and more drone attacks there. In 2011, the United States killed Anwar al-Awlaki, a U.S. citizen and AQAP member who helped lead the terrorist group’s campaign against targets in the United States and Europe. Awlaki has continued to inspire terrorists after his death, with Boston Marathon plotters downloading his sermons before their attack. Awlaki also inspired the Fort Hood shooter in 2009 and the attacks on the Charlie Hebdo office in 2015.

Wuhayshi’s death, however, comes as Yemen is falling apart. Earlier this year, Hadi’s government fell to the Houthi rebels, Yemeni Shiites who oppose both Yemen’s traditional order and the Sunni fanatics of AQAP who see Shiites as apostates. Alarmed by Houthi ties to Iran, Saudi Arabia has led an intervention in Yemen on Hadi’s behalf, bombing the Houthis and trying to reverse their gains. AQAP seems to be flourishing amid the chaos, as its enemies turn on one another.

But with Wuhayshi’s death, AQAP may find it difficult to further exploit the Yemeni civil war. Personal connections, reputation, and charisma play a bigger role in leadership in the jihadi cause than do formal rank, and it is not clear if Qasim al-Raimi, the designated new leader, can retain the support of the AQAP rank and file. There is always a chance, of course, that Raimi proves an even more effective leader than Wuhayshi, and some observers see him as “more dangerous and aggressive.” (Lest we forget: In 1992, the Israelis killed Hezbollah’s Secretary-General Abbas al-Musawi, one of the group’s most competent leaders. Musawi was replaced by Hassan Nasrallah, who has proven one of the most effective terrorist and guerrilla leaders in modern times.)

The bad news is that Raimi and AQAP may seek revenge, both out of genuine anger and to score points within the jihadi community. Al-Qaida’s chief bomb-maker, Ibrahim al-Asiri, may still be out there and has likely passed his sophisticated techniques on to others in Yemen.

The bad news is that Raimi and AQAP may seek revenge, both out of genuine anger and to score points within the jihadi community.

Over time, however, Wuhayshi’s death may push AQAP to focus even more on Yemen and less on the West. His close, personal ties to the al-Qaidacore may have been part of why AQAP was a steadfast ally of Zawahiri in his power struggle with the Islamic State. The opportunities and risks in the civil war are both tempting and frightening for AQAP. On the one hand, by taking up arms against the hated Shiites, AQAP can position itself as the defender of Yemen’s Sunnis, a strategy that has worked well for the Islamic State in Iraq and Syria. AQAP might gain more recruits and local support, while drawing foreign fighters and money from Sunnis eager to find yet another Shiite-Iran axis to oppose. Not surprisingly, AQAP has stepped up its operations against the Houthis in recent months.

AQAP also has an opportunity to govern. And the bad news for the West is that it has learned from its own many mistakes on this front. In the past when AQAP made gains, it tried to impose a strict version of Islamic law that alienated local communities. Now when its fighters seize territory, theywork with local tribal figures and other elites, avoiding the most controversial measures and trying to portray themselves as guardians, not overlords.

Wuhayshi’s death also comes at a time when the broader jihadi movement is split between backers of al-Qaida and supporters of the Islamic State, a struggle in which AQAP has long played an important role. As al-Qaida’s most active anti-Western affiliate, AQAP was important to Zawahiri’s claim that he was leading the struggle against the United States. Its strength in Yemen, moreover, also expanded al-Qaida’s presence and prestige to an important part of the Arab world. Islamic State supporters have already conducted attacks in Yemen, and the death of Wuhayshi offers them a chance to expand their influence there. The core leadership of AQAP is not likely to join the Islamic State, but some of its cells and supporters could break off if Raimi proves a weak leader.

