Although a few political analysts have been focusing on the white working class for years, it is only in response to the rise of Donald Trump that this large group of Americans has begun to receive the attention it deserves. Now, thanks to a comprehensive survey that the Public Religion Research Institute (PRRI) undertook in collaboration with the Brookings Institution, we can speak with some precision about the distinctive attitudes and preferences of these voters.

There are different ways of defining the white working class. Along with several other survey researchers, PRRI defines this group as non-Hispanic whites with less than a college degree, with the additional qualification of being paid by the hour or by the job rather than receiving a salary. No definition is perfect, but this one works pretty well. Most working-class whites have incomes below $50,000; most whites with BAs or more have incomes above $50,000. Most working-class whites rate their financial circumstances as only fair or poor; most college educated whites rate their financial circumstances as good or excellent. Fifty-four percent of working-class whites think of themselves as working class or lower class, compared to only 18 percent of better-educated whites.

The PRRI/Brookings study finds that in many respects, these two groups of white voters see the world very differently. For example, 54 percent of college-educated whites think that America’s culture and way of life have improved since the 1950s; 62 percent of white working-class Americans think that it has changed for the worse. Sixty-eight percent of working-class whites, but only 47 percent of college-educated whites, believe that the American way of life needs to be protected against foreign influences. Sixty-six percent of working-class whites, but only 43 percent of college-educated whites, say that discrimination against whites has become as big a problem as discrimination against blacks and other minorities. In a similar vein, 62 percent of working-class whites believe that discrimination against Christians has become as big a problem as discrimination against other groups, a proposition only 38 percent of college educated whites endorse.

This brings us to the issue of immigration. By a margin of 52 to 35 percent, college-educated whites affirm that today’s immigrants strengthen our country through their talent and hard work. Conversely, 61 percent of white working-class voters say that immigrants weaken us by taking jobs, housing, and health care. Seventy-one percent of working-class whites think that immigrants mostly hurt the economy by driving down wages, a belief endorsed by only 44 percent of college-educated whites. Fifty-nine percent of working-class whites believe that we should make a serious effort to deport all illegal immigrants back to their home countries; only 33 percent of college-educated whites agree. Fifty-five percent of working-class whites think we should build a wall along our border with Mexico, while 61 percent of whites with BAs or more think we should not. Majorities of working-class whites believe that we should make the entry of Syrian refugees into the United States illegal and temporarily ban the entrance of non-American Muslims into our country; about two-thirds of college-educated whites oppose each of these proposals.

Opinions on trade follow a similar pattern. By a narrow margin of 48 to 46 percent, college-educated whites endorse the view that trade agreements are mostly helpful to the United States because they open up overseas markets while 62 percent of working-class whites believe that they are harmful because they send jobs overseas and drive down wages.

It is understandable that working-class whites are more worried that they or their families will become victims of violent crime than are whites with more education. After all, they are more likely to live in neighborhoods with higher levels of social disorder and criminal behavior. It is harder to explain why they are also much more likely to believe that their families will fall victim to terrorism. To be sure, homegrown terrorist massacres of recent years have driven home the message that it can happen to anyone, anywhere. We still need to explain why working-class whites have interpreted this message in more personal terms.

The most plausible interpretation is that working-class whites are experiencing a pervasive sense of vulnerability. On every front—economic, cultural, personal security—they feel threatened and beleaguered. They seek protection against all the forces they perceive as hostile to their cherished way of life—foreign people, foreign goods, foreign ideas, aided and abetted by a government they no longer believe cares about them. Perhaps this is why fully 60 percent of them are willing to endorse a proposition that in previous periods would be viewed as extreme: the country has gotten so far off track that we need a leader who is prepared to break so rules if that is what it takes to set things right.

       

Event Information

Register for the Event

With a number elections now underway in Europe and the United States, populist politicians are gaining support by tapping into frustration with the lingering effects of the global financial crisis and the eurocrisis, mounting fears of terrorism, concerns surrounding record levels of migration, and growing doubt over political elites’ abilities to address these and other crises. The global economic order is already beginning to be impacted by the mounting political pressure against it. Trade deals such as the Trans-Pacific Partnership that form the cornerstone of the global economic order have met with significant resistance. Brexit’s reverberations have already been felt in international markets. Fissures within the European Union and American anxiety towards a U.S. global role could have a pronounced impact on the international economic system.

On July 14, the Brookings Project on International Order and Strategy (IOS) hosted an event tied to the recent publication of Nonresident Senior Fellow Daniel Drezner’s new paper, “Five Known Unknowns about the Next Generation Global Political Economy.” The event was an opportunity to discuss the future of the global economic order given rising populism and discontent with globalization. Panelists included Nonresident Senior Fellow Daniel Drezner, professor of international politics at the Fletcher School of Law and Diplomacy at Tufts University; Caroline Atkinson, head of Google’s global public policy team and former White House deputy national security advisor for international economics; and David Wessel, director of the Brookings Hutchins Center on Fiscal and Monetary Policy.

Thomas Wright, director of IOS, provided brief opening remarks and moderated the discussion.

Video

• The future of the global economic order in an era of rising populism

Audio

• The future of the global economic order in an era of rising populism

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160714_global_economic_order_transcript

       

       

       

       

The rise of SuperPACs, the decision in Citizens United, and intensified polarization in Congress has ignited a flame under the already robust academic debate over the role of money in elections. Last week, Lee Drutman wrote an article for Vox outlining the recent contribution of Raymond J. La Raja and Brian Schaffner made to the debate with their book, Campaign Finance and Political Polarization: When Purists Prevail.

The crux of the book argues that allowing political parties to control more money, not less, is the key to reducing polarization. This runs counter to many pro-reform writings, focused chiefly on empowering small donors in order to counter big-money politics. La Raja and Schaffner counter this narrative, suggesting parties channel money to create moderation, rather than small donors, which are polarizing.

Drutman pushes back on both accounts by taking issue with some of the underlying assumptions in When Purists Prevail, including the weight they place on median voter theory and the extent parties will spend money on moderate candidates in primary elections. He marshals a host of recent research to support the critique, including: a recent Brookings paper on the strength of political parties, data on the power of outside money in congressional elections, and research showing moderate districts do not necessarily produce moderate candidates.

Click here to read the full article on Vox.

       

Event Information

Register for the Event

As the sixth anniversary of Citizens United v. FEC approaches on January 21, both experts and ordinary citizens believe the United States is confronting a campaign finance crisis. Citizens United and related court cases have unleashed a flood of dark money that many believe could drown our democracy. It is estimated that over $5 billion will be spent on the 2016 presidential race—more than 3 times the amount spent in 2008 (already the most expensive election cycle in history). A comprehensive poll conducted by the New York Times and CBS News in the spring of 2015 showed that 84 percent of adults—including 90 percent of Democrats and 80 percent of Republicans—believe that money has too much influence in American political campaigns. Even the richest Americans agreed: 85 percent of adults making $100,000 or more share that same belief.

There has been much handwringing about this state of affairs. But there has been too little public attention paid to finding solutions. On the sixth anniversary of Citizens United, the Governance Studies program at Brookings hosted current and former government officials, lobbyists, donors, advocates, and other experts to discuss how to resolve the campaign finance crisis. They focused on innovative reform efforts at the federal, state, and local levels which offer the hope of addressing the problem of big money in politics.

Panelists will included:

Cheri Beasley, Associate Justice, North Carolina Supreme Court
Daniel Berger, Partner, Berger & Montague, P.C.
John Bonifaz, Co-Founder and President, Free Speech for People
Norman L. Eisen, U.S. Ambassador to the Czech Republic (2011-2014); Special Assistant and Special Counsel to the President (2009-2011); Visiting Fellow, The Brookings Institution
Bruce Freed, Founder and President, Center for Political Accountability
Steve Israel, Member, U.S. House of Representatives (D-NY)
Roger Katz, Chair, Government Oversight Committee, Maine State Senate (R)
Allen Loughry, Justice, Supreme Court of Appeals of West Virginia
Chuck Merin, Executive Vice President, Prime Policy Group; Lobbyist
Connie Morella, Ambassador to OECD (2003-2007); Member, U.S. House of Representatives (R-Md., 1987-2003)
Jeffrey Peck, Principal, Peck Madigan Jones; Lobbyist
Nick Penniman, Executive Director, Issue One
Trevor Potter, Commissioner, Federal Election Commission (1991-1995; Chairman,1994)
John Pudner, Executive Director, Take Back Our Republic
Ann Ravel, Commissioner, Federal Election Commission (Chairwoman, 2015)
Timothy Roemer, Ambassador to India (2009-2011); Member, U.S. House of Representatives (D-Ind., 1991-2003); member 9/11 Commission; Senior Strategic Advisor to Issue One
John Sarbanes, Member, U.S. House of Representatives (D-Md.)
Claudine Schneider, Member, U.S. House of Representatives (R-R.I.,1981-1991)
Peter Schweizer, President, Government Accountability Institute
Zephyr Teachout, CEO, Mayday PAC
Lucas Welch, Executive Director, The Pluribus Project
Fred Wertheimer, Founder and President, Democracy 21
Tim Wirth, Member, U.S. Senate (D-Colo.,1987-1993); Member, U.S. House of Representatives (D-Colo.,1975-1987)
Dan Wolf, Chair, Committee on Steering and Policy, Massachusetts State Senate (D)

Click here for a full agenda.

Video

• The campaign finance crisis in America and how to fix it - Part 1
• The campaign finance crisis in America and how to fix it - Part 2
• The campaign finance crisis in America and how to fix it - Part 3
• The campaign finance crisis in America and how to fix it - Part 4

Audio

• The campaign finance crisis in America and how to fix it: A solutions summit (Part 1)
• The campaign finance crisis in America and how to fix it: A solutions summit (Part 2)
• The campaign finance crisis in America and how to fix it: A solutions summit (Part 3)
• The campaign finance crisis in America and how to fix it: A solutions summit (Part 4)

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• Solution Summits Agenda120
• 20160121_campaign_finance_summit_transcript

       

       

       

       

       

       

       

       

       

       

       

In new Urban-Brookings Tax Policy Center analysis of Earned Income Tax Credit (EITC) take-up at the county level, Benjamin Harris, a fellow in Economic Studies, and Research Assistant Lucie Parker use zip-code level data on taxes and demographics to take a "fresh look" at the EITC. "Since its creation in 1975," they write, "the Earned Income Tax Credit has played a major role in the U.S. safety net." Earlier this year, Harris presented EITC take-up using IRS data from 2007. Compare that to the new list of ten counties with the highest share of EITC recipients below:

Rank	County	EITC Share (pct)
10	Sharkey Co., MS	50.5
9	Quitman Co., MS	50.7
8	Coahoma Co., MS	51.6
7	Starr Co., TX	52.1
6	Claiborne Co., MS	52.7
5	Humphreys Co., MS	53.0
4	Buffalo Co., SD	54.1
3	Shannon Co., SD	54.5
2	Holmes Co., MS	55.5
1	Tunica Co., MS	56.1

"The regional variation EITC claiming is stark," Harris and Parker conclude. "The counties with the highest share of taxpayers claiming the EITC are overwhelming located in the Southeast. ... [O]ver half the taxpayers in a large share of counties in Alabama, Georgia, and Mississippi claim the EITC. With few exceptions, almost all counties with high EITC claiming are located in the South. Relative to the South, the Northeast and the Midwest have much lower claiming rates. Moreover, average EITC benefit closely follows the pattern for share of taxpayers taking up the credit: in counties where more taxpayers claim the credit, the credit is larger on the whole."

Visit this U.S. map interactive to get county level data on share of taxpayers claiming EITC as well as average EITC amount, in dollars, per county.

      

Each year millions of low- to moderate-income Americans supplement their income by claiming the Earned Income Tax Credit (EITC) during tax season. Last year, 1 in 5 taxpayers claimed the credit and earned an average of nearly $2,400.

This tax season, some of those eligible for the EITC may also be able to claim, for the first time, a new credit created by the Affordable Care Act (ACA) to offset the cost of purchasing health insurance for lower-income Americans. It’s called the ACA premium tax credit.

To qualify for the ACA premium tax credit, filers need first to have an annual income that falls between 100 and 400 percent of the federal poverty line (between $11,670 and $46,680 for a single-person household in 2014). Beyond the income requirements, however, filers must also be ineligible for other public or private insurance options like Medicaid or an employer-provided plan.

Why the tax credit overlap matters

Identifying the Americans eligible for both credits is important because it sheds light on how many still need help paying for health insurance even after the ACA extended coverage options.

In a recent study of the EITC-eligible population, Elizabeth Kneebone, Jane R. Williams, and Natalie Holmes estimated what share of EITC-eligible filers might also qualify for the ACA premium tax credit this year.

Below, see a list of the top 10 states with the largest overlap between filers eligible for the EITC and those estimated to qualify for the ACA premium tax credit.* Notably, none of these states has expanded Medicaid coverage to low-income families after the passage of the ACA.

Nationally, an estimated 7.5 million people (4.2 million “tax units”) are likely eligible for both the ACA premium tax credit and the EITC. Nearly 1.3 million of those tax units are from the following ten states.

1. Florida

Overlap: 22.5 percent / 405,924 tax units
State-based exchange? No Expanded Medicaid coverage? No

2. Texas

Overlap: 21.4 percent / 513,061 tax units
State-based exchange? No Expanded Medicaid coverage? No

3. South Dakota

Overlap: 20.5 percent / 15,124 tax units
State-based exchange? No Expanded Medicaid coverage? No

4. Georgia

Overlap: 19.8 percent / 186,020 tax units
State-based exchange? No Expanded Medicaid coverage? No

5. Louisiana

Overlap: 19.6 percent / 86,512 tax units
State-based exchange? No Expanded Medicaid coverage? No

6. Idaho

Overlap: 19.3 percent / 28,855 tax units
State-based exchange? Yes Expanded Medicaid coverage? No

7. Montana

Overlap: 18.9 percent / 18,138 tax units
State-based exchange? No Expanded Medicaid coverage? No

8. Wyoming

Overlap: 18.4 percent / 7,276 tax units
State-based exchange? No Expanded Medicaid coverage? No

9. Utah

Overlap: 18.1 percent / 42,284
State-based exchange? No (Utah runs a small businesses marketplace, but it relies on the federal government for an individual marketplace) Expanded Medicaid coverage? No

10. Oklahoma

Overlap: 18.0% / 63,045 tax units
State-based exchange? No Expanded Medicaid coverage? No

* For the purposes of this list, we measured the overlap in “tax units,” not people. One tax unit equals a single tax return. If a family of four together qualifies for the ACA premium tax credit, they would be counted as one tax unit, not four, since they filed jointly with one tax return.

       

Each year, one in five households filing a federal income tax return claims the Earned Income Tax Credit (EITC). Targeted primarily to lower-income workers with children, it is one of many credits and deductions filers take each year on their federal income tax forms. However, unlike typical credits and deductions, the EITC is a refundable credit, meaning that after offsetting what is owed to the government filers receive the remainder of the benefit as a refund.

By supplementing earnings for low- and moderate-income households, the EITC helps bridge the gap between what the labor market provides and what it takes to support a family. It encourages and rewards work and has become one of the nation’s largest and most effective anti-poverty programs. In contrast to other work support and poverty alleviation programs, it achieves this with very little bureaucracy beyond what otherwise exists to administer the tax code.

Although the EITC began in 1975 as a small credit (no more than $400), a number of targeted expansions in subsequent years mean that today the EITC’s assistance can be considerable. In 2015, a single parent with three children working full-time all year at the federal minimum wage ($7.25 an hour) is eligible for a credit of $6,242, a boost of more than 40 percent above her earnings of $15,080 (though combined it still leaves her 12 percent below the federal poverty level).

However, the only way to obtain these substantial benefits is to claim the EITC on the annual federal income tax return. While lump-sum payments have perceived benefits (such as being able to pay off debts, make larger purchases, or force savings), the EITC’s single annual disbursement can present a challenge for the working parent trying to make ends meet throughout the year. It can also be problematic for households wanting to stretch out their refund as an emergency savings reserve.

My 2008 paper, “Periodic Payment of the Earned Income Tax Credit,” proposed an option that would allow a family to receive a portion of the EITC outside of tax time, striking a balance between lump-sum delivery and the need for resources throughout the year. Specifically, half of the credit could be claimed in four payments spread out during the year, while the remaining credit would continue to be paid as part of the tax refund.

Since then, several significant developments have occurred. A little-used option for receiving some of the EITC in each paycheck ended in 2010. In 2014, the federal government initiated a new tax credit advance payment process to subsidize health insurance premiums through monthly disbursement of the Affordable Care Act’s Premium Tax Credit. Other countries providing assistance similar to the EITC have continued to innovate and offer access to benefits during the year. Finally, members of Congress and think tanks have proposed alternatives to a single lump-sum disbursement of the EITC, and others have begun to explore and experiment with alternatives, most notably in Chicago, where a 2014 pilot program made quarterly payments to 343 households.

In light of these developments, this paper reviews the author’s original EITC periodic payment proposal, examines emerging alternatives, and addresses the following key questions:

• What is the demand for periodic payment alternatives?
  
  
• What benefits will accrue from the availability of periodic payment?
  
  
• What risks are associated with periodic payment and how can they be managed?
  
  
• What is the administrative feasibility of periodic payment?

The emerging answers point a way forward for identifying different distribution options that would enhance the EITC’s value to low- and moderate-income working families.

Downloads

• Report

       

       

       

       

       

       

EXECUTIVE SUMMARY

In November 2008, President George W. Bush convened the first G-20 summit in Washington to address the worst global financial economic crisis since the Great Depression. This summit provided a long-overdue opportunity for a dramatic and lasting change in global governance. This was followed by the election of Barack Obama, who had campaigned on a distinctly different foreign policy platform compared with his Republican rival, Senator John McCain. These two events were no mere coincidence.

The global crisis has moved the United States, along with the rest of the world, toward a new global economic order, with the G-20 summit as one of the principal manifestations of the new global governance system. Of course, movement toward this new economic arrangement and progress toward reformed global governance are not inevitable. It will take a clear and sustained commitment to a new set of values and strong leadership, especially from President Obama and the United States, to ensure that the G-20 summit is not a short-lived exception to what had been a long-standing stalemate in global governance reform. The effectiveness of the G-20 in addressing the global economic crisis could lay the foundation for a new global order and provide the impetus for the many other necessary global governance reforms. Whether or not this happens will depend to a significant extent on the direction chosen by President Obama.

The president’s vision of inclusion and openness and his approach to governing, which favors innovative and far-reaching pragmatic responses to key national and global challenges, make him a great candidate for this role. In due course the G-20 summit can also serve as a platform for addressing other pressing global issues, including trade, climate change, energy and food security and reform of global institutions. To achieve such an outcome, President Obama and other world leaders need to demonstrate a clear vision and strong leadership starting at the G-20 Summit in Pittsburgh and beyond.

“Old Economic Order” versus “New Economic Order”

From recent debates on foreign policy and global governance, we have identified two different perspectives or sets of principles underlying the approaches toward U.S. and global foreign policy. Table 1 summarizes the key elements of what we call the “Old Economic Order” in juxtaposition to the “New Economic Order.”

Table 1: Old versus New Economic Order

(Note: This table is adapted from one first presented by the authors in a seminar at the IMF in June 2007. See www.imf.org/external/np/seminars/eng/2007/glb/bl030607.pdf )

In the Old Order, the nation state is the point of departure, stressing the importance of sovereignty and national interest as the key principles driving a unilateral and assertive foreign policy. In contrast, the New Order’s starting point considers that we live in a global society, where interdependency and recognition of common interests are the key principles to be pursued in reciprocal relations and with mutual respect across borders. Under the Old Order the rules of national power politics prevail, as competing blocs and fixed alliances strive for predominance, with “hard power” if necessary. Instead, the New Order operates on the basis of a new multilateralism, which builds on the prevalence of global networks in all spheres of life and multiple coalitions across borders, where bargaining for compromise and the tools of “soft power” prevail. Finally, the Old Order promotes the notion that a single economic and political model should prevail, while the New Order accepts that different economic and political models coexist and compete side by side.

In the most simple terms, the Old Order broadly reflects the principles underlying the foreign policy agenda of the Bush administration and Senator John McCain’s presidential platform, while the New Order approximates those underpinning the platform of Senator Barack Obama’s presidential campaign and of his administration’s foreign policy stance. Key elements of the Old Order (except the last one) have also been attributed to the current foreign policy approach of Russia, while New Order principles can be ascribed to the European Union.

In fact, what is reflected in these two approaches is the difference between twentieth-century principles of foreign policy versus principles appropriate to today’s realities. We believe there are three interrelated sets of drivers of change that necessitate moving from the Old Order to the New Order. These drivers include the changing global demographic and economic balance, emerging global threats and the need for a more effective global governance system.

Drivers of Change

The first driver of change is the shifting global demographic and economic balance. By 2050, the world population is projected to reach 9.1 billion, up from 6.4 billion today, with the increase occurring almost entirely in today’s developing countries. China is widely predicted to be the largest economy in the early 2040s, with the U.S. economy in second place and India’s in third. Other emerging market economies, including Brazil, Indonesia and Russia, will be important economic players, while individual European countries will recede in importance. Continental Eurasia will be the new hub of global integration as China, India, Russia, the European Union and the Middle East’s energy-producing countries knit their economies ever closer together. The United States will remain a superpower, but only one among others. Together, the major world powers will have to confront the fact that people in poorer and weaker states will feel left behind. Simultaneously, cross-border networks—economic and political, public and private, elite and grassroots, legitimate and illegitimate—will continue to grow and will weaken the traditional hold states have over the economic, financial, social and political actions of their citizens. These networks will create bonds that will either reinforce or undermine global stability.

The second driver of change is a set of emerging global threats:

• The current financial and economic crisis—triggered by poor macroeconomic management and lax financial regulation—reflects the realities of long-term financial imbalances among key economies. It proves the difficulties of managing a highly interdependent global financial system in the absence of agreed-upon global financial surveillance, supervision and regulation. It is likely that risks of global financial stress will continue in the coming decades.
• Global disparities will increase as the rich and the rapidly growing economies do well, while many poor and stagnating countries are left behind. There is potential for rising disparities within countries, too. These inequities will reinforce risks of domestic and cross-border conflict and terrorism. At the same time, the United States and other industrialized countries face a progressive loss of traditional industries, jobs and wages. Aging populations and overburdened pension systems will challenge their fiscal stability and may lead to groundswells of anti-globalization sentiments.
• Rising food and energy prices, environmental threats and the risks of global epidemics—reinforced by population pressures—particularly affect the poorest countries.
• Growing global interdependencies across borders and sectoral lines mean that individual countries can no longer address these threats alone and that a global response has to be coordinated across sectors.

The third driver of change is the growing and widespread recognition that the current system of global governance has become increasingly fragmented, ineffective, outdated and resistant to change. This systemic weakness is reflected in the persistent stalemate on many of the pressing global issues—most notably the Doha trade round—but also on global poverty, climate change and the risk of pandemics. Moreover, global institutions have become unrepresentative in the face of the changed global economic and political balances. Hence their legitimacy is suffering badly, and yet there is stalemate in the reform of individual international organizations.

Together, these three factors have made the principles of the Old Order irrelevant and strongly point in the direction of a New Order. They represent the new reality for governments, citizens and international institutions and force them to adopt new principles and reform existing institutions.

While the drivers are strong and the new global reality is seemingly unassailable, change is not inevitable. Old habits die hard. In the United States, traditions of self-reliance and “exceptionalism” continue to shape Americans’ views of the rest of the world. At the same time, the widespread belief in the virtues of unfettered markets and low taxes, the influence of special interests for protection (agriculture, labor, old industry, banking) and the prevailing fractiousness of political decision-making may well undermine President Obama’s efforts to move toward a new global paradigm. Compounding the entrenchment of the Old Order, new nations that are still recovering from centuries of colonialism—facing economic and political instability and wishing to catch up with the successful industrial countries—are lured to a strong sovereign nation state, unfettered control over their borders and their citizens, and a confrontational approach to foreign policy. Even the much admired willingness of the Europeans to give up sovereignty in favor of supranational institutions has its limits, not least when it comes to giving up their prerogatives of dominating the governing boards of the international financial institutions and other global forums.

Leadership, conviction and persistence will be required among many actors on the global stage to ensure there is progress toward effective reform of global institutions. This potential for change is exemplified by the recent emergence of the G-20 summit as a vehicle for global governance.

The G-20 Summit—Origins, Options and Obstacles

Origins. The G-20 summit had its origins in the annual meetings of the G7—the leaders of a group of seven major Western industrial countries who gathered annually starting in the 1970s, initially to enhance economic and financial policy coordination in reaction to a major financial crisis. After the break-up of the Soviet Union, the G8 was formed by the addition of the Russian Federation. The G8 increasingly became preoccupied with global economic and political issues—in effect assuming the role of a global steering group. But widespread criticism began to mount about its role. The G8 summits were seen as ritualistic in process, ineffective in impact and increasingly unrepresentative in the face of global population and economic shifts, and hence lacking in legitimacy as a global steering group. The onset of the global financial crisis in mid-2008 pushed President George W. Bush into convening the G-20 Summit on November 15, 2008.

The ministerial-level G-20 was first created in the aftermath of the 1997-98 East Asia financial crisis. By convening representatives from 10 industrialized economies and 10 emerging market economies, the G-20 presented a much more geographically and culturally diverse group than the G8. With about 90 percent of the world’s economy and two thirds of the world’s population, the G-20 is also much more representative than the G8. Emerging market economies have been fully engaged in managing the proceedings of the meetings of G-20 finance ministers and central bank governors. It is therefore not surprising that there had been persistent calls by some experts and politicians for using the G-20 as a platform to replace the G8. While moving from G8 to G-20 summit might not create an optimal global steering group, it is a pragmatic and effective step, especially in response to crisis.

Options. Will the G-20 be a short-lived experiment or will it prove an effective tool of global governance? Various options are under debate among experts and practitioners. One possibility is to return to the G8 summits like the one Italy hosted in 2009 and Canada plans to host in 2010. There is concern that the G-20 format is too unwieldy for effective exchanges among the key players. Hence, there will be continuing debates about reducing the size of the summit to somewhere between thirteen and sixteen members, as reflected in the recent proposal by the French President, Nicolas Sarkozy, to create a G14. However, there are pressures to expand the number of participants to include more countries and to expand regional representation. Then there are proposals to develop a constituency-based approach to membership, with universal participation as in the case of the international financial institutions. Further, German Chancellor Angela Merkel and a United Nations Commission chaired by Nobel laureate Joseph Stiglitz propose to establish an Economic Security Council at the UN.

None of these options will likely materialize in the foreseeable future. Instead there are two probable outcomes: The first is the continuation of the G-20 summit with a gradually expanding mandate beyond the current crisis. For this to be successful, it is critical that the G-20 format proves its effectiveness in the coming months and years. This outcome has three requirements: that the number of participants does not expand; that participants focus on a limited number of action items; and that a small but effective secretariat is established to support and monitor the G-20 summit with logistics and technical expertise.

The most likely alternative to the G-20 summit is what is frequently referred to as “variable geometry.” Under this scenario, selected world leaders would convene on specific topics in shifting constellations, with participation of the most important actors decided separately for each topic. For example, the G-20 might continue to meet on global financial and economic matters for some time to come, while different groups would convene for action on climate change, nuclear proliferation or other topics. Support for this plan appears to be emerging from the Obama administration. It co-convened the summit on climate change at the tail-end of the 2009 G8 Summit, hosts the September 2009 G-20 economic summit in Pittsburgh and has called for a summit on nuclear non-proliferation in the spring of 2010. The challenge for summits of “variable geometry” is the ever-shifting number and composition of participants, the difficulty of systematic organization and follow-up and continuing debates about who would convene the summits, when, and with what participation.

Obstacles. As we look ahead, we see a number of challenges for the evolution of global summits beyond the G8, whether toward an effective G-20 or some alternative, especially summits of variable geometry. These challenges emanate from the diverging interests of four sets of players: the United States, Europe, the new emerging powers and the rest of the world.

For the foreseeable future, active U.S. leadership is needed to overcome inertia and collective action problems in addressing global challenges and breaking the stalemate in global governance reform. The Obama administration appears to strongly support a paradigm shift toward a new global order, but so far has not announced its position on summit modalities.

Europe is a key player and has proven a major obstacle to global governance reform as it continues to claim far too many chairs at the G-20 (and in other global forums and institutions) for its economic and demographic weight. In effect, Europeans can either retain their over-representation, which gives them a fragmented voice and weakens their influence while also weakening the global institutions; or they can bundle their votes, chairs and voice for greater impact and to ensure more effective international organizations. Unfortunately, the current stalemate on internal EU governance reform blocks any new European approach to global governance reform.

The new emerging powers, especially China, India and Brazil, will face the challenge of moving beyond their traditional role of the “excluded” and “representatives of the South.” They will need to accept co-responsibility for solving global problems and creating effective global governance institutions. They will have to look beyond issue-specific South-South coalitions to North-South coalitions where it is in their and the global interest (e.g., the push for international financial institution reform, for EU for consolidation, for the completion of the Doha Round, etc.). There are hopeful signs that this is beginning to happen. South Korea’s leadership of next year’s G-20 represents a critical test of whether the new powers are ready to participate and conduct a G-20 forum at the leaders’ level, not only ministerial.

Finally, there is the challenge of how to include the “excluded.” The G-20 is much more inclusive than the G8, but it still leaves out a majority of countries with a third of the world’s population. Options for associating the rest of the world with the summit include ad hoc outreach (as the G8 has done), expanding regional representation (as already practiced with the EU), introducing a constituency approach (as for the IFIs) and seeking a closer alignment with the UN (perhaps through an Economic Security Council). With the exception of the first two—which risk further expanding the number of participants at G-20 summits—none of the other options are likely to materialize soon. However, G-20 leaders will have to be sensitive to the needs of the “excluded” and ensure that the interests of the poorest countries are not neglected.

Conclusion

Great changes in the economic and political balance among countries, global threats and an antiquated global governance system confront the world community today. With the economic crisis as an immediate driver and a new U.S. president, the G-20 summit format has the potential to make a real shift in the global economic order in which a new set of values underpin the way countries and people cooperate across borders. To the extent that President Obama has articulated his vision of the global order and America’s role in it, we believe he is headed in the direction that stresses common interests in a global society, the need for multilateral action and understanding for alternative approaches to economic and political development. This is very promising. The effectiveness of the G-20 in addressing the global economic crisis could lay the foundation for a new global order and provide the impetus for the many other necessary global governance reforms.