For now, Wuhayshi’s death means the United States has another point in the struggle against the jihadi movement. In the long term, successful disruption is more likely if the United States and its allies can keep the pressure on AQAP, forcing its leaders to go on the run and hindering their ability to communicate — particularly difficult challenges for a group in transition under new leadership. Wuhayshi’s death also comes on the heels of the deaths of several other AQAP members, including its top ideologue and spokesman. Having to hide also makes it difficult for the group to govern, as its exposed leaders run the risk of being killed. But AQAP has lost many leaders before, yet remains a force to be reckoned with. So at best, this should be seen as winning a battle, not the war.

On December 12, 2015, 195 countries adopted the Paris Agreement, the most ambitious climate change pact to date. The document lays out a plan to curb greenhouse gas emissions, among other climate-related initiatives. Participating countries must now find ways to translate those ambitions into policy, and answer important questions about financing, transparency and accountability, national implementation, and accelerated emissions reduction goals, to name but a few. But one issue looms large: coal.

Coal-fired electricity is responsible for producing 40 percent of the world’s power and about 70 percent of its steel. The coal industry employs millions worldwide and provides billions of people with electricity. Analysts estimate that the world has hundreds of years of coal reserves in the ground, at current consumption levels. Its abundance, low price, and global availability make it a difficult fuel source to give up. But despite coal’s advantages, it poses significant environmental and health risks. Ten percent of coal consists of ash, which contains radioactive and toxic elements. It is responsible for over $50 billion in medical costs annually in the European Union alone. The environmental consequences of coal use, such as water contamination and habitat destruction, are common. Burning coal adds millions of tons of dangerous particulates and greenhouse gases, including carbon, to the atmosphere.

States and societies around the world rely on coal, even though many of its dangers have been known for decades. If the Paris Agreement is to succeed, global leaders must address the reasons why many countries—particularly in the developing world—still rely on coal. Better yet, they must find new ways to provide coal-reliant countries with affordable, alternative energy, and invest in new technologies that could help mitigate coal’s negative consequences.

COAL ACROSS THE WORLD

Globally, coal production and consumption has risen almost continuously for more than 200 years. The International Energy Agency has estimated that the world burned approximately 7,876 million tons of coal in 2013, adding over 14.8 gigatons of carbon to the atmosphere. But global coal statistics do not tell us much about markets and trends. In fact, coal usage varies enormously around the world, with some regions transitioning away from the resource as others have increasingly embraced it.

For example, stringent environmental, health, and safety policies in the United States have put increasing pressure on the coal industry. Well-funded environmental groups have succeeded in closing coal-fired power plants, and many states on the country’s west coast and in its northeast have aimed to create a coal-free power grid. Yet market forces have turned out to be the nail in U.S. coal’s coffin. The rise of natural gas in the United States has gave the country’s electricity producers an incentive to shift away from coal. In fact, U.S. coal consumption declined from a billion tons in 2008, to roughly 850 million tons by 2013. This year, analysts suggest that coal will fuel only 32 percent of all U.S. electricity, and natural gas will become the country’s leading electricity source for the first time. As a result of low prices, low returns, and political controversy, investors have shied away from coal, which has caused major coal companies to struggle to stay afloat. Of all announced new electricity generation capacity in the United States, not a single megawatt is coal-fired. Although change is happening, it will likely be decades before coal is no longer an important fuel source in the U.S. economy. Canada’s coal sector faces similar pressures: weak demand from Asia, public opposition to the construction of new export facilities, domestic environmental legislation, and the shale boom have all taken their toll.

In Europe, stringent air quality controls and climate change regulations have cut the use of coal dramatically in Denmark, Sweden, and the United Kingdom. But the EU emissions trading scheme, which relies on carbon offsets and carbon dioxide caps, has proven disappointing. In fact, most European countries still lack an economically competitive and readily available alternative to coal. Plus, the coal industry still has political power in capitals like Berlin and Warsaw, which lowers the European common denominator for energy policy, as well as its policies that fight climate change.

Photo courtesy of REUTERS/James Regan/File Photo. Coal is stockpiled at the Blair Athol mine in the Bowen Basin coalfield near the town of Moranbah, Australia, June 1, 2012.

In Asia, both Japan and South Korea are set to expand their use of coal despite signing the Paris Agreement. After the Fukushima disaster, Japan has implemented ambitious renewables and energy efficiency policies, but those cannot take the place of its nuclear energy production on their own. These countries are entirely import dependent, which makes natural gas prices high. This, in turn, makes natural gas a less likely fuel source as the countries transition to greener electricity. In this context, high-efficiency coal plants appear to be a viable alternative, especially as nuclear power remains highly controversial.

And outside of advanced economies, coal often plays the role it once played in Europe and North America. For over a decade, China was the main engine of global coal consumption, driving booms in coal mining and shipping. China’s domestic coal production skyrocketed, and other countries, such as Australia, experienced coal booms to keep pace with Chinese demand. Although China produced and consumed almost as much coal as the rest of the world combined in 2014, it seems that the country’s consumption has peaked. But China will still rely heavily on coal-fired electricity for decades. The country remains a key player in steel production, and millions of its citizens continue to work in the mining industry, despite recent layoffs.

South Asian countries continue to invest heavily in new coal-fired electricity plants and industrial projects. India may appreciate the risks of climate change, but its chief concern is delivering low-cost power to 350 million of its citizens who lack electricity. Coal is set to play a prominent role in meeting such goals. Countries like Indonesia, Thailand, and Vietnam have followed suit as they search for low-cost electricity to power their countries.

In short, coal remains a big player in the global fuel mix, even as it faces tough challenges from stringent environmental regulations, competition from other fuel sources, and a lack of new investments.

Photo courtesy of REUTERS/Sheng Li/Files. A labourer carries honeycomb briquettes at a coal processing factory in Shenyang, Liaoning province in this December 2, 2009 file photo.

WHITHER COAL?

Different strategies apply in different parts of the world when it comes to eradicating coal, despite the global agreement in Paris. Just as there is not a global energy grid, there is also no single, global transition to lower-carbon energy. Although some countries are transitioning away from coal, others continue to transition toward it.

Second, pragmatism and persistence—rather than ideological purity—remain key values as countries transition towards low-carbon economies. Natural gas provides North America with a backup fuel as it transitions to green energy. Without major bulk terminals on the west coast, western U.S. coal producers will not find new markets for their products overseas. And in Europe, policymakers will have to make good on long-promised and long-delayed changes to energy policy and infrastructure. If Germany and other EU states are to achieve promised clean energy transitions, coal production must be scaled back substantially across the continent. European leaders must also build an “Energy Union” that will accelerate the flow of cross-border electricity, if they are to achieve the Paris Accord’s climate change goals. Europe must also reform its existing carbon pricing mechanisms. And across China, Europe, and North America, workers will have to be re-educated for new job opportunities as the coal market dries up.

But for now, coal still keeps the light on around the world. It powers new, high-tech economies, as well as a huge share of traditional manufacturing. If hundreds of millions of Africans and Asians are to gain access to electricity, new coal-fired power plants will have to come online in the years ahead. As coal continues to play a prominent role in industrial processes like steel and cement making, technological investments are required to limit its consequences.

To tackle these challenges, coal advocates, as well as some climate experts, suggest that more countries must invest in carbon capture and sequestration (CCS) research. But such investments are lagging, and the world would require several dozen CCS projects in order to make the technology commercially viable in the long term.

If the Paris Accord is to succeed, the earth’s atmosphere cannot remain a free dump for billions of tons of pollution every year. In fact, virtually all greenhouse gas emissions must be reduced. Countries can impose taxes, cap-and-trade schemes, and regulation to make this happen. Governments will have to design unique strategies that are custom fit to their countries, and, in some cases, find opportunities with their neighbors as well. For example, some private and public institutions have chosen to stop financing coal-fired projects, and the Obama administration has indicated it will not give out new leases for coal mining on federal land. Others will choose to build more coal-fired plants until the alternatives are cheaper, or until someone pays them not to.