However, Europe, China and India are also critical for progress. Moreover, if President Obama is believed to fail the test of competence at home or a major shock hits the United States, a reversal is possible in the U.S. In any case, significant changes in global governance will take time to transpire. We may well see a long period of transition with only gradual improvement in current institutions. In the meantime, pressures for increased regionalism, bilateral deals among the big players, geopolitical competition among power blocs and growing instability and threats from the “excluded” will undermine international cooperation and the whole idea of a global order.

The G-20 summit forum represents a great opportunity for world leaders to begin to put into action the principles of a new global order. It will allow them to address the immediate global financial and economic crisis in a collaborative spirit. And in due course the G-20 summit can also serve as a platform for addressing other pressing global issues, including trade, climate change, energy and food security, and reform of global institutions. To achieve such an outcome, President Obama and other world leaders need to demonstrate a clear vision and strong leadership at the G-20 Summit in Pittsburgh and beyond.

Downloads

• Download

      

Nearly eight years after a U.S.-led invasion toppled the Taliban regime, Afghanistan remains far from stable. As President Barack Obama considers alternatives to increasing the number of U.S. troops in Afghanistan, his administration’s new counternarcotics strategy meshes well with counterinsurgency and state-building efforts in the country. It is a welcome break from previous ineffective and counterproductive policies. The effectiveness of the policy with respect to counternarcotics, counterinsurgency and state-building, however, will depend on the operationalization of the strategy. The details are not yet clear, but the strategy potentially faces many pitfalls.

Efforts to bankrupt the Taliban through eradication are futile and counterproductive since they cement the bonds between the population and the Taliban. But interdiction is very unlikely to bankrupt the Taliban either. Security needs to come first before any counternarcotics policy has a chance of being effective. Counterinsurgent forces can prevail against the Taliban, without shutting down the Taliban drug income, by adopting an appropriate strategy that provides security and rule of law to the population and by sufficiently beefing up their own resources vis-à-vis the Taliban. Rural development is a long term and multifaceted effort. Simplistic strategies that focus simply on price ratios or try to raise risk through “seed-burn-seed” approaches are ineffective. Wheat replacement strategy as a core of the alternative livelihoods effort is singularly inappropriate for Afghanistan. Shortcuts do not lead to sustainable policies that also mitigate conflict and enhance state-building.

The Obama administration will need to reduce expectations for quick fixes and present realistic timelines to Congress, the U.S. public and the international community for how long rural development and other counternarcotics policies in Afghanistan will take to show meaningful and sustainable progress that advances human security of the Afghan people, mitigates conflict and enhance state building. Unless this is conveyed, there is a real danger that even a well-designed counternarcotics policy will be prematurely and unfortunately discarded as ineffective.

The New Strategy in Afghanistan’s Context

In summer 2009, the Obama administration unveiled the outlines of a new counternarcotics policy in Afghanistan. The new policy represents a courageous break with previous misguided efforts there and thirty years of U.S. counternarcotics policies around the world. Instead of emphasizing premature eradication of poppy crops, the new policy centers on increased interdiction and rural development. This approach strongly enhances the new counterinsurgency policy focus on providing security to the rural population, instead of being preoccupied with the numbers of incapacitated Taliban and al Qaeda.

In Afghanistan, somewhere between a third and a half of its GDP comes from poppy cultivation and processing and much of the rest from foreign aid, so the illicit poppy economy determines the economic survival of a large segment of the population. This is true not only of the farmers who cultivate opium poppy frequently in the absence of viable legal and illegal economic alternatives. But, as a result of micro- and macro-economic spillovers and the acute paucity of legal economic activity, much of the economic life in large cities is also underpinned by the poppy economy. After a quarter century of intense poppy cultivation, the opium poppy economy is deeply entrenched in the socio-economic fabric of the society. Islamic prohibitions against opiates notwithstanding, the poppy economy inevitably underlies Afghanistan’s political arrangements and power relations. Profits from taxing poppy cultivation and protecting smuggling rings bring substantial income to the Taliban. A recent CRS report (August 2009) estimates the income at $70-$100 million per year, which accounts for perhaps as much as half of Taliban income. But many other actors in Afghanistan profit from the opium poppy economy in a similar way: former warlords cum government officials; members of Afghanistan’s police; tribal chiefs; and independent traffickers.

Moreover, the Taliban and many others who protect the opium poppy economy from efforts to suppress it derive much more than financial profits. Crucially, they also obtain political capital from populations dependent on poppy cultivation. Such political capital is a critical determinant of the success and sustainability of the insurgency since public support or at least acceptance are crucial enablers of an insurgency. Indeed, as I detail in my forthcoming book, Shooting Up: Counterinsurgency and the War on Drugs, along with providing order that the Afghan government is systematically unable to provide and capitalizing on Ghilzai Pashtun sentiments of being marginalized, protection of the poppy fields is at the core of the Taliban support. By not targeting the farmers, the new counternarcotics strategy is thus synchronized with the counterinsurgency efforts because it can deprive the Taliban of a key source of support. Its overall design also promises to lay the necessary groundwork for substantial reductions in the size and impacts of the illicit economy in Afghanistan.

However, while appropriate in its overall conception, the new strategy has pitfalls. Specifically how to operationalize interdiction and rural development will to a great extent determine the effectiveness of the strategy—not only with respect to the narrow goal of narcotics suppression, but also with respect to counterinsurgency and state-building. While many of the details still remain to be developed, some of those that have trickled out give reasons for concern.

Effects of Previous Eradication-Centered Policy

During the 2008-09 growing season, the area of cultivation in Afghanistan fell by 22% to 123,000 hectares and opium production fell by 10 percent to 6,900 metric tons (mt). Much of this decline in cultivation was driven by market forces largely unrelated to policy: After several years of massive overproduction in Afghanistan that surpassed the estimated global market for opiates by almost three times, opium prices were bound to decline. Even at 6,900 mt, production still remains twice as high as world demand, leading to speculation that someone somewhere is stockpiling opiates.

More significant, the persistence of high production betrays the ineffectiveness of simplistic policies, such as premature forced eradication before alternative livelihoods are in place, which since 2004 (until the new Obama strategy) was the core of the counternarcotics policy in Afghanistan. Policies that fail to address the complex and multiple structural drivers of cultivation and ignore the security and economic needs of the populations dependent on poppy cultivation generate vastly counterproductive effects with respect to not only counternarcotics efforts, but also counterinsurgency, stabilization and state building.

The eastern Afghan province of Nangarhar provides a telling example. For decades, Nangarhar has been one of the dominant sources of opium poppy. But over the past two years, as a result of governor Gul Agha Shirzai’s suppression efforts—including bans on cultivation, forced eradication, imprisonment of violators and claims that NATO would bomb the houses of those who cultivate poppy or keep opium—cultivation declined to very low numbers. This has been hailed as a major success to be emulated throughout Afghanistan.

In fact, the economic and security consequences were highly undesirable. The ban greatly impoverished many, causing household incomes to fall 90% for many and driving many into debt. As legal economic alternatives failed to materialize, many coped by resorting to crime, such as kidnapping and robberies. Others sought employment in the poppy fields of Helmand, yet others migrated to Pakistan where they frequently ended up recruited by the Taliban. The population became deeply alienated from the government, resorting to strikes and attacks on government forces. Districts that were economically hit especially severely, such as Khogiani, Achin and Shinwar, have become no-go zones for the Afghan government and NGOs. Although those tribal areas have historically been opposed to the Taliban, the Taliban mobilization there has taken off to an unprecedented degree. The populations began allowing the Taliban to cross over from Pakistan, and U.S. military personnel operating in that region indicate that intelligence provision to Afghan forces and NATO has almost dried up. Tribal elders who supported the ban became discredited, and the collapse of their legitimacy is providing an opportunity for the Taliban to insert itself into the decision-making structures of those areas. And all such previous bans in the province, including in 2005, turned out to be unsustainable in the absence of legal economic alternatives. Thus, after the 2005 ban, for example, poppy cultivation inevitably swung back.

The Ingredients of Success

Security
The prerequisite for success with respect to narcotics is security, i.e. sustained state control of territory. Without it, Afghanistan cannot be stabilized and the state strengthened; nor can counternarcotics policies be effective. Whether one adopts iron-fisted eradication or sustainable rural development as the core of a counternarcotics policy, security is essential. Without security first, counternarcotics efforts have not yet succeeded anywhere. Suppression without alternative livelihoods in place requires firm control of the entire territory to prevent illicit crop displacement and harsh suppression of the population dependent on illicit crops. Apart from being problematic with respect to human rights, this harsh approach is also very costly politically. Rural development requires security, otherwise investment will not come in, the population will not make risky long-term investments in legal crops and structural drivers of cultivation will not be effectively addressed. Development under a hail of bullets simply does not work, and in the context of insecurity, illicit economies persist and dominate.

Nor have counternarcotics policies, such as eradication or interdiction, succeeded in bankrupting or severely weakening any belligerent groups profiting from drugs anywhere in the world. Not in China, Thailand, Burma, Peru, Lebanon or even Colombia. Instead, they cement the bonds between marginalized populations dependent on illicit crops and belligerents plus severely reduce human intelligence flows to the counterinsurgent forces.

But counterinsurgent forces can prevail against insurgents and terrorists without stopping or reducing the terrorists’ drug-based financial inflows—either by increasing their own forces and resources vis-à-vis the belligerents or by adopting a smarter strategy that is either militarily more effective or wins the hearts and minds. This was the case in China, Thailand, Burma, and Peru where counterinsurgents succeeded without eradication. Evidence that counterinsurgent forces can prevail without bankrupting the belligerents through eradication also holds in the case of Colombia where the FARC has been weakened militarily not because of the aerial spraying of coca fields, but in spite of it. Today, more coca is grown there than at the beginning of Plan Colombia; but as a result of U.S. resources and training, Colombian forces were capable of greatly weakening the FARC even though forced eradication virtually eliminated human intelligence from the population to the government.

Interdiction with the Right Focus
The broad focus of the new counternarcotics strategy on interdiction is well placed, but interdiction’s effectiveness will depend on its objectives and execution. Just like eradication, interdiction will not succeed in bankrupting the Taliban. The Taliban has many other sources of income, including donations from Pakistan and the Middle East, taxation of legal economic activity, smuggling with legal goods, wildlife and illicit logging. In fact, it rebuilt itself in Pakistan between 2002 and 2004 without access to the poppy economy. Overall, drug interdiction has a very poor record in substantially curtailing belligerents’ income, with only a few successes registered in, for example, highly localized settings in Colombia and Peru.

Instead, the objective of the policy should be to reduce the coercive and corrupting power of organized crime groups. But achieving that requires a well-designed policy and a great deal of intelligence. Previous interdiction efforts in Afghanistan have in fact had the opposite effect: they eliminated small traders and consolidated the power of big traffickers, giving rise to the vertical integration of the industry. They also strengthened the bonds between some traffickers and the Taliban (although many traffickers continue to operate independently or are linked to the government).

Large-scale interdiction that targets entire networks and seeks to eliminate local demand for opium from local traders, which some are arguing for, is extraordinarily resource-intensive given the structure of the Afghan opium industry. Prioritization will need to be given to devoting scarce resources to drug interdiction or directly to counterinsurgency. The odds of success are not high. But even if such an interdiction strategy did succeed in shutting down local demand, the policy would become counterproductive since in local settings its effects would approximate the effects of eradication, thus once again alienating the population. Such large-scale interdiction is thus not currently appropriate for Afghanistan.

But even the NATO-led selective interdiction of targeting designated Taliban-linked traffickers (the United States has identified fifty such traffickers) is not free from pitfalls. First, selective interdiction can actually provide opportunities for the Taliban to directly take over the trafficking role or strengthen the alliance between the remaining traffickers and the Taliban, thus achieving the opposite of what it aims for. In fact, interdiction measures in Peru and Colombia frequently resulted in tightening the belligerents-traffickers nexus and belligerents’ takeover of trafficking.

Second, uncalibrated interdiction can provoke intense turf wars among the remaining traffickers, thus intensifying violence in the country and muddling the battlefield picture by introducing a new form of conflict. Mexico provides a vivid example of such an undesirable outcome. In the Afghan tribal context, such turf wars can easily become tribal or ethnic warfare.

Third, such selective interdiction can also send the message that the best way to be a trafficker is to be a member of the Afghan government, thus perpetuating a sense of impunity and corruption and undermining long-term state building and legitimacy.

Finally, the effectiveness of interdiction is to a great extent dependent on the quality of rule of law in Afghanistan plus the capacity and quality of the justice and corrections systems, all of which are woefully lacking in Afghanistan and are deeply corrupt.

Comprehensive Rural Development
Rural development appropriately lies at the core of the new strategy because, despite the enormous challenges, it has the best chance to effectively and sustainably strengthen the Afghan state and reduce the narcotics economy. But for rural development to do that, it needs to be conceived as broad-based social and economic development that focuses on improvements in human capital—including health care and education—and addresses all of the structural drivers of opium poppy cultivation. In Afghanistan, these drivers include insecurity; lack of physical infrastructure (such as roads), electrification and irrigations systems; lack of microcredit; lack of processing facilities; and the absence of value-added chains and assured markets. They also include lack of land titles and, increasingly, the fact that land rent by sharecroppers has become dependent on opium poppy cultivation as land concentration has increased over the past eight years. Poppy cultivation and harvesting are also very labor-intensive, thus offering employment opportunities unparalleled in the context of Afghanistan’s economy.

The price-profitability of poppy in comparison to other crops is only one of the drivers and frequently not the most important one. Without other structural drivers being addressed, farmers will not switch to licit crops even if they fetch more money than the illicit ones. By the same token, however, farmers are frequently willing to sacrifice some profit and forgo illicit crop cultivation as long as the licit alternatives bring them sufficient income and address all of the structural drivers, including the insecurity to which farmers are exposed in illicit economies.

Unfortunately, the wheat distribution program that was the core of rural development in Afghanistan last year (and that is slated to be its key component this year) is likely to be woefully ineffective for several reasons. First, in 2008, the program was based solely on an unusually high price ratio of wheat to poppy, driven by poppy overproduction and a global shortage of wheat. However, this price ratio is unlikely to hold; Afghanistan’s wheat prices are dictated anyway by surrounding markets, such as Pakistan and Kazakhstan. Second, the program did nothing to address the structural drivers. In fact, it had counterproductive effects because the free distribution of wheat undermined local markets in seeds. Afghan farmers can obtain seeds; their challenge lies in how to obtain profit afterwards. Thus, some sold the wheat seed instead of cultivating it. Third, those who actually cultivated wheat frequently did so not for profit, but for subsistence to minimize costs of buying cereals on the market. In fact, because of land distribution issues, many Afghan farmers do not have access to enough land to cover even their subsistence needs with wheat monocropping. A key lesson from alternative development over the past thirty years is that monocropping substitution strategies are particularly ineffective. Fourth, if all of current poppy farmers switched to wheat cultivation, Afghanistan would experience a great increase in unemployment since wheat cultivation employs 88% less labor than poppy cultivation and harvesting do.

Instead of wheat, rural development in Afghanistan needs to emphasize diversified high-value, high-labor-intensive crops, such as fruits, vegetables and specialty items like saffron. Generating lasting off-farm income opportunities will also be important, but even more challenging than jump-starting legal agromarkets.

After eight years of underresourcing and neglecting agriculture development, the new counternarcotics policy’s focus on the farm is appropriate. But the new strategy needs to take care not to throw away the baby with the bath water. The effort still needs to include developing value-added chains and assured internal and external markets plus enabling sustained access to them. Once again, thirty years of history of alternative livelihoods show that without value-added chains and accessible markets even productive legal farms become unsustainable and farmers revert back to illicit crops.

Finally, rural development requires time. Perhaps in no country in the world since Mao wiped out poppy cultivation in China in the 1950s did counternarcotics efforts face such enormous challenges as they do in Afghanistan—in terms of the scale of the illicit economy, its centrality to the overall economy of the country and hence its vast marco- and micro-economic and political effects, the underdevelopment of the country and its human capital and the paucity of viable economic alternatives. Even under much more auspicious circumstances along all the above dimensions, counternarcotics rural development in Thailand took thirty years.

Conclusion

Clearly, there is a need to quickly bring some economic, social and rule of law improvements to the lives of the Afghan people. Without such quick, visible and sustainable change, it will become impossible to rebuild the confidence of the Afghan people in the future, harness their remaining aspirations and to persuade them that the central state with support of the international community is preferable to the Taliban or local warlord- or tribal-based fiefdoms. But there is an equal need to urge strategic patience in the United States—both for counterinsurgency and for counternarcotics.

Eradication can be a part of the mix of counternarcotics policies, but should only be adopted in areas that are free of violent conflict and where sufficient legal economic alternatives are available to the population. Interdiction needs to focus on reducing the coercive and corrupting power of crime groups. Before interdiction measures are undertaken, an analysis of second and third- order effects needs to be conducted. It needs to be carefully calibrated with the strength of law enforcement in Afghanistan to avoid provoking dangerous turf wars, ethnic violence and cementing the relationship between the Taliban and the traffickers. It also needs to target top traffickers linked to the Afghan government. Interdiction needs to encompass building the justice and corrections system in Afghanistan and broad rule of law efforts. Rural development needs to address all structural drivers of poppy cultivation. It needs to focus not only on the farm, but also on value-added chains and assured markets. It needs to emphasize diversified high-value, high-labor intensive crops, and not center on wheat.

Evaluations of counternarcotics policies need to back away from simplistic and inappropriate measures, such as the numbers of hectares eradicated or traffickers caught. Instead, the measures need to encompass the complexity of the issue, including, size of areas cultivated with licit as well as illicit crops, human development indexes, levels of education, the number of resource-poor farmers dependent on illicit crops for basic subsistence or vulnerable to poverty-driven participation in illicit economies, food security, availability of legal microcredit, prevalence of land titles and accessibility of land, infrastructure density and cost of infrastructure use (such as road tolls), availability of non-belligerent dispute resolution and arbitrage mechanisms, quality of property rights, prevalence of value-added chains, and accessibility of markets. The United States and its allies must reduce public expectations for quick fixes and dedicate increased resources to rural development for a long time. Although U.S. forces do not need to stay in Afghanistan for decades, economic development will take that long.

Downloads

• Download

      

Policy Brief #182

Protection of people from oppressive governments, civil conflict and disasters has moved to the top of the international agenda. The United Nations Security Council authorized all measures necessary to protect civilians in Libya as the airstrikes began. Humanitarian agencies-working in more places and under more difficult conditions than ever before-are grappling with the aftermath of Japan's massive earthquake even as they are also working with displaced people in Haiti and Ivory Coast and responding to hundreds of thousands of people fleeing Libya. And increasingly these agencies are not only trying to assist people through provision of relief items, but also trying to protect them. But with so many global organizations mobilizing to protect civilians when disasters strike and conflicts break out, the concept of protection has begun to lose its distinctive meaning.

Can anyone "do" protection? In The Politics of Protection: The Limits of Humanitarian Action (Brookings Institution Press, 2011), I describe how protection has been stretched to include all manner of important activities-from provision of food to curriculum development, from advocacy to monitoring, from building latrines to voter registration. Beyond affirming the responsibility of governments to protect their people, international law offers no clear guidance on how to translate the principles of protection into action.

Given the likelihood that conflicts will continue and natural disasters will increase in the future, much more attention is needed on the question of protection, which has emerged over the years from international humanitarian law, refugee law and human rights law. The most visible part of the international humanitarian system is the vast array of U.N. agencies and nongovernmental organizations. Yet military forces, the International Committee of the Red Cross, and thousands of civil society organizations are also major actors in humanitarian response. This brief describes observations and recommendations on protection in humanitarian work culled from my forthcoming book.

	RECOMMENDATIONS
	With changes in the nature of conflict and with the likelihood of increasing severity and frequency of sudden-onset disasters because of climate change, more attention needs to be paid to understanding how humanitarian actors can-and cannot-protect people. The United Nations and other humanitarian actors should consider the following recommendations: Humanitarian agencies need to re-evaluate what protection means in the context of today's conflicts and to recognize their own limitations in keeping people safe. If they are serious about protecting people, they need to work with national military and police forces which have the resources to provide such physical protection. This is hard for humanitarian agencies that see their work as grounded in principles of impartiality, independence and neutrality. NGOs should review their current policies and practices on protection to ensure that they are not promising more than they can deliver or being used as a cover for the lack of effective political action.   " As the term "protection of civilians" has come to mean different things for different actors, the U.N. Office for the Coordination of Humanitarian Affairs should develop a very short summary statement of what it means to protect civilians that can be broadly used by a range of different communities and individuals in different contexts. The office should then collect the best practices to illustrate how protection of civilians is effectively carried out on the ground.   As both conflicts and disasters take on a distinctive form when they occur in urban areas, much more work is needed to retool humanitarian assistance for urban environments. This means that humanitarian agencies need to work with municipal authorities in preparing for and responding to urban residents affected by violence and disasters.   In light of the fact that climate change is likely to result in more large-scale and varied types of displacement, U.N. agencies and researchers should analyze the gaps in international legal protection for those forced to leave their countries because of climate change-induced environmental factors. Guidelines should be developed to assist governments considering evacuation or relocation of populations from areas likely to be affected by natural disasters or climate change.   Given the pace of technological change taking place with robotic armaments, the International Committee of the Red Cross should convene a group of experts from the military research and international law communities to begin to identify the gaps in international humanitarian law resulting from the widespread use of those technologies.

Downloads

• Download Policy Brief

       

Policy Brief #185

The unprecedented surge in incarceration since 1980 has stimulated a national debate between those who claim that locking up over 2 million people is necessitated by public safety concerns, and those who say the human and financial burden of imprisoning so many of our citizens is intolerable.

But framing the incarceration debate as a tradeoff between public safety and public finance is far too narrow. The best evidence suggests the prison population would be substantially reduced with negligible effects on crime rates. Crime could actually be reduced if the savings were put to use in strengthening other criminal justice programs and implementing other reforms. Making this case requires that we confront widespread skepticism about the possibility of reducing criminal behavior on the outside.

The research community has made real progress in identifying the causal effect of various crime-related policies in recent years, providing us with proven alternatives to prison for controlling crime. The key has been to make greater use of experimental methods of the sort that are common in medicine, as well as "natural experiments" that arise from naturally occurring policy or demographic shifts.

	RECOMMENDATIONS
	The resources currently dedicated to supporting long prison sentences should be reallocated to produce swifter, surer, but more moderate punishment. This approach includes hiring more police officers -we know now that chiefs using modern management techniques can make effective use of them.   Increased alcohol excise taxes reduce not only alcohol abuse but also the associated crime at very little cost to anyone except the heaviest drinkers. Federal and state levies should be raised.   Crime patterns and crime control are as much the result of private actions as public. The productivity of private-security efforts and private cooperation with law enforcement should be encouraged through government regulation and other incentives.   While convicts typically lack work experience and skills, it has proven very difficult to increase the quality and quantity of their licit employment through job creation and traditional training, either before or after they become involved with criminal activity. More effective rehabilitation (and prevention) programs seek to develop non-academic ("social-cognitive") skills like self-control, planning, and empathy.   Adding an element of coercion to social policy can also help reduce crime, including threatening probationers with swift, certain and mild punishments for illegal drug use, and compulsory schooling laws that force people to stay in school longer.

The unprecedented surge in incarceration since 1980 has stimulated a national debate between those who claim that locking up over 2 million people is necessitated by public safety concerns, and those who say the human and financial burden of imprisoning so many of our citizens is intolerable. This debate played itself out vividly in the U.S. Supreme Court's May 2011 decision (Brown v. Plata) requiring California to dramatically scale back the size of its prison population. The majority's decision written by Justice Anthony Kennedy focused on inhumane conditions in California's prisons. In dissent, Justice Antonin Scalia emphasized the "terrible things [that were] sure to happen as a consequence of this outrageous order," while Justice Samuel Alito argued the majority was "gambling with the safety of the people of California." These dissenting opinions will sound familiar to states considering cutbacks in incarceration to balance dwindling state budgets.

However, framing the incarceration debate as a tradeoff between public safety and public finance is far too narrow. Prison is not the only option we have for controlling crime. But making the case for alternative approaches has historically been an uphill battle. What noted crime expert and UCLA professor Mark Kleiman calls the "brute force" strategy of locking up lots of people in prison has an obvious logic to it. The perception that "prison works" is reinforced by today's crime rates, now at a 50-year low.

In contrast, there is an abiding skepticism about the effectiveness of other efforts to change criminal behavior on the outside. One reason for this skepticism is the difficulty of distinguishing cause from effect in crime data. For decades, criminologists have maintained that one obvious alternative to prison - putting more police on the streets to help deter crime - doesn't work, because the numbers suggest a positive association between the crime rate and the number of police. (This is analogous to the association between the large numbers of physicians in areas with high concentrations of sick people, such as hospitals.)

Confidence in rehabilitation through social programs also is low, because recidivism rates are so high, even among inmates who participate in re-entry programs. In a recent interview, for example, the Los Angeles District Attorney told Time that, with respect to rehabilitation for gang-involved inmates, "we predict with some degree of confidence . . . it will fail in many, many, many cases."

Fortunately, in recent years researchers have made real progress in identifying the impact of various crime-related policies. The key has been to make greater use of experimental methods of the sort common in medicine, as well as "natural experiments" that arise from naturally occurring policy or demographic shifts.

The over-riding conclusion of the best new research is that there is "money on the table"; we can reduce the financial and human costs of crime without stimulating resurgence in crime rates.

Prisons and crime

Much of the reluctance to reduce the prison population reflects a belief that the extraordinary reduction in crime that occurred in the 1990s was caused by a surge in imprisonment. But even a casual look at the actual statistics challenges the view that prison trends get all or most of the credit for the crime drop.

Looking at three periods from recent history, we see that the crime drop of the 1990s did coincide with a large increase in the prison population. But the large crime increase during the prior period was also associated with a jump in imprisonment - and so was the relatively static crime pattern since 2000. If the prison surge of the 1990s gets credit for the crime drop, then fairness requires that the prison surge of the 1980s gets the blame for the crime increase of that period, while the prison increase of the 2000s was largely irrelevant. This type of armchair analysis supports almost any conclusion.

PERCENTAGE CHANGE
	Prisoners/cap	Robbery rate
1984-1991	+66	+33
1991-2000	+42	-47   (the crime drop)
2000-2008	+10	0

Studies suggest that increased use of imprisonment indeed should receive part of the credit for the crime drop of the 1990s, in the sense that crime was lower than it would have been had we taken all the funds devoted to prison increases and spent it for purposes other than crime control. But is that the right counterfactual? If the vast increase in prison expenditures came at the expense of alternative crime-control efforts that might be even more effective, then the net effect of the imprisonment boom is not so clear, even qualitatively.

Alternatives to prison

Prison alternatives can be organized into two large and somewhat overlapping bins of crime-control activities, which we label "changing individual propensities towards crime" and "changing the offending environment." Under each heading, we identify particularly promising programs, based on recent assessments of costs and benefits. We conclude with rough calculations that highlight the potential magnitude of the inefficiency within our current policy approach - that is, how much extra crime-prevention could be achieved by simply reallocating resources from less-efficient to more-efficient uses.

Changing individual propensities towards crime

1. The difficulties of changing poverty and adverse mental health: While a large body of criminological and psychological theory has emphasized the role of economic disadvantage and mental health problems in contributing to criminal behavior, empirical evidence suggests that job training and mental health courts are not the most cost-effective ways to control crime - not because these disadvantages don't matter, but because they are so difficult to modify in practice.
    
2. Coercive social policy: The average high school graduation rate in the America's 50 biggest urban school systems is about 53 percent. One of the few levers available to policymakers to ensure youth stay in school is to raise the compulsory schooling age - although it is natural to wonder what good schooling will do for youth who are being forced to go against their will. It is thus striking that we have strong quasi-experimental evidence from both the United States and Great Britain that cohorts exposed to an increased compulsory schooling age have reduced crime involvement. That benefit augments the usual list of benefits associated with more schooling, and it complements the benefits of early childhood interventions like Perry Preschool (a two-year preschool program for disadvantaged 3- and 4-year-olds) and Head Start (the large-scale federal preschool program).
    
3. Social-cognitive skill interventions: Most of the economics-of-crime literature has focused on ways of reducing crime by changing the incentives that confront potential offenders, with very little attention devoted to helping people respond to the incentives they already face. A growing body of evidence shows that social-cognitive skills - for example, impulse control, inter-personal skills and future orientation - influence people's response to incentives and predict criminal involvement, schooling and employment participation.

Moreover, intervention research also suggests that targeted efforts to improve the social-cognitive skills of young people at risk and to modify the social systems that may contribute to or reinforce delinquency can reduce crime. The benefits of such efforts can far exceed their costs.

Changing the offending environment

1. Swiftness and certainty, not severity, of punishment: Much of the increase in America's prison population since the 1970s comes from an increase in average sentence lengths. Yet new data from the randomized Hawaii Opportunity Probation with Enforcement (HOPE) experiment found that frequent drug testing, followed immediately by a very short jail stay for dirty urine, substantially reduced drug use and criminality among probationers. Studies of the federal government's Community Oriented Policing Services (COPS) police hiring grants provides further empirical support for the growing suspicion that swiftness and certainty of punishment may actually be most important for controlling crime. The notion that crime is reduced by simply putting more police on the streets without changing what they do, and that deterrence (rather than simply incapacitation) may be an important mechanism behind this result, also overturns the conventional wisdom that prevails in many criminology circles.
    
2. Demand curves for criminogenic goods are negatively sloped: The federal and state excise taxes on beer and liquor have declined markedly (in real terms) since World War II. These rates are considerably below the marginal external social cost, even if effects on crime are not considered. Many people outside the economics profession are skeptical that modest changes in the price of alcohol can do much to change use, given the social context in which drinking so frequently occurs; the possibility that many of highest-risk alcohol users have some level of dependency; and how little attention so many people pay to a 5, 10 or even 20 percent change in prices. Yet the empirical evidence that raising taxes and prices would reduce some types of crime is very strong.
    
3. Private co-production: Most of the research on crime control strategies focuses on the role played by government and non-profit interventions. But private citizens and businesses account for a surprisingly large share of resources devoted to preventing crime. State and local governments can help reduce crime indirectly by encouraging private actions that make law enforcement more productive. Two examples for which benefits exceed costs by an order of magnitude are building the police-tracking infrastructure for Lojack, and creating the legal framework for Business Improvement Districts (where local businesses are subject to tax payments that go in part toward making the neighborhood clean and safe).

It bears repeating that the goal is not to identify the "best" alternative to prison, but rather the best portfolio of options.