Globally, coal may indeed be at the beginning of the end. But the energy transition is not strictly global. It is also national, regional, and local. Coal remains economically competitive—attractive even—in many parts of the world. Some countries will wage wars on coal, which will be as much economic and financial as they are political. But some countries, like India, will host coal booms regardless of the consequences. After Paris, there is no point in ignoring coal. It will be powering the world—and the world’s debates—for decades to come.

This piece was originally published by Foreign Affairs.

In many African countries, women still cannot own land or resources, a significant barrier to their ability to start businesses and take advantage of the continent’s economic potential.  Fellow Anne Kamau explores their plight.

Video

• Challenges for Women in the African Economy

"At the end of the day, we need to remember that Daesh is more a product of the civil wars than it is a cause of them. And the way that we’re behaving is we’re treating it as the cause.  And the problem is that in places like Syria, in Iraq, potentially in Libya, we are mounting these military campaigns to destroy Daesh and we’re not doing anything about the underlying civil wars.  And the real danger there is—we have a brilliant military and they may very well succeed in destroying Daesh—but if we haven’t dealt with the underlying civil wars, we’ll have Son of Daesh a year later." – Ken Pollack

“Part of the problem is how we want the U.S. to be more engaged and more involved and what that requires in practice. We have to be honest about a different kind of American role in the Middle East. It means committing considerable economic and political resources to this region of the world that a lot of Americans are quite frankly sick of… There is this aspect of nation-building that is in part what we have to do in the Middle East, help these countries rebuild, but we can’t do that on the cheap. We can’t do that with this relatively hands off approach.” – Shadi Hamid

In this episode of “Intersections,” Kenneth Pollack, senior fellow in the Center for Middle East Policy and Shadi Hamid, senior fellow in the Project on U.S. Relations with the Islamic World and author of "Islamic Exceptionalism: How the Struggle over Islam is Reshaping the World," discuss the current state of upheaval in the Middle East, the Arab Spring, and the political durability of Islamist movements in the region. They also explain their ideas on how and why the United States should change its approach to the Middle East and areas of potential improvement for U.S. foreign policy in the region. 

Show Notes

Fight or flight: America’s choice in the Middle East

Security and public order

Islamists on Islamism today

Temptations of Power: Islamists & Illiberal Democracy in a New Middle East

Ending the Middle East’s civil wars

A Rage for Order: The Middle East in turmoil, from Tahrir Square to ISIS

Building a better Syrian opposition army: How and why

With thanks to audio engineer and producer Zack Kulzer, Mark Hoelscher, Carisa Nietsche, Sara Abdel-Rahim, Eric Abalahin, Fred Dews and Richard Fawal.

Subscribe to the Intersections on iTunes, and send feedback email to intersections@brookings.edu.

France has been struck by an unprecedented three terror attacks in the last 18 months. In what’s called Operation Sentinelle, 13,000 French military personnel now patrol streets and protect key sites across the country, assisting police and other security agencies. “The fact that the armed forces are visible,” said French Defense Minister Jean-Yves Le Drian at a Brookings event on July 20, “help to reassure the French people that they are safe both at home and abroad.”

Do the challenges facing France today mean that it should reduce its engagement overseas, focusing instead on security at home? Le Drian doesn’t think so, and I agree. In a new book titled "Who is the Enemy?," he particularly emphasizes the multifaceted ISIS threat. As he said at Brookings: 

"Every war [has] two enemies…[Today’s] war [with ISIS] also sets in place two concepts of the “enemy” that are radically different: From a strategic point of view, we are dealing with a proto-state; at the heart of this entity, there is a terrorist army." 

It only further complicates matters, of course, that France faces ISIS threats on several fronts: in Syria and Iraq, on the one hand, and also on its own territory. This, Le Drian stressed, means “we must seek coherence in our military action.” It also helps explain why France remains one of the most active countries in the fight against the so-called Islamic State, as well as other extremist groups in the Middle East and in sub-Saharan Africa. In 2013 and 2014, France intervened in Mali in order to prevent jihadi groups from taking over the country. The French military also has a presence in Djibouti, Lebanon, Côte d’Ivoire, the Central African Republic, Gabon, Senegal, as well as in the Pacific (in French Polynesia and New Caledonia)—not to mention Syria, where France uses the Mediterranean Sea-based Charles de Gaulle aircraft carrier to strike ISIS targets. 

France is not a warmongering country—rather, it is responding to the fact that overseas threats come to it. Although it remains unclear to what extent the Nice attacker had connections with foreign terrorist networks, it has been established that the November 2015 Paris attacks were planned and orchestrated from Syria. This, among other considerations, has prompted France to engage further in Iraq and Syria. The rationale, as Minister Le Drian explained, is: 

“[T]rading our peace by reducing our military involvement doesn’t make sense. The more we let ISIS consolidate its presence on the Middle East, the more it will gather resources, attract fighters, and plan more attacks against us.” 

Team player

French policy isn’t just about ensuring its own security—rather, its many contributions are integrated within global efforts, including U.S.-led ones. As Le Drian said at Brookings: “I am convinced that the French-American relationship is stronger and better than ever.” France is a prominent participant of the 66-member international coalition against ISIS, and in that capacity participated in the first joint meeting of that group’s foreign and defense ministers in Washington this month. 

France remains a key member of the joint military operation Inherent Resolve in Iraq and Syria, which has damaged or destroyed over 26,0000 ISIS-related targets since August 2014. The Charles de Gaulle carrier—with 26 aircrafts on board—has been an essential part of that coalition mission. Following specific instructions from U.S. Defense Secretary Ash Carter and his counterpart in Paris, Minister Le Drian, French and U.S. intelligence agencies cooperate closely in intelligence-sharing. And just last week, President François Hollande announced that France will soon be supplying artillery to Iraq to support its fight against ISIS. Beyond the Iraq-Syria theater, France is cooperating with the United States and other partners in Libya, another country that is both a victim and source of extremist threats. 

The French Defense Ministry’s efforts to double-down on protecting French citizens within France, therefore, has not reduced its overseas role. Particularly now that the United Kingdom will leave the European Union, France’s military role has never been so important. France—along with Germany, which recently suggested it would raise its defense spending significantly—should continue to play a leading role as one the top defense actors in the West. 

Summary

At the Gleneagles Summit in 2005, leaders of the G8 group of nations committed to increase aid to poor nations by $50 billion per year. During the same year, in a meeting in Paris, donors promised to coordinate their interventions for more effective delivery. These commitments are now often referred to as the promise of donors to “scale up aid.” Increasing aid flows and improving coordination are indeed important goals and, in fact, goals that donors seem to have trouble meeting. The international donor community met this fall in Accra and will meet in Doha in November 2008 to review progress with this aspect of scaling up aid, and it is hoped that they will recommit to meet the ambitious targets set three years ago.

Scaling up aid is only one of the challenges that donors face. A more important challenge is to “scale up through aid,” meaning that aid flows should not merely support short-lived, one-time and partial development interventions—pilot projects, short-term technical assistance, programs that only address part of the problem, but leave major bottlenecks unaddressed—but should support projects, programs and policies that scale up successful interventions in a country, region or globally to reach the entire target population. Scaling up means that programs are long-term and sustained and that external support is aligned with country needs and deals comprehensively with the development challenges—often by working in partnership with other donors and pooling resources. This is the scaling up challenge that donors should address head-on, but so far have not.

This policy brief reports on the findings of an in-depth review of the literature and practice of scaling up development interventions and focuses on the role that aid donors can play in supporting scaling up for effective development. It stresses that successful scaling up with external assistance means that donor agencies need to: work with a vision and leadership; help create the political constituencies for large-scale implementation; create linkages among project, program and policy interventions; strengthen the institutional capacity of the implementing entities; provide for effective incentives and accountabilities of their own staff and management; work together with each other; monitor and evaluate the progress of programs with special attention to the scaling up dimension; and finally make sure they focus on effective preparation and flexible implementation of the scaling up process. While this is a long-term agenda, donors can take a few practical steps right away that will provide a basis for a more ambitious effort over time.