What the status quo costs us

Our review of the best available social science suggests that America's current approach to crime control is woefully inefficient. Much greater crime control could be achieved at lower human and financial cost. To illustrate the potential gains from improving the efficiency of the current system, consider the following hypothetical policy experiment.

Imagine that we changed sentencing policies and practices in the United States so that the average length of a prison sentence reverted to what it was in 1984 - i.e., midway through the Reagan administration. This policy change would reduce our current prison population by around 400,000 and total prison spending (currently $70 billion annually) by about $12 billion per year.

What would we give up by reducing average sentence lengths back to 1984 levels? In terms of crime control: not all that much. Assume that society "breaks even" on the $12 billion we spend per year to have average sentence lengths at 2009 rather than 1984 (so that the benefits to society are just worth $12 billion), although more pessimistic assumptions are also warranted.

What could we do instead with our newly acquired $12 billion? One possibility would be to put more police on the streets. Currently, the United States spends around $100 billion per year on police protection, so this hypothetical policy switch would increase the nation's police budget by 12 percent, enabling deployment of as many as 100,000 more police officers. The estimated elasticity of crime with respect to police is far larger (in absolute value) than even the most optimistic assessment of what the elasticity of crime would be with respect to increased sentence lengths. This resource reallocation would lead to a decline of hundreds of thousands of violent and property crime victimizations each year.

A different way to think about the potential size of this efficiency gain is to note that the benefit-cost ratio for increased spending on police may be on the order of 4:1. If the benefit-cost ratio for marginal spending on long prison sentences is no more than 1:1, then reducing average sentence lengths to 1984 levels in order to increase spending on police could generate net benefits to society on the order of $36 billion to $90 billion per year.

Suppose instead that we devote the resources from a $12 billion cut in prison spending to supporting high-quality preschool programs. This would enable a large increase in federal spending on preschool services - for example, $12 billion would represent a 150 percent increase in the annual budget for Head Start (currently around $8 billion per year). Currently Head Start can enroll only around half of eligible 3 and 4-year-olds, and provides early childhood education services that are far less intensive than successful, widely-cited model programs like the Perry Preschool and Abecedarian. Head Start children participate in the program for shorter periods (usually one year, versus two to five years for the others), and the educational attainment of Head Start teachers is lower.

A 150 percent increase in Head Start's budget could dramatically expand the program on both the extensive and intensive margins. Given available data, the benefit-cost ratio of this expenditure would fall in the range of 2:1 to 6:1 - that is, from two to six dollars in long-term benefit for every dollar spent. Reallocating resources from long prison sentences to early childhood education might generate from $12 billion to $60 billion in net benefits to society.

If crime reduction is a key goal, we might do better still by focusing on human capital investments in the highest-risk subset of the population - through efforts to address social-cognitive skill deficits of young people already involved in the criminal justice system. Marvin Wolfgang's seminal cohort studies found that only a small fraction of each cohort commits the bulk of all crime. While early intervention programs target children during the time of life in which they are most developmentally "plastic," interventions with adolescents and young adults can be more tightly targeted on those whose arrest histories suggest they are likely to end up as serious offenders. Another benefit of targeting criminally active teens and adults is an immediate crime reduction payoff.

What sort of social-cognitive skill development could we provide to high-risk young people with $12 billion per year?

With around $1 billion, we could provide functional family therapy (FFT) to each of the roughly 300,000 youths on juvenile probation. E.K. Drake and colleagues estimate that FFT costs something less than $2,500 per youth, with a benefit-cost ratio that may be as high as 25:1 from crime reduction alone.

With the remaining $11 billion we could provide multi-systemic therapy (MST) to almost every arrestee age 19 and under. The cost of MST is around $4,500 per year, with a benefit-cost ratio of around 5:1.

Estimates such as these indicate that diverting $12 billion from long prison sentences to addressing social-cognitive skill deficits among high-risk youth could generate net social benefits on the order of $70 billion per year. Even if FFT and MST, when implemented at large scale, are only half as effective as previous experiments suggest, this resource switch would still generate substantial societal benefits.

The preceding calculations are intended to be illustrative rather than comprehensive benefit-cost analyses, and, clearly, they are subject to a great deal of uncertainty. Nevertheless, they strongly suggest the enormous efficiency gains that could result from reallocating resources from prisons to other uses that will, among other beneficial outcomes, reduce crime.

A key challenge we currently face is that our government systems are not well suited to converting the fifth year of a convicted drug dealer's prison term into an extra year or two of Head Start for a poor child. Government agency heads have strong incentives to maximize the budgets of their agencies, and pour any resources that are freed-up from eliminating ineffective program activities back into their own agencies. This is the intrinsic difficulty of rationalizing policies across domains, agencies, and levels of government. If we could solve this problem - and orient the policy system to up-weight evidence from design-driven research - then in our quest for effective crime control, it appears possible that we could have more for less.

Downloads

• Download Policy Brief

       

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.

Downloads

• Download Full Report

      

Missouri's population is spreading out, adding to the costs of providing services and infrastructure across the state, according to a new study released today by the Brookings Institution Center on Urban and Metropolitan Policy.

The 84-page study, Growth in the Heartland: Challenges and Opportunities for Missouri, reports that Missouri's population is quickly dispersing, with smaller metropolitan areas experiencing some of the state's fastest growth and residency in unincorporated areas on the rise. Though new residents and jobs fueled prosperity in the 1990s, the report finds that growth has slowed in the past year, and suggests that the state's highly decentralized development patterns could become troublesome as Missouri contends with a slowing economy and serious budget deficits.

Sponsored by the Ewing Marion Kauffman Foundation, Growth in the Heartland provides the most comprehensive and up-to-date body of research and statistics yet assembled analyzing the direction, scope, and implications of development in Missouri. In addition to assessing the consequences of those trends for the state's fiscal health, economic competitiveness, and quality of life, the report addresses the potential role of state and local policy in shaping those trends in the future. Specific findings of the report conclude that:

• Growth in the Columbia, Springfield, Joplin, and St. Joseph metropolitan areas strongly outpaced that of the Kansas City and St. Louis metropolitan areas in the 1990s. Altogether the four smaller areas captured fully one-quarter of the state's growth and doubled the growth rate of the Kansas City and St. Louis areas.
  
  
• Population and job growth also moved beyond the smaller metro areas and towns into the state's vast unincorporated areas. Overall, residency in these often-outlying areas grew by 12.3 percent in the 1990s—a rate 50 percent faster than the 8.1 percent growth of towns and cities.
  
  
• Most rural counties reversed decades of decline in the 1990s, with eight in ten rural counties experiencing population growth and nine in ten adding new jobs. By 2000, more rural citizens lived outside of cities and towns than in them, as more than 70 percent of new growth occurred in unincorporated areas.

"Missouri experienced tremendous gains during the last decade, but the decentralized nature of growth across the state poses significant fiscal challenges for the future," said Bruce Katz, vice president of Brookings and director of the policy center. "The challenge for Missouri is to give communities the tools, incentives, and opportunities to grow in more efficient and fiscally responsible ways."

The Brookings Institution Center on Urban and Metropolitan Policy is committed to shaping a new generation of policies that will help build strong neighborhoods, cities, and metropolitan regions. By informing the deliberations of state and federal policymakers with expert knowledge and practical experience, the center promotes integrated approaches and practical solutions to the challenges confronting metropolitan communities. Learn more at www.brookings.edu/urban.

      

Executive Summary

Tax increment finance (TIF) is a popular and potentially powerful tool for places that need economic development the most yet have the least to spend. By allowing jurisdictions to use portions of their tax base to secure public-sector bonds, the mechanism allows fiscally strapped localities to finance site improvements or other investments so as to "level the playing field" in economic development.

However, poorly designed TIF programs can cause problems. Not only can they increase the incentives for localities to engage in inefficient, zero-sum competition for tax base with their neighbors. Also, lax TIF rules may promote sprawl by reducing the costs of greenfield development at the urban fringe. It is therefore critical that state legislatures design TIF rules well.

In view of this, an analysis of the way TIF is designed and utilized in Missouri shows that:

• Missouri law creates the potential for overuse and abuse of TIF. Vague definitions of the allowable use of TIF permit almost any municipality, including those market forces already favor, to use it. Weak limits on its use for inefficient inter-local competition for tax base touch off struggles between localities. And the inclusion of sales tax base in the program tilts it toward lower-wage jobs and retail projects, which rarely bring new economic activity into a region.
  
  
• Thanks to these flaws, TIF is used extensively in high-tax-base Missouri suburban areas with little need for assistance in the competition for tax base. This is especially true in the St. Louis metropolitan area. There, TIF money very frequently flows to purposes other than combating "blight" in disadvantaged communities' its classic purpose. In fact, less than half of the 21 St. Louis-area cities that were using TIF in 2001 were disadvantaged or "at-risk" when evaluated on four indicaters of distress. On another measure, just seven of the 20 suburban areas using TIF fell into the "at-risk" category.
  
  
• TIF is also frequently being used in the outer parts of regions' particularly in the St. Louis area. Most notably, only nine of the St. Louis region's 33 TIF districts lie in the region's core. Conversely, 14 of the region's 38 TIF districts lie west of the region's major ring road (I-270). These districts, moreover, contain 57 percent of the TIF-captured property tax base in the region. By contrast, the Kansas City region shows a pattern more consistent with the revitalization goals of TIF. The vast majority of the districts lie in the region's center city, though the huge size of the city means many are still geographically far-flung.

In sum, poorly designed TIF laws are being misused at a time when state and local fiscal pressures require every dollar be spent prudently. As a result, a potentially dynamic tool for reinvestment in Missouri's most disadvantaged communities threatens to become an engine of sprawl as it is abused by high-tax-base suburban areas that do not need public subsidies.

For these reasons, Missouri would be well-served by significant reforms in the laws governing TIF:

• The allowable purposes for TIF should be more strictly defined to target its use to places with the most need for economic development.
  
  
• Higher level review of local determinations that TIF subsidies will support net contributions to the regional or state economy (the "but-for" requirement) should be implemented.
  
  
• Local TIF administrators should be required to show that TIF subsidies are consistent with land-use and economic development needs both locally and in nearby areas.

If such reforms were put in place, TIF could be returned to its attractive main purpose: that of providing resources that would not otherwise be available to localities that badly need them to promote needed economic development and redevelopment.

Downloads

• Download

      

 Bruce Katz's keynote presentation to the Mid-America Region Council discussed what metropolitan areas need to succeed in a competitive world, with specific information about how Greater Kansas City compares to other regions and areas for improvement.

The urban center hosts and participates in a variety of public forums. To view a complete list of these events, please visit the urban center's Speeches and Events page which provides copies of major speeches, powerpoint presentations, event transcripts, and event summaries.

 

Downloads

• Download

      

*A slightly modified version of this commentary appeared in the St. Louis Post-Dispatch on October 19, 2004.

So it looks like Missouri's gubernatorial race will turn on "character" issues.

GOP consultant Paul Zemitzsch predicts Secretary of State Matt Blunt will portray Claire McCaskill, the Democratic state auditor, as "an extra-liberal female candidate" and "waffler" when things get ugly. McCaskill, for her part, has already countered one attack on her "hypocrisy" with her own attack on Blunt's veracity.

Look for more talk about character as Election Day approaches.

Yet that would be too bad.

Missouri needs to talk about some other things this fall.

In a recent statewide report, "Growth in the Heartland: Challenges and Opportunities for Missouri," for example, we argued that Missouri faces a land-use and competitive crisis that demands serious attention.

The crisis is not new—we described it two years ago—but the fact remains that Missouri's chaotic style of low-density development is defacing the state's rural heritage, gutting towns and cities, and exacting a heavy toll on Missourians' pocketbooks and quality of life just when the state needs to compete at a higher level on those factors.

Just look around:

Strip malls and home sites chewed across nearly 350 square miles of Missouri prairie and fields in the 1990s as sprawl engulfed rural Missouri and the state continued to develop land almost four times as fast as it's been adding population.

Cities are struggling, as fast exurban growth either outstrips city and town growth or, in the case of St. Louis, drains the center-city of vibrancy.

And recently decline has spread beyond the state's big urban centers into numerous older suburbs, so that inner-ring municipalities like Wellston and Rock Hill in the St. Louis area, or Raytown and Grandview near Kansas City, now suffer from population losses.

Why do these trends matter? For some the concern is cultural. They fear the state is losing its rural ambiance. For others the threat is environmental. They know scattershot development is tainting the Ozark lakes and degrading Missouri's natural areas.

However, for us the concern is mostly economic: By remaining virtually laissez faire on growth and development issues, we fear the Show Me State is undercutting its ability to parlay its very real assets in the life sciences and other high-value industries into a broader prosperity.

On the one hand, Missouri's dispersed development adds to the size of the state's enormous—and crumbling—highway system. Already Missouri taxpayers struggle with a maintenance backlog that will require half a billion dollars a year over the next 10 years—$200 million more than current finding will provide.

On the other, we suspect that the state's spread-out, low-quality development diminishes Missouri's appeal to the educated workers necessary to prosper in biotech, medical instruments, and infomatics. Educated workers gravitate to vibrant urban centers with plenty of amenities. Missouri's sprawl, by contrast, drives them away by draining the state's downtowns and Main Streets of life and variety.

And so we say it again: Missouri and the gubernatorial candidates need to face up to some tough realities this fall:

• Missouri can't afford to keep sprawling, even with tax revenues stronger this year. Blunt and McCaskill need to tell Missourians how they will foster more efficient, less chaotic growth that doesn't break the bank

 

Ditto the highway issue: Notwithstanding rural pleas, Missouri can't afford to keep building new roads until it contends with the maintenance hole it's paved itself into. The candidates absolutely must explain how they will modernize the state's deteriorating transportation system while aligning it with the principles of sound land-use and fiscal sanity

 

And what about the whole connection of economic vitality to strong cities and higher education? Growth now depends on brainpower and quality of life. Therefore, the candidates owe it to Missourians to detail how they will bolster the quality and affordability of Missouri's colleges and universities. They also must explain how they plan to bolster the state's flagging town and city centers to attract and retain the best and the brightest

In sum, the Show Me State stands at a crossroads.

With huge issues about their state's future livability and prosperity in the balance, Missourians shouldn't buy into a campaign focused on character issues and divisive wedge issues.

Instead, they should insist candidates Blunt and McCaskill address the state's problems head on and get to work.

 

      

*A slightly modified version of this commentary appeared in The Springfield News-Leader on October 24, 2004.

The Missouri gubernatorial race is going down to the wire, and guess what? Contentious social and moral issues are predominating.

Last week Republican Matt Blunt questioned McCaskill's values, saying his stand against gay marriage matched the values of mainstream Missourians.

For her part, McCaskill, the Democratic state auditor, has parried Blunt on gays, guns, and abortion by insisting that Republicans don't have a lock on values just because Democrats like her don't wear religion on their sleeves.

Look for more sniping on gays, guns, and abortion as the campaigns careen toward election day.

Which would be too bad.

Missouri—and particularly the Springfield region—needs to talk about some other things this fall.

In a major statewide report, "Growth in the Heartland: Challenges and Opportunities for Missouri," after all, we argued that Missouri today faces an outright land-use, environmental, and competitive crisis that has little to do with gay marriage or concealed-carry gun rules.

The crisis is not new—we described it two years ago—but the fact remains that Missouri's chaotic style of low-density development is gobbling up the state's rural heritage, gutting towns and cities, and exacting a heavy toll on Missourians' pocketbooks and quality of life just when the state needs to compete at a higher level on exactly those factors.