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In its 50th year, the Medicare program currently provides health insurance coverage for more than 49 million Americans and accounts for $600 billion in federal spending. With those numbers expected to rise as the baby boomer generation ages, many policy experts consider this impending expansion a major threat to the nation’s economic future and question how it might affect the quality and value of health care for Medicare beneficiaries.

On June 5, the Center for Health Policy at Brookings and the USC Leonard D. Schaeffer Center for Health Policy and Economics hosted a half-day forum on the future of Medicare. Instead of reflecting on historical accomplishments, the event looked ahead to 2030—a time when the youngest Baby Boomers will be Medicare-eligible—and explore the changing demographics, health care needs, medical technology costs, and financial resources available to beneficiaries. The panels focused on modernizing Medicare's infrastructure, benefit design, marketplace competition, and payment mechanisms. The event also included the release of five policy papers from featured panelists.

Please note that presentation slides from USC's Dana Goldman will not be available for download. For more information on findings from his presentation download the working paper available on this page or watch the event video.

Video

• Challenges and opportunities facing Medicare in 2030
• Eligibility, benefit design, and financial support
• Could improving choice and competition in Medicare Advantage be the future of Medicare?
• Improving provider payment in Medicare

Audio

• Strengthening Medicare for 2030

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• Burtless Slides
• 20150605_medicare_2030_transcript

International jihad has undergone a wholesale internal revolution in recent years. The dramatic emergence of the Islamic State (IS) and its proclamation of a Caliphate means that the world no longer faces one Sunni jihadi threat, but two, as IS and al-Qaida compete on the global stage. What is the relationship between the groups and how do their models differ? Is IS’s rapid organizational expansion sustainable? Can al-Qaida adapt and respond?

Read "Jihadi Rivalry: The Islamic State Challenges al-Qaida"

In a new Brookings Doha Center Analysis Paper, Charles Lister explores al-Qaida and IS’s respective evolutions and strategies. He argues that al-Qaida and its affiliates are now playing a long game by seeking to build alliances and develop deep roots within unstable and repressed societies. IS, on the other hand, looks to destabilize local dynamics so it can quickly seize control over territory.

Lister finds that the competition between IS and al-Qaida for jihadi supremacy will continue, and will likely include more terrorist attacks on the West. Accordingly, he calls for the continued targeting of al-Qaida leaders, the disruption of jihadi financial activities, and greater domestic intelligence and counter-radicalization efforts. Lister concludes, however, that state instability across the Muslim world must be addressed or jihadis will continue to thrive.

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Millions of Egyptians took to the streets in January 2011 chanting “‘ish, hurriyya, ‘adalah ijtima‘iyya,” or bread, freedom, and social justice. This simple chant captured protestors’ desire for a new Egypt defined by economic, political, and social change. Five years later, however, the attainment of those demands seems more elusive than ever. In the economic sphere, Egypt still faces the major challenge of high unemployment, particularly among educated youth. Why do so many of Egypt’s young university graduates struggle to find employment?

Read "Educated but unemployed: The challenge facing Egypt’s youth"

In this policy briefing, Adel Abdel Ghafar analyzes the roots of Egypt’s youth unemployment crisis, starting with the structural issues plaguing the country’s educational system. He then examines other contributing factors including neoliberal economic reforms, gender inequality, and the lack of entrepreneurship. Abdel Ghafar warns that failing to address the unemployment issue will increase the likelihood of another uprising.

Abdel Ghafar thus argues that the Egyptian government must urgently undertake reforms and devote extensive resources to dealing with youth unemployment. Specifically, he recommends ways in which Egypt can revamp public university funding, promote vocational training, stimulate entrepreneurship, and increase the participation of women in the workforce.

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Baltimore police officer Edward Nero, one of six being tried separately in relation to the arrest and death of Freddie Gray, has been acquitted on all counts. The outcome for officer Nero was widely expected, but officials are nonetheless aware of the level of frustration and anger that remains in the city. Mayor Stephanie Rawlings Blake said: "We once again ask the citizens to be patient and to allow the entire process to come to a conclusion."

Since Baltimore came to national attention, Brookings scholars have probed the city’s challenges and opportunities, as well addressing broader questions of place, race and opportunity.

• In this podcast, Jennifer Vey describes how, for parts of Baltimore, economic growth has been largely a spectator sport: "1/5 people in Baltimore lives in a neighborhood of extreme poverty, and yet these communities are located in a relatively affluent metro area, in a city with many vibrant and growing neighborhoods."
• Vey and her colleague Alan Berube, in this piece on the "Two Baltimores," reinforce the point about the distribution of economic opportunity and resources in the city:
  

  In 2013, 40,000 Baltimore households earned at least $100,000. Compare that to Milwaukee, a similar-sized city where only half as many households have such high incomes. As our analysis uncovered, jobs in Baltimore pay about $7,000 more on average than those nationally. The increasing presence of high-earning households and good jobs in Baltimore City helps explain why, as the piece itself notes, the city’s bond rating has improved and property values are rising at a healthy clip."

• Groundbreaking work by Raj Chetty, which we summarized here, shows that Baltimore City is the worst place for a boy to grow up in the U.S. in terms of their likely adult earnings:

• Here Amy Liu offered some advice to the new mayor of the city: "I commend the much-needed focus on equity but…the mayoral candidates should not lose sight of another critical piece of the equity equation: economic growth."
• Following an event focused on race, place and opportunity, in this piece I drew out "Six policies to improve social mobility," including better targeting of housing vouchers, more incentives to build affordable homes in better-off neighborhoods, and looser zoning restrictions.
• Frederick C. Harris assessed President Obama’s initiative to help young men of color, "My Brother’s Keeper," praising many policy shifts and calling for a renewed focus on social capital and educational access. But Harris also warned that rhetoric counts and that a priority for policymakers is to "challenge some misconceptions about the shortcomings of black men, which have become a part of the negative public discourse."
• Malcolm Sparrow has a Brookings book on policing reform, "Handcuffed: What Holds Policing Back, and the Keys to Reform" (there is a selection here on Medium). Sparrow writes:
  

  Citizens of any mature democracy can expect and should demand police services that are responsive to their needs, tolerant of diversity, and skillful in unraveling and tackling crime and other community problems. They should expect and demand that police officers are decent, courteous, humane, sparing and skillful in the use of force, respectful of citizens’ rights, disciplined, and professional. These are ordinary, reasonable expectations."

Five more police officers await their verdicts. But the city of Baltimore should not have to wait much longer for stronger governance, and more inclusive growth.

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Student enrollment and expenditures per student have been on the rise in sub-Saharan Africa over the past decade. Yet, financing gaps still exist for achieving universal quality education throughout the region, especially in countries with strong demographic pressures. Many African countries are facing a dilemma of how best to balance scarce resources and the growing demands to improve education quality for their children and youth.

On April 27, the Center for Universal Education and the Africa Growth Initiative at Brookings hosted a discussion of the state of education financing in sub-Saharan Africa. Albert Motivans of UNESCO’s Institute for Statistics presented the main findings of a new report "Financing Education in sub-Saharan Africa," which focuses on the new challenges related to expanding access, equity and quality education. Shantayanan Devarajan of the World Bank and Brookings Senior Fellow Jacques van der Gaag provided commentary, and Senior Fellow Mwangi Kimenyi, director of the Africa Growth Initiative, moderated the discussion.

After the discussion, the panelists took audience questions.

Audio

• Africa’s Education Financing Challenge

Transcript

• Transcript (.pdf)
• Motivans UNESCO presentation (.pdf)
• Financing Education in Sub-Saharan Africa (.pdf)

Event Materials

• event_transcript_africa_education
• Motivans PPT_FINAL
• Finance_Education_Africa

The world order that was created in the aftermath of World War II has produced immense benefits for peoples across the planet. The past 70 years have seen an unprecedented growth in prosperity, lifting billions out of poverty. Democratic government, once rare, has spread to over 100 nations around the world, on every continent, for people of all races and religions. And, although the period has been marked by war and suffering as well, peace among the great powers has been preserved. There has been no recurrence of the two devastating world wars of the first half of the 20th century.