Just look around the Springfield area:

Forty-five percent of the region's growth in the 1990s took place in the unincorporated "open country," the exurban places often least equipped to manage it.

Strip malls and home sites are chewing up the region's beautiful Ozarks scenery.

And all the while newcomers are flocking to small outlying towns like Willard, Republic, Clever, Niza, and Ozark—all of which hit "hypergrowth" in the 1990s and struggle to keep up.

As to the results, they have been predictably mixed: New jobs and vitality have been accompanied by the water-quality problems that have fouled Lake Taneycomo and Table Rock Lake. Taxes are increasing as local governments strain to provide the necessary roads, services, or sewer hook-ups. And with more sprawl coming, more traffic and mini-malls could soon undercut the region's reputation as the quaint heartland of rural America.

Why do these trends matter? For some the concern is cultural. They fear the state is losing its rural heritage. For others the threat is environmental. They are disturbed by the degradation of the Ozark lakes and other nearby natural areas.

However, for us the concern is mostly economic: By remaining virtually laissez faire on growth and development issues, we fear the Show Me State is undercutting its ability to parlay its very real assets into a broader prosperity.

Spread-out development patterns, for example, raise costs in the state for businesses and individual taxpayers. That's because highly dispersed development often increases the capital and operations costs of roads, sewer lines, schools, and police or fire services.

Similarly, Missouri's dispersed development adds to the size of the state's enormous—and crumbling—highway system. Missouri taxpayers consequently struggle with a maintenance backlog that will require half a billion dollars a year over the next 10 years—some $200 million more than current finding will provide.

And likewise, we suspect that the state's spread-out, low-quality development diminishes Missouri's appeal to highly educated workers—that critical factor if the state is going to appeal to entrepreneurs, well-educated retirees, and leading-edge techies and scientists.

This is especially important in the Springfield region, where the recent boom has clearly been built on the appeal of the region's improving downtown and cultural facilities, high quality of life, and stunning natural beauty.

And so we say it again—Missouri and the gubernatorial candidates need to face up to some tough realities this fall:

• Missouri can't afford to keep sprawling, even with tax revenues stronger this year. So Blunt and McCaskill need to tell Missourians how they will foster more efficient, less chaotic growth that doesn't break the bank

Or take the highway issue: Notwithstanding rural pleas for new blacktop, Missouri can't afford to keep building new roadways as it tries to dig itself out of the maintenance hole it's paved itself into. Blunt and McCaskill should also say how they will modernize the state's flagging transportation system while aligning it with the principles of sound land-use and fiscal sanity

And what about the whole connection of economic energy to strong cities and higher education? Growth now depends on brainpower and quality of life. For that reason, the candidates owe it to Missourians to detail how they will bolster the quality and accessibility of Missouri's colleges and universities, given the state's inadequate state fiscal system. And they should likewise explain how they plan to revive the state's flagging town and city centers both for the benefit of residents and to attract and retain the best and the brightest for the future

Missouri, in sum, stands at a crossroads.

Other heartland states, like Michigan and Pennsylvania, now recognize the links between educated workers, strong urban and rural centers, and economic competitiveness—and are taking action. Missouri needs to face up to the challenge.

Similarly, other states are moving to reap the fiscal benefits of nudging development into more sensible patterns, so Missouri should think about that too.

As to the agitations of wedge issues like abortion and concealed weapons or gay marriage, Missourians should take them in stride. "Values" are important, sure, but at the same time, there's a land-use and competitive crisis underway in Missouri that both the candidates and voters ignore at their peril this election.

       

This is the third in a series of reports on the demographic and political dynamics under way in key “battleground” states, deemed to be crucial in deciding the 2008 election. As part of the Metropolitan Policy Program’s Blueprint for American Prosperity, this series will provide an electoral component to the initiative’s analysis of and prescriptions for bolstering the health and vitality of America’s metropolitan areas, the engines of the U.S. economy. This report focuses on three major battleground states in the Midwest—Ohio, Michigan, and Missouri—and finds that:

Ohio, Michigan and Missouri all feature eligible voter populations dominated by white working class voters. However, this profile is changing, albeit more slowly than in faster-growing states like Colorado or Arizona, as the white working class declines and white college graduates and minorities, especially Hispanics, increase. The largest effects are in these states’ major metropolitan areas— Cleveland, Columbus, and Cincinnati in Ohio: Detroit in Michigan; and St. Louis and Kansas City in Missouri— especially in their suburbs.

In Ohio, these trends could have their strongest impact in the fast-growing and Democratic-trending Columbus metro, where Democrats will seek to tip the entire metro in their favor by expanding their margin in Franklin County and reducing their deficit in the suburbs. The trends could also have big impacts in the Cleveland metro (especially its suburbs), in the Cincinnati metro (especially Hamilton County) and in the mediumsized metros of the Northeast (Akron, Canton, and Youngstown). Overall, the GOP will be looking to maintain their support among the declining white working class, especially among whites with some college, who have been trending Democratic. Also critical to their prospects is whether the growing white college-educated group will continue its movement toward the Democrats.

In Michigan, these trends will likely determine whether the fast-growing and populous Detroit suburbs continue shifting toward the Democrats, a development which would tip the Detroit metro (44 percent of the statewide vote) even farther in the direction of the Democrats. The trends will also have a big impact on whether the GOP can continue their hold on the conservative and growing Southwest region of the state that includes the Grand Rapids metro. The GOP will seek to increase its support among white college graduates, who gave the GOP relatively strong support in 2004, but have been trending toward the Democrats long term.

In Missouri, these trends will have their strongest impact on the two big metros of Democratic-trending St. Louis (38 percent of the vote)—especially its suburbs— and GOP-trending Kansas City (20 percent of the statewide vote). The Democrats need a large increase in their margins out of these two metros to have a chance of taking the state, while the GOP simply needs to hold the line. The trends will also have a significant impact on the conservative and growing Southwest region, the bulwark of GOP support in the state, where the Republicans will look to generate even higher support levels. The GOP will try to maintain its support from the strongly pro-GOP white college graduate group, which has been increasing its share of voters as it has trended Republican.

These large, modestly growing states in the heartland of the United States will play a pivotal roll in November’s election. Though experiencing smaller demographic shifts than many other states, they are each changing in ways that underscore the contested status of their combined 48 Electoral College votes in this year’s presidential contest.



Table Of Contents:
Executive Summary » 
Introduction and Data Sources and Definitions » 
Ohio » 
Michigan » 
Missouri » 
Endnotes »

Downloads

• Download

       

Earlier this month, Missouri voters overwhelmingly rejected a 10-year, 3/4 cent sales tax increase to boost statewide transportation investment. With local referendums an increasingly popular method to raise transportation funding in an era of federal uncertainty, the result has lessons for Missouri’s transportation interests and the country as a whole.

Like many states, Missouri has a clear infrastructure deficit. A legislatively-mandated citizens committee found the state needs an additional $600 million to $1 billion in investment per year. The problem is finding the money. Outside of federal funds, the state primarily relies on a 17.3 cent gasoline tax and local property taxes to fund transportation projects, plus location-specific revenue streams like a half-cent sales tax in St. Louis city and county. Yet with Missouri residents driving less in recent years—down 5 percent per capita between 2000 and 2012-—there is less money available to fund critical projects.

This vote offered one remedy. The statewide bump in sales tax would’ve generated upwards of $5 billion over the ten-year period. The new monies would go to 800 projects across Missouri, primarily for roadways. The governance was a similarly unequal split, with the state department of transportation directly controlling all but 10 percent of the new revenue.

And this is where the referendum’s problems become clear. While each of the state’s seven transportation districts managed their own project list, there was no guarantee local sales taxes would be spent on local projects. There were also legitimate questions whether a heightened focus on roadways made sense in the face of falling statewide driving. This was at the heart of the opposition argument, led by Missourians for Better Transportation Solutions.

In many ways, the Missouri results reflect what happened in a failed 2012 Atlanta referendum. That transportation package contained a hodgepodge of road and rail projects, barely increased connectivity across the sprawling metro region and couldn’t align local interest groups. Much like Missouri, Atlanta has clear transportation needs—but voters sensed the current plan wouldn’t do enough to adequately improve their commutes and livability.

As Missouri’s transportation leaders regroup, they’d be wise to follow the “economy-first” lesson of successful referendums in places like Los Angeles, Denver and Oklahoma City. The common thread in all three was a great job proving the need for greater infrastructure investment. But as my colleagues outlined in a recent report, they also captured how transportation could support industrial growth and metro-wide economic health. Americans have proven time and again they’ll pay for transportation projects, but they want to know what they’re getting and how it will benefit their communities.

In this sense, I’m heartened by a recent Kansas City Star editorial related to their failed streetcar vote the same day. Even with a failed vote, the metro area still needs a better infrastructure network. The key is for public, private and civic leaders to continue working with the public to determine which transportation investments will best support regional economic growth for decades to come.

Ballot measures may fail, but they’ll always provide lessons to improve the plans that will pass.

       

Municipal elections in Ferguson, Mo. are fast approaching. Amid the backdrop of the US Department of Justice identifying systemic racial bias by law enforcement and an over-reliance on traffic fines and court fees for revenue, there are great challenges to overcome.

It would be one thing if Ferguson was unique. It is not.

Ferguson (containing just over 21,000 people) is one of 91 jurisdictions in St. Louis County, each with its own governments to run, services to provide, and budgets to balance. This kind of governmental fragmentation, a product of state law, is repeated in many metropolitan areas across the country. Suburban fragmentation makes providing public services inefficient; complicates regional planning; and, according to a recent OECD report  diminishes economic growth, productivity, and social mobility.

The problems wrought by fragmentation have only been compounded in recent years by rapid economic and demographic changes. In the 2000s, suburbs in the nation’s largest metro areas became home to more poor residents and more African Americans than cities for the first time. Since 2000, the number of high-poverty neighborhoods (with poverty rates above 20 percent) more than doubled in the suburbs, while the number of majority-minority neighborhoods grew by almost half.

Many suburban communities dealing with rising poverty and new populations are ill-equipped to address growing and changing needs. That’s particularly true in places like Ferguson, where population and jobs have declined over the years. According to new Brookings research, residents of Ferguson lived near 14 percent fewer jobs in 2012 than they did in 2000. The resulting strains on local tax bases amount to one reason that local governments throughout the St. Louis region came to rely heavily on revenue-raising tactics like traffic fines and court fees.

Part of the mandate of the Ferguson Commission convened by Missouri Governor Nixon is to address the issue of governance, which will require confronting the region’s fragmented landscape. The commission can learn from states that have encouraged the sharing of services across municipalities or regions that are pursuing more collaborative approaches to respond to shared challenges around issues like housing, transportation, or community development.

But while these strategies can reduce the typically competitive approaches employed by neighboring suburbs, they still come up against deeper structural limitations that collaboration alone cannot overcome. The commission should consider a bolder response to the region’s fragmentation and fiscal challenges.

One model the commission can learn from is Minneapolis-St. Paul’s regional revenue sharing structure.

Established in 1971 by the Minnesota Fiscal Disparities Act, Minneapolis-St. Paul’s regional tax base sharing mechanism gives residents access to adequate resources for local services like public safety, irrespective of where they live. According to a study by Myron Orfield and Nicolas Wallace, the law has dramatically reduced tax disparities between high and low-income areas, allowing for reinvestment in the central cities and in fiscally challenged communities. And it has reduced the incentive for municipalities to “steal” revenue-generating land uses from neighbors (very frequently a waste of taxpayer dollars), promoting more integrated regional economic development.

The model works by mandating that each municipality within the designated seven-county area contribute 40 percent of its annual growth in commercial-industrial tax revenues to a regional pool. These resources are then redistributed to the participating municipalities based on local capacity. The mechanism helps equalize local available resources, filling local budget gaps where they exist, without undermining local autonomy.

For the vast majority of communities, the sharing program has meant lower taxes and better services. A 2012 study concluded that without the program, nearly 80 percent of the region’s 186 municipalities would have to raise taxes to maintain their current level of services. Revenue sharing has enabled the cities of Minneapolis and St. Paul to invest in higher quality public services like policing and education over the decades since the law was enacted. Many older suburbs bear less of the public burden for repairing old infrastructure, renewing public facilities, cleaning up brownfields, upgrading neighborhood housing, or dealing with abandoned properties. Even many developing bedroom suburbs have benefited from revenue sharing since these places often lack a strong commercial tax base, leading to shortages in infrastructure or education funding.

These results indicate that regional revenue sharing can enable at-risk suburbs like Ferguson to pay for basic services like public safety without relying excessively on fining their small citizenries.

The path to creating revenue sharing programs in our metropolitan areas runs through state legislatures. The Minnesota law was passed in the 1970s with “a unique coalition of central-city and suburban legislators working together to ensure the future economic vitality of the entire state.” The same case should be made today in Missouri to rural, urban, and suburban representatives alike. With better services and lower taxes for the vast majority of municipalities, the political math adds up.

As Orfield and Wallace put it, regions facing growing economic, social, and fiscal disparities have a choice: “allow the disparity to deepen or work to find solutions that can benefit all.” If we are serious about fixing Ferguson and other places like it, states across the country, starting with Missouri, must address the structural governance and fiscal flaws that lie at the heart of the matter. 

       

The Ferguson Commission—convened by Missouri Governor Jay Nixon in the aftermath of the police shooting death of Michael Brown—was given a daunting task. Its charge was not only to examine the underlying causes of “the social and economic conditions that impede progress, equality, and safety in the St. Louis region,” but also to issue a report “containing specific, practical policy recommendations for making the region a stronger, fairer place for everyone to live.”

Reflecting the magnitude of that charge, the Ferguson Commission’s final report, released on Monday, totals almost 200 pages and contains 189 calls to action that span a range of issue areas, from police and court reform, to creating higher-quality education and training opportunities, to improving access to jobs, transportation, and affordable housing.

The sweeping scope of the report’s recommendations is in proportion to the complexity of the shifting economic and demographic trends and the legacy of racial discrimination that helped set the stage for last summer’s events. Like many of its neighboring communities, and suburbs across the country, Ferguson has recently experienced rapid demographic and economic changes, transitioning from a largely white to a majority black community that has seen its poor population double since 2000.

The report’s authors emphasize that they want readers to “realize how interconnected all of these issues are.” (That’s one reason for the interactive online design—to allow users to navigate across related initiatives, even if they fall in different issue areas.) And the commission situates their calls to action within a regional framework that recognizes these issues operate at a scale broader than one neighborhood or suburb.

Even so, the challenge of municipal fragmentation looms large, both in the commission’s report and in any move towards implementing its recommendations. The report acknowledges that “the current state of municipal fragmentation is both a result of and a propagator of racial disparity” and that many of St. Louis’ suburbs “have problems with budgets because of their small size.” The commission calls for consolidation of the region’s 60 local police departments and 81 municipal courts, a move which could improve oversight and compliance and save the region millions of dollars a year.

But the commission stops short of addressing the municipalities themselves, many of which would continue to struggle with strapped budgets even after these reforms. Capping the share of municipal revenue generated by fines and fees, as the state legislature has done, could help curb abusive practices, but it doesn’t solve the underlying problem. Many of these small municipalities don’t have the resources they need to meet their current budget obligations, let alone pay for additional services and programs that increase access to opportunity (like those called for in the Ferguson Commission’s report).