Today, however, that liberal order is being challenged by a variety of forces—by powerful authoritarian governments and anti-liberal fundamentalist movements, as well as by long-term shifts in the global economy and changes in the physical environment. The questions we face are whether this liberal world order is worth defending, and whether it is capable of surviving the present challenges. We believe the answer to both questions is an emphatic “yes.”

To say that a “liberal” world order is worth defending is, of course, a declaration on behalf of a certain set of principles—a belief that the rights of the individual are primary, that it is the responsibility of governments to protect those rights and that democratic government, in particular, offers the best chance for human dignity, justice and freedom. This is not a universally held view. The leaders of some nations and more than a few people around the world disagree on this hierarchy of values.

There is, and always has been, a division about how nations should be governed, and about the differences in and between democratic and autocratic forms, the role of religion and the connections to economic structures. While recognizing that these differences exist and that every structure has its failings, the authors of this report are confident in their conviction that the liberal world order offers the best hope for meeting human aspirations, both material and spiritual, and for calling forth the very best in people across the world.

To strengthen and preserve this order, however, will require a renewal of American leadership in the international system. The present world order has been forged by many hands and peoples, but the role of the United States in both shaping and defending it has been critical. American military power, the dynamism of the U.S. economy, and the great number of close alliances and friendships that the United States enjoys with other powers and peoples have provided the critical architecture in which this liberal world order has flourished. A weakening of America’s commitment or its capabilities, or both, would invariably lead to its collapse.

But in recent years, many have come to doubt America’s ability to continue playing this role. Only seven years ago, pundits were talking of a “post-American world” with a declining United States and a remarkable “rise of the rest”. These days, however, that prognosis appears to have been at least premature. The United States has substantially recovered from the Great Recession, while the once-heralded “rise of the rest” has stalled.

A new foundation for an effective U.S. foreign policy for a new international environment needs to be established, but it should be recognized that the United States is not omnipotent and faces limitations in what it can do. The emphasis must be on taking advantages of American comparative advantages in certain key areas, doing what the United States does best, and in a way that reflects what those around the world want and need from America.

To this end, this paper focuses on four baskets of policies—Strengthening and Adapting the Liberal Economic Order; Strengthening the International Security Order; Taking Advantage of the Energy Revolution; and Playing to America’s Strengths in Education, Innovation and Entrepreneurship.

A key task for American political leaders and policy advocates will be to demonstrate and explain how the pieces fit together: how trade enhances security; how military power undergirds prosperity; and how providing access to American education strengthens the forces dedicated to a more open and freer world. By looking at the whole picture, the importance of the individual strands of policy will be clearer and therefore easier to sell.

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• Strengthening the liberal world order

The latest BLS employment report showed remarkable strength in the U.S. job market even as global financial markets were trembling. Employers added 292,000 to their payrolls in December. Upward revisions in previous BLS estimates also boosted gains in October and November. In the last quarter of 2015, payrolls increased at a rate of 284,000 per month, a remarkable performance in the face of rising uncertainty about prospects for the world economy. U.S. employers added a total of 2.65 million jobs in 2015, the second best calendar-year gain of the current recovery. (Gains were stronger in 2014 but smaller in earlier years of the recovery.)

As usual, private employers accounted for an overwhelming share of the job gains. Ninety-seven percent of the gains in the fourth quarter and 96 percent of the gains last year occurred as a result of employment gains in the private sector. Whatever the uncertainty of the world economic outlook, U.S. employers have enough confidence in their own prospects to keep adding to their payrolls at a healthy clip. Public employment remains about 375,000 (1.7 percent) lower than it was at the onset of the Great Depression. Though government payrolls are now growing, in percentage terms they have been rising much more slowly that private payrolls.