There is no easy solution, but there are models for the region to consider that could ameliorate the negative effects of fragmentation (e.g., municipal collaboration, municipal consolidation, and regional revenue sharing and governance structures) and potentially ease the way for the broader slate of reforms recommended by the commission.

Presented with a Gordian knot of a challenge, the Ferguson Commission has put forward its framework for changing the status quo—what it believes “to be the best starting point, the beginning of a path toward a better St. Louis.” And the reality is that failing to act on the deep-seated challenges facing the region means struggling suburbs like Ferguson, and their residents, will only fall further behind.

       

While antibiotics are necessary and crucial for treating bacterial infections, their misuse over time has contributed to a rather alarming rate of antibiotic resistance, including the development of multidrug-resistance bacteria or “super bugs.” Misuse manifests throughout all corners of public and private life; from the doctor’s office when prescribed to treat viruses; to industrial agriculture, where they are used in abundance to prevent disease in livestock. New data from the World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) confirm that rising overuse of antibiotics has already become a major public health threat worldwide.

As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies. In fact, recent estimates suggest that every year more than 23,000 people die due to drug-resistant infections in the U.S., and many more suffer from complications caused by resistant pathogens. Further, infections will be harder to control. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.

Fundamental Approaches to Slowing Resistance

Incentivize appropriate use of antibiotics. Many patients and providers underestimate the risks of using antibiotics when they are not warranted, in part because these drugs often have rapid beneficial effects for those who truly need them.  In many parts of the world the perception that antibiotics carry few risks has been bolstered by their low costs and availability without a prescription or contact with a trained health care provider. Education efforts, stewardship programs, and the development of new clinical guidelines have shown some success in limiting antibiotic use, but these fixes are limited in scope and generally not perceived as cost-effective or sustainable. Broader efforts to incentivize appropriate use, coupled with economic incentives, may be more effective in changing the culture of antibiotic use. These options might include physician or hospital report cards that help impact patient provider selection, or bonuses based on standardized performance measures that can be used to report on success of promoting appropriate use.  While these might create additional costs, they would likely help control rates of drug resistant infections and outweigh the costs of treating them.

Reinvigorate the drug development pipeline with novel antibiotics. There has not been a new class of antibiotics discovered in almost three decades, and companies have largely left the infectious disease space for more stable and lucrative product lines, such as cancer and chronic disease. Antibiotics have historically been inexpensive and are typically used only for short periods of time, creating limited opportunities for return on investment. In addition, unlike cancer or heart disease treatments, antibiotics lose effectiveness over time, making them unattractive for investment. Once they are on the market, the push to limit use of certain antibiotics to the most severe infections can further constrict an already weak market.

Late last year, H.R. 3742, the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, was introduced and referred to the House Energy and Commerce Subcommittee on Health. If enacted, the ADAPT Act would create a streamlined development pathway to expedite the approval of antibiotics that treat limited patient populations with serious unmet medical needs. This could potentially reduce costs and development time for companies, thereby encouraging investment in this space. Regulators have indicated that they would also welcome the opportunity to evaluate benefits and risk for a more selective patient subpopulation if they could be confident the product would be used appropriately. The bill has received a great deal of support and would help address a critical public health need.

Advance new economic incentives to remedy market failure. Innovative changes to pharmaceutical regulation, research and development (R&D), and reimbursement are necessary to alleviate the market failure for antibacterial drugs. A major challenge, particularly within a fee-for-service or volume-based reimbursement system, is providing economic incentives that promote investment in drug development without encouraging overuse.  A number of public and private stakeholders, including the Engelberg Center for Health Care Reform and Chatham House’s Centre on Global Health Security Working Group on Antimicrobial Resistance, are exploring alternative reimbursement mechanisms that  “de-link” revenue from the volume of antibiotics sold. Such a mechanism, combined with further measures to stimulate innovation, could create a stable incentive structure to support R&D.

Improve tracking and monitoring of resistance in the outpatient setting. There is increasing concern about much less rigorous surveillance capabilities in the outpatient setting, where drug-resistant infections are also on the rise. Policymakers should consider new incentives for providers and insurers to encourage a coordinated approach for tracking inpatient and outpatient resistance data. The ADAPT Act, mentioned above, also seeks to enhance monitoring of antibiotic utilization and resistance patterns. Health insurance companies can leverage resistance-related data linked to health care claims, while providers can capture lab results in electronic health records. Ultimately, this data could be linked to health and economic outcomes at the state, federal, and international levels, and provide a more comprehensive population-based understanding of the impact and spread of resistance. Current examples include the Food and Drug Administration’s (FDA) Sentinel Initiative and the Patient-Centered Outcomes Research Institute’s PCORnet initiative. 

Antibiotic resistance is an urgent and persistent threat. As such, patients and providers will continue to require new antibiotics as older drugs are forced into retirement by resistant pathogens. Stewardship efforts will remain critical in the absence of game-changing therapies that parry resistance mechanisms. Lastly, a coordinated surveillance approach that involves diverse stakeholder groups is needed to understand the health and economic consequences of drug resistance, and to inform antibiotic development and stewardship efforts.

       

Antimicrobial resistance is one of the most significant threats to public health globally. It will worsen in the coming decades without concerted efforts to spur the development of new antibiotics, while ensuring the appropriate use of existing antibiotics. Antimicrobial therapy is essential for treating and preventing bacterial infections, some of which can be life-threatening and acquired as a result of
critical medical interventions, including surgery, chemotherapy and dialysis. However, the international rise in antimicrobial resistance has weakened our antibiotic armamentarium and multi-resistant bacteria now cause over 150,000 deaths annually in hospitals around the world (WHO, 2013). Unfortunately, the evolution of drug-resistant pathogens is unavoidable due to random genetic changes in the pathogens that can render antibiotics ineffective. While antibiotic therapy can succeed in killing susceptible pathogens, it also inadvertently selects for organisms that are resistant. Because each exposure to antibiotics contributes to this process, efforts to restrict antibiotic usage only slow the development of resistance. Ultimately, innovative antimicrobial drugs with diverse mechanisms of action will be needed to treat emerging resistant pathogens.

Combating resistance

Inappropriate use of antibiotics contributes significantly to the acceleration of resistance. Needlessly exposing patients to antibiotics (for example, for viral or mild infections likely to resolve on their own), the use of overly broad-spectrum antibiotics and suboptimal doses of appropriate therapy hasten the evolution of resistant pathogens. While affordable, rapid and accurate point-of-care diagnostics are essential for determining appropriate therapy for many bacterial diseases, routine clinical use will be limited if the tests are too expensive or not accessible during routine clinical encounters. In the absence of a clear diagnostic result, many health care providers prescribe empiric broadspectrum therapy without knowing exactly what they are treating. Although inappropriate use is widespread in many parts of the world, where antibiotics are available without a prescription or oversight by a health care provider or stewardship team, overuse abounds even where antibiotic prescribing is more tightly regulated.

Studies conducted in the USA indicate that around 258 million courses of antibiotics are dispensed annually for outpatient use (Hicks, 2013) and up to 75 per cent of ambulatory antibiotic prescriptions are for the treatment of common respiratory infections, which may or may not be bacterial in origin (McCaig,1995). Recent evidence suggests that over half of these prescriptions are not medically indicated. For example, 60 per cent of US adults with a sore throat receive an antibiotic prescription after visiting a primary care practice or emergency department, despite the fact that only ten per cent require treatment with antibiotics. This is particularly troubling given the availability of rapid tests that can detect Group A Streptococcus, the bacteria responsible for the ten per cent of cases that require antibiotic treatment.

The overuse of antibiotics has been driven largely by their low cost and clinical effectiveness, which has led many patients to view them as cure-alls with few risks. This perception is reinforced by the fact that antibiotics are curative in nature and used for short durations. However, the clinical effectiveness of these drugs decreases over time, as resistance naturally increases, and this process is accelerated with inappropriate use. Moreover, there are numerous consequences associated with the use of antibiotics, including over 140,000 emergency department visits yearly in the USA for adverse incidents (mostly allergic reactions; CDC, 2013a). In addition, antibiotics can eliminate protective bacteria in the gut,
leaving patients vulnerable to infection with Clostridium difficile, which causes diarrhoeal illness that results in 14,000 deaths every year in the USA (CDC, 2013b). It is estimated that antimicrobial resistance costs the US health care system over US$20 billion annually in excess care and an additional $35 billion in lost productivity (Roberts et al., 2009).

The inappropriate use of antimicrobial drugs is particularly concerning because highly resistant pathogens can easily cross national borders and rapidly spread around the globe. In recent years, strains of highly drug-resistant tuberculosis, carbapenem-resistant Enterobacteriaceae and other resistant pathogens have spread outside their countries of origin within several years of their detection. Because resistant bacteria are unlikely to stay isolated, stewardship efforts must be improved globally and international attention is needed to improve surveillance of emerging pathogens and resistance patterns.

A major challenge for clinicians and regulators will be to find stewardship interventions that can be scaled-up and involve multiple stakeholders, including providers, drug manufacturers, health care purchasers (insurers), governments and patients themselves. Such interventions should include practical and costeffective educational programmes targeted towards providers and patients that shift expectations for antibiotic prescriptions to a mutual understanding of the benefits and risks of these drugs.

Educational programmes alone, however, will not be sufficient to lower prescribing rates to recommended levels. Pushing down the inappropriate use of antibiotics also warrants stronger mechanisms that leverage the critical relationships between the stakeholders. For example, health care purchasers can play an important role by using financial disincentives to align prescribing habits with clinical guidelines that are developed by infectious disease specialists in the private and public sectors. This type of approach has the potential to be effective because it includes multiple stakeholders that share responsibility for the appropriate use of antibiotics and, ultimately, patient care.

Key obstacles to antibiotic development

The continual natural selection for resistant pathogens despite efforts to limit antibiotic use underscores the need for new antibiotics with novel mechanisms of action. To date, antimicrobial drug innovation and development have not kept pace with resistance. The number of approved new molecular entities (NME) to treat systemic infections has been steadily declining for decades (see Figure 1). Some infections are not susceptible to any antibiotic and in some cases the only effective drugs may cause serious side effects, or be contra-indicated due to a patient’s allergies or comorbidities (e.g. renal failure). There is significant unmet medical need for therapies that treat serious and life-threatening bacterial diseases caused by resistant pathogens, as well as some less serious infections where there are few treatment alternatives available (e.g. gonorrhoea).

Antibiotic development for these areas of unmet medical need has been sidelined by a number of scientific, regulatory and economic obstacles. While the costs and complexity of any clinical trial necessary for approval by drug regulators can be substantial, in part due to the large study samples needed to demonstrate safety and efficacy, the infectious disease space faces a number of unique clinical challenges. Patients with serious drug-resistant infections may be in need of urgent antibiotic therapy, which can preclude efficient consent and timely trial enrolment procedures; prior therapy can also confound treatment effects if the patient is later enrolled in a trial for an experimental drug. In addition, many patients with these pathogens are likely to have a history of longterm exposure to the health care setting and may have significant comorbidities that render them less likely to meet inclusion criteria for clinical trials.

Emerging infections for which there are few or no treatment options also tend to be relatively rare. This makes it difficult to conduct adequate and well-controlled trials, which typically enrol large numbers of patients. However, clinical drug development can take many years and waiting until such infections are more common is not feasible. Another issue is that it may also not be possible to conclusively identify the pathogen and its susceptibility at the point of enrolment due to the lack of rapid diagnostic technologies. Ultimately, uncertainty about the aetiology of an infection may necessitate trials with larger numbers of patients in order to achieve sufficient statistical power, further compounding the challenge of enrolling seriously ill infectious disease patients in the first place.

The need to conduct large trials involving acutely ill patients that are difficult to identify can make antibiotic development prohibitively expensive for drug developers, especially given that antibiotics are relatively inexpensive and offer limited opportunities to generate returns. Unlike treatments for chronic diseases, antibiotic therapy tends to last no longer than a few weeks, and these drugs lose efficacy over time as resistance develops, leading to diminishing returns. The decline in antimicrobial drug innovation is largely due to these economic obstacles, which have led developers to seek more durable and profitable markets (e.g. cancer or chronic disease) in recent decades. There are only a handful of companies currently in the market and the development pipeline is very thin. Changes to research infrastructure, drug reimbursement and regulation are all potentially needed to revitalise antibiotic innovation.

Opportunities to streamline innovative antibiotic development

In the USA, several proposals have been made to expedite the development and regulatory review of antibiotics while ensuring that safety and efficacy requirements are met. In 2012, the US President’s Council of Advisors on Science and Technology recommended that the US Food and Drug Administration (FDA) create a ‘special medical use’ (SMU) designation for the review of drugs for subpopulations of patients with unmet medical need. Drug sponsors would be required to demonstrate that clinical trials in a larger patient population would need much more time to complete or not be feasible. A drug approved under the SMU designation could be studied in subgroups of patients that are critically ill, as opposed to the broader population, under the condition that the drug’s indication would be limited to the narrow study population. The SMU designation was discussed at an expert workshop convened by the Brookings Institution in August 2013. Many participants at the meeting agreed that there is a pressing need to develop novel antibiotics and that such a limited-use pathway could support the appropriate use of newly approved drugs.

The Infectious Diseases Society of America developed a related drug development pathway called the Limited Population Antibacterial Drug (LPAD) approval mechanism. The LPAD approach calls for smaller, faster and less costly clinical trials to study antibiotics that treat resistant bacteria that cause serious infections. Both the SMU and LPAD approaches would allow drug developers to demonstrate product safety and efficacy in smaller patient subpopulations and provide regulatory clarity about acceptable benefit–risk profiles for antibiotics that treat serious bacterial diseases. The US House of Representatives is currently considering a bill¹ that incorporates these concepts.

A recent proposal from the drug manufacturer industry for streamlined antibiotic development is to establish a tiered regulatory framework to assess narrow-spectrum antibiotics (e.g. active versus a specific bacterial genus and species or a group of related bacteria) that target resistant pathogens that pose the greatest threat to public health (Rex, 2013: pp. 269–275). This is termed a ‘pathogen-focused’ approach because the level of clinical evidence required for approval would be correlated with the threat level and feasibility of studying a specific pathogen or group of pathogens. The pathogen-focused approach was also highlighted at a recent workshop at the Brookings Institution (Brookings Institution, 2014). Some experts felt that the approach is promising but emphasised that each pathogen and experimental drug is unique and that it could be challenging to place them in a particular tier of a regulatory framework. Given that pathogen-focused drugs would likely be marketed internationally, it will be important for drug sponsors to have regular interactions and multiple levels of discussion with regulators to find areas of agreement that would facilitate the approval of these drugs.

Antibiotics with very narrow indications could potentially support stewardship as well by limiting use to the most seriously ill patients. Safe use of these drugs would likely depend on diagnostics, significant provider education, labelling about the benefits and risks of the product, and the scope of clinical evidence behind its approval. Because these antibiotics would be used in a very limited manner, changes would potentially need to be made to how they are priced and reimbursed to ensure that companies are still able to generate returns on their investment. That said, a more focused drug development programme with regulatory clarity could greatly increase their odds of success and, combined with appropriate pricing and safe use provisions, could succeed in incentivising antimicrobial drug development for emerging infections.

Endnote
1 H.R. 3742 – Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013.

References
Barnett, M. L. and Linder, J. A., 2014. ‘Antibiotic prescribing to adults with sore throat in the United States, 1997–2010’. JAMA Internal Medicine, 174(1), pp. 138–140.

Brookings Institution, 2013. Special Medical Use: Limited Use for Drugs Developed in an Expedited Manner to Meet an UnmetMedical Need. Brookings Institution. Available at: www.brookings.edu/events/2013/08/01-special-medical-use

Brookings Institution, 2014. Modernizing Antibacterial Drug Development and Promoting Stewardship. Available at: www.brookings.edu/events/2014/02/07-modernizing-antibacterialdrug-development [Accessed 11 March 2014].

CDC, 2013a. Antibiotic resistance threats in the United States,2013 [PDF] CDC. Available at: www.cdc.gov/drugresistance/threatreport-2013/pdf/ar-threats-2013-508.pdf#page=25 [Accessed 16 January 2014].

CDC, 2013b. Clostridium difficile. Antibiotic resistance threats in the United States, 2013 [PDF] CDC. Available at: www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=50 [Accessed 16 January 2014].

Hicks, L. A. et al., 2013. ‘US Outpatient Antibiotic Prescribing, 2010’. New England Journal of Medicine, 368(15), pp. 1461–1463.
Infectious Disease Society of America, 2012.

Limited Population Antibacterial Drug (LPAD) Approval Mechanism. Available at: www.idsociety.org/uploadedFiles/IDSA/News_and_Publications/IDSA_News_Releases/2012/LPAD%20one%20pager.pdf [Accessed 5 March 2014].

Infectious Disease Society of America, 2012. Limited Population Antibacterial Drug (LPAD) Approval Mechanism [PDF] Infectious
Disease Society of America. Available at: www.idsociety.org/uploadedFiles/IDSA/News_and_Publications/IDSA_News_Releases/2012/LPAD%20one%20pager.pdf  [Accessed 18 January 2013].

Kumarasamy, K. K., Toleman, M. A., Walsh, T. R. et al.,2010. ‘Emergence of a new antibiotic resistance mechanism in India,
Pakistan, and the UK: A molecular, biological, and epidemiological study’. Lancet Infectious Diseases, 10(9), pp. 597–602.

McCaig, L. F. and Hughes, J. M., 1995. ‘Trends in antimicrobial drug prescribing among office-based physicians in the United
States’. Journal of the American Medical Association, 273(3), pp. 214–219.

President’s Council of Advisors on Science and Technology, 2012. Report to the President on Propelling Innovation in Drug
Discovery, Development and Evaluation. Available at:www.whitehouse.gov/sites/default/files/microsites/ostp/pcast-fdafinal.pdf    [Accessed 5 March 2014].

Rex, J. H. et al., 2013. ‘A comprehensive regulatory framework to address the unmet need for new antibacterial treatments’. Lancet Infectious Diseases, 13(3), pp. 269–275.

Roberts, R. R., Hota, B., Ahmad, I. et al., 2009. ‘Hospital and societal costs of antimicrobial – Resistant infections in a Chicago
teaching hospital: Implications for antibiotic stewardship’. Clinical Infectious Diseases, 49(8), pp. 1175–1184.

WHO (World Health Organization), 2010. Fact Sheet: Rational Use of Medicines [webpage] WHO. Available at:
www.who.int/mediacentre/factsheets/fs338/en [Accessed 28 February 2014].

WHO (World Health Organization), 2013. Antimicrobial Drug Resistance [PDF] WHO. Available at: http://apps.who.int/gb/ebwha/pdf_files/EB134/B134_37-en.pdf [Accessed 6 March 2014].

WHO (World Health Organization), 2013. Notified MDR-TB cases (number per 100,000 population), 2005–12. WHO. Available at:
https://extranet.who.int/sree/Reports?op=vs&path=/WHO_HQ_Reports/G2/PROD/EXT/MDRTB_Indicators_map [Accessed 28 February 2014].

Downloads

• Antibiotics Stewardship and Innovation

       

After years of warnings from the public health community about the growing threat of antibiotic resistance, yesterday the White House announced a national strategy to combat the growing problem of antibiotic resistance within the U.S. and abroad. The administration’s commitment represents an important step forward, as antibiotic-resistant infections are responsible for 23,000 deaths annually, and cost over $50 billion in excess health spending and lost productivity.  The administration’s National Strategy on Combating Antibiotic-Resistant Bacteria includes incentives for developing new drugs, more rigorous stewardship of existing drugs, and better surveillance of antibiotic use and the pathogens that are resistant to them.  President Obama also issued an Executive Order that establishes an interagency Task Force and a non-governmental Presidential Advisory Council that will focus on broad-based strategies for slowing the emergence and spread of resistant infections. 

While antibiotics are crucial for treating bacterial infections, their misuse over time has contributed to a rather alarming rate of antibiotic resistance, including the development of multidrug-resistance bacteria or “super bugs.” Misuse manifests throughout all corners of public and private life; from the doctor’s office when prescribed to treat viruses; to industrial agriculture, where they are used in abundance to promote growth in livestock. New data from the World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) confirm that rising overuse of antibiotics has already become a major public health threat worldwide.

The administration’s announcement included a report from the President’s Council of Advisors on Science and Technology (PCAST) titled “Combatting Antibiotic Resistance,” which includes recommendations developed by a range of experts to help control antibiotic resistance. In addition, they outline a $20 million prize to reward the development of a new rapid, point-of-care diagnostic test. Such tests help health care providers choose the right antibiotics for their patients and streamline drug development by making it easier to identify and treat patients in clinical trials.  

The Need for Financial Incentives and Better Reimbursement

A highlight of the PCAST report is its recommendations on economic incentives to bring drug manufacturers back into the antibiotics market. Innovative changes to pharmaceutical regulation and research and development (R&D) will be welcomed by many in the health care community, but financial incentives and better reimbursement are necessary to alleviate the market failure for antibacterial drugs. A major challenge, particularly within a fee-for-service or volume-based reimbursement system is providing economic incentives that promote investment in drug development without encouraging overuse.

A number of public and private stakeholders, including the Engelberg Center for Health Care Reform and Chatham House’s Centre on Global Health Security Working Group on Antimicrobial Resistance, are exploring alternative reimbursement mechanisms that “de-link” revenue from the volume of antibiotics sold. Such a mechanism, combined with further measures to stimulate innovation, could create a stable incentive structure to support R&D. Further, legislative proposals under consideration by Congress to reinvigorate the antibiotic pipeline, including the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, could complement the White House’s efforts and help turn the tide on antibiotic resistance. Spurring the development of new antibiotics is critical because resistance will continue to develop even if health care providers and health systems can find ways to prevent the misuse of these drugs.

       

Downloads

• Table of Contents
• Chapter One

Ordering Information:

• {CD2E3D28-0096-4D03-B2DE-6567EB62AD1E}, 9780815727415, $32.00 Add to Cart
• {9ABF977A-E4A6-41C8-B030-0FD655E07DBF}, 9780815725794, $26.00 Add to Cart

      

For more than a decade, government assistance to Afghanistan, Iraq, and Pakistan (the so-called AIP countries) has dominated United States aid efforts. And as the examples below illustrate, American institutions and mindsets found it extraordinarily difficult to adjust to aid in unsafe places. Cameron Munter draws on his experience as the head of the Provincial Reconstruction Team (PRT) in Mosul, Iraq in 2006 and as ambassador of the United States to Pakistan in Islamabad in 2011, with a description of U.S. reconstruction and state-building from which we may find lessons to consider in the future.

In 2006, when he went to Mosul as the first leader of the first PRT, the American civilian and military authorities in Baghdad painfully learned that the post-conflict situation would not correct itself. The undergrowth of our own bureaucratic structure prevented us from gaining a sophisticated understanding of our surroundings. Members of the PRT came and left after a few months, without passing on their hard-obtained knowledge. Local authorities quickly realized that the PRT had neither the money nor the firepower of the brigade commanders. And most of all, the guiding principles in place were still the creation of a kind of constitutional framework where political leaders, police, courts, businesspeople, and citizens would have institutions familiar to Americans, institutions that would work as we knew how to make them work.

Munter arrived in Pakistan at a time of great hope for U.S.-Pakistani relations. In 2011, in a series of meetings with the U.S. deputy secretary of state for resources and the head of USAID, Kerry-Lugar-Berman priorities took center stage: education, energy efficiency, job creation, special projects in the tribal areas, and public health. It is one thing to define a task and quite another to apply it to the specific context of a country in which security considerations prevent most USAID workers from even laying eyes on their projects. Overall, it seems the United States was much better at measuring its commitment to a prosperous, democratic Pakistan at peace with its neighbors by counting how much it spent and how fast rather than creating the proper relationship with those on the ground with whom it might have partnered.

Under these circumstances, what are lessons learned? When security is shaky, assistance is difficult. It may be that in situations like the AIP countries, we only have the capacity to engage in humanitarian aid and immediate reconstruction. If that is so, then the whole question of engagement in dangerous places is reopened: In a military setting, with military tasks, and thus a military system of organization, can civilian assistance succeed? Money spent is the way we measure commitment in such a setting, and that doesn’t bring the results we need.

Downloads

• Imagining assistance: Tales from the American aid experience in Iraq in 2006 and Pakistan in 2011

      

We are kicking off the new Millions Learning video series with a spotlight on Teach For All, one of the 14 case studies examined in the Millions Learning report. Teach For All is an international network of local, independent partner country organizations dedicated to improving educational opportunities for children and youth around the globe. From China to Bulgaria to Peru to Ghana, each partner organization recruits and trains recent top-performing graduates and professionals to teach in their country’s underserved communities for two years, with the ultimate goal of developing a cadre of education leaders, both inside and outside of the classroom.

In this video, Wendy Kopp, CEO and co-founder of Teach For All, discusses Teach For All’s unique approach to building a pipeline of future “learning leaders and champions” and the role that a supportive policy environment plays in enabling this process. Kopp then explains how Teach For All grew from the original Teach For America and Teach First in the United Kingdom to an international network of 40 partner countries, sharing her own lessons learned along the way.

To learn more about Millions Learning, please visit our interactive report, Millions Learning: Scaling up quality education in developing countries, and/or visit our webpage.

Video

• Getting millions to learn: Interview with Wendy Kopp of Teach For All

       

Extreme poverty around the world has decreased from around 2 billion people in 1990 living under $2 per day to 700 million today. Further, nine out of 10 children are now enrolled in primary schools, an increase over the last 15 years. Progress in both areas since 2000 has been part of the United Nations Millennium Development Goals, which set targets for reducing extreme poverty in eight areas, and which were the guiding principles for global development from 2000 to 2015. Today, the global community, through the UN, has adopted 17 Sustainable Development Goals to continue these poverty reduction efforts. 

In this new episode of Intersections podcast, host Adrianna Pita engages Brookings scholars Laurence Chandy and Rebecca Winthrop in a discussion of how digital technologies can be harnessed to bring poverty reduction and education to the most marginalized populations.

Listen:

Chandy, a fellow in the Global Economy and Development program at Brookings, says that the trends in getting people digitally connected "are progressing at such speed that they’re starting to reach some of the poorest people in the world. Digital technology is changing what it means to be poor because it’s bringing poor people out of the margins.”

Winthrop, a senior fellow and director of the Center for Universal Education at Brookings, says that "I think [education] access is crucial. And I do think that’s almost the first wave because without it we could work on all the ed tech—fabulous apps, great language translated content—but if you do not have the access it’s not going to reach the most marginalized."

Listen to this episode above; subscribe on iTunes; and find more episodes on our website.

Chandy was a guest on the Brookings Cafeteria Podcast in 2013; Winthrop has been a guest on the Cafeteria a few times to discuss global education topics, including: access plus education; investing in girls' education; and getting millions learning in the developing world.

       

In 2015 the international community agreed on a set of ambitious sustainable development goals (SDGs) for the global society, to be achieved by 2030. One of the lessons that the implementation of the Millennium Development Goals (MDG s) has highlighted is the importance of a systematic approach to identify and sequence development interventions—policies, programs, and projects—to achieve such goals at a meaningful scale. The Chinese approach to development, which consists of identifying a problem and long-term goal, testing alternative solutions, and then implementing those that are promising in a sustained manner, learning and adapting as one proceeds—Deng Xiaoping’s “crossing the river by feeling the stones”—is an approach that holds promise for successful achievement of the SDGs.

Having observed the Chinese way, then World Bank Group President James Wolfensohn in 2004, together with the Chinese government, convened a major international conference in Shanghai on scaling up successful development interventions, and in 2005 the World Bank Group (WBG ) published the results of the conference, including an assessment of the Chinese approach. (Moreno-Dodson 2005). Some ten years later, the WBG once again is addressing the question of how to support scaling up of successful development interventions, at a time when the challenge and opportunity of scaling up have become a widely recognized issue for many development institutions and experts.

Since traditional private and public service providers frequently do not reach the poorest people in developing countries, social enterprises can play an important role in providing key services to those at the “base of the pyramid.”

In parallel with the recognition that scaling up matters, the development community is now also focusing on social enterprises (SEs), a new set of actors falling between the traditionally recognized public and private sectors. We adopt here the World Bank’s definition of “social enterprises” as a social-mission-led organization that provides sustainable services to Base of the Pyramid (BoP) populations. This is broadly in line with other existing definitions for the sector and reflects the World Bank’s primary interest in social enterprises as a mechanism for supporting service delivery for the poor. Although social enterprises can adopt various organizational forms—business, nongovernmental organizations (NGOs), and community-based organizations are all forms commonly adopted by social enterprises—they differ from private providers principally by combining three features: operating with a social purpose, adhering to business principles, and aiming for financial sustainability. Since traditional private and public service providers frequently do not reach the poorest people in developing countries, social enterprises can play an important role in providing key services to those at the “base of the pyramid.” (Figure 1)

Figure 1. Role of SE sector in public service provision

Social enterprises often start at the initiative of a visionary entrepreneur who sees a significant social need, whether in education, health, sanitation, or microfinance, and who responds by developing an innovative way to address the perceived need, usually by setting up an NGO, or a for-profit enterprise. Social enterprises and their innovations generally start small. When successful, they face an important challenge: how to expand their operations and innovations to meet the social need at a larger scale. 

Development partner organizations—donors, for short—have recognized the contribution that social enterprises can make to find and implement innovative ways to meet the social service needs of people at the base of the pyramid, and they have started to explore how they can support social enterprises in responding to these needs at a meaningful scale. 

The purpose of this paper is to present a menu of approaches for addressing the challenge of scaling up social enterprise innovations, based on a review of the literature on scaling up and on social enterprises. The paper does not aim to offer specific recommendations for entrepreneurs or blueprints and guidelines for the development agencies. The range of settings, problems, and solutions is too wide to permit that. Rather, the paper provides an overview of ways to think about and approach the scaling up of social enterprise innovations. Where possible, the paper also refers to specific tools that can be helpful in implementing the proposed approaches. 

Note that we talk about scaling up social enterprise innovations, not about social enterprises. This is because it is the innovations and how they are scaled up that matter. An innovation may be scaled up by the social enterprise where it originated, by handoff to a public agency for implementation at a larger scale, or by other private enterprises, small or large. 

This paper is structured in three parts: Part I presents a general approach to scaling up development interventions. This helps establish basic definitions and concepts. Part II considers approaches for the scaling up of social enterprise innovations. Part III provides a summary of the main conclusions and lessons from experience. A postscript draws out implications for external aid donors. Examples from actual practice are used to exemplify the approaches and are summarized in Annex boxes.

Downloads

• Download the full paper (PDF)