*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.

 

      

Event Information

The Metropolitan Policy Program at Brookings, hosted The Political Geography of America's Purple States: Five Trends That Will Decide the 2008 Election, a briefing on a new series of reports on the political demography of "purple" states in the 2008 election.

Purple states-or states where the current balance of political forces does not decisively favor one party or the other-will play an undeniably pivotal role in the upcoming election and include: Virginia and Florida in the South; the Intermountain West states of Colorado, New Mexico, Nevada, and Arizona; Michigan, Missouri, and Ohio in the Heartland; and Pennsylvania.

On October 10, 2008 at the National Press Club in Washington DC, authors William Frey and Ruy Teixeira highlighted the political and demographic trends in these 10 battleground states, focusing not only on their role in the 2008 election, but their position as toss-ups in years to come.

The session opened with an overview of the demographic shifts shaping all the contested states studied, and evolved into a detailed presentation of the trends that are testing and reshaping the balance of their voting populations, focusing particularly on five trends that Frey and Teixeira believe will decide the 2008 election. Feedback from James Barnes, political correspondent for the National Journal, helped shape the conversation.

Event Materials

• Agenda
• Presentation
• Biographies

       

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 »

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Nearly a week after the death of 18 year-old Michael Brown in Ferguson, Mo., protests continue in the 21,000-person suburban community on St. Louis’ north side and around the nation.

Amid the social media and news coverage of the community’s response to the police shooting of the unarmed teenager, a picture of Ferguson and its history has emerged.

The New York Times and others have described the deep-seated racial tensions and inequalities that have long plagued the St. Louis region, as well as the dramatic demographic transformation of Ferguson from a largely white suburban enclave (it was 85 percent white as recently as 1980) to a predominantly black community (it was 67 percent black by 2008-2012).

But Ferguson has also been home to dramatic economic changes in recent years. The city’s unemployment rate rose from roughly 7 percent in 2000 to over 13 percent in 2010-12. For those residents who were employed, inflation-adjusted average earnings fell by one-third. The number of households using federal Housing Choice Vouchers climbed from roughly 300 in 2000 to more than 800 by the end of the decade.

Amid these changes, poverty skyrocketed. Between 2000 and 2010-2012, Ferguson’s poor population doubled. By the end of that period, roughly one in four residents lived below the federal poverty line ($23,492 for a family of four in 2012), and 44 percent fell below twice that level.

These changes affected neighborhoods throughout Ferguson. At the start of the 2000s, the five census tracts that fall within Ferguson’s border registered poverty rates ranging between 4 and 16 percent. However, by 2008-2012 almost all of Ferguson’s neighborhoods had poverty rates at or above the 20 percent threshold at which the negative effects of concentrated poverty begin to emerge. (One Ferguson tract had a poverty rate of 13.1 percent in 2008-2012, while the remaining tracts fell between 19.8 and 33.3 percent.)

Census Tract-Level Poverty Rates in St. Louis County, 2000

Census Tract-Level Poverty Rates in St. Louis County, 2008-2012

As dramatic as the growth in economic disadvantage has been in this community, Ferguson is not alone.

Within the nation’s 100 largest metro areas, the number of suburban neighborhoods where more than 20 percent of residents live below the federal poverty line more than doubled between 2000 and 2008-2012. Almost every major metro area saw suburban poverty not only grow during the 2000s but also become more concentrated in high-poverty neighborhoods. By 2008-2012, 38 percent of poor residents in the suburbs lived in neighborhoods with poverty rates of 20 percent or higher. For poor black residents in those communities, the figure was 53 percent.

Like Ferguson, many of these changing suburban communities are home to out-of-step power structures, where the leadership class, including the police force, does not reflect the rapid demographic changes that have reshaped these places.

Suburban areas with growing poverty are also frequently characterized by many small, fragmented municipalities; Ferguson is just one of 91 jurisdictions in St. Louis County. This often translates into inadequate resources and capacity to respond to growing needs and can complicate efforts to connect residents with economic opportunities that offer a path out of poverty.

And as concentrated poverty climbs in communities like Ferguson, they find themselves especially ill-equipped to deal with impacts such as poorer education and health outcomes, and higher crime rates. In an article for Salon, Brittney Cooper writes about the outpouring of anger from the community, “Violence is the effect, not the cause of the concentrated poverty that locks that many poor people up together with no conceivable way out and no productive way to channel their rage at having an existence that is adjacent to the American dream.” 

None of this means that there are 1,000 Fergusons-in-waiting, but it should underscore the fact that there are a growing number of communities across the country facing similar, if quieter, deep challenges every day.

A previous version of this post misstated the Ferguson unemployment rate in 2000. It has since been corrected.

       

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.

       

Event Information

As the prevalence of drug-resistant bacteria continues to rise, there is a pressing need for new drugs to combat infections by these organisms. However, research and development in this area has slowed, creating a public health concern that we lack the drugs necessary to treat multi-drug resistant infections. Challenges to promoting antibacterial drug development may be scientific, methodological, regulatory, or economic in nature.

On Wednesday, May 9, 2012, the Engelberg Center for Health Care Reform convened an expert workshop, "Facilitating Antibacterial Drug Development,” that explored solutions to methodological and regulatory challenges that could make the development process more efficient. This meeting brought together diverse multi-stakeholder experts—including medical product developers, health care professionals, researchers, patient advocates, representatives of the U.S. Food and Drug Administration, and other groups—to explore the following issues:

• Existing paradigms for antibacterial drug development;
• Novel approaches to further antibacterial drug development, including use of pharmacokinetics and pharmacodynamics, Bayesian methods, innovative clinical trial designs, new data sources, alternate clinical endpoints, and new regulatory tools; and
• Short- and long-term opportunities to advance the antibacterial drug development enterprise through collaboration among stakeholders, improved regulatory science, and other means.

For more information on FDA’s Antibacterial Drug Development Task Force, click here.

Event Materials

• May 9 Event Summary
• Antibacterial Drug Development Participant List
• Facilitating Antibacterial Drug Development Agenda
• Facilitating Antibacterial Drug Development Discussion Guide
• Panel 1 Brad Spellberg Presentation
• Panel 1 George Talbot Presentation
• Panel 1 John Powers Presentation
• Panel 1 Thomas Fleming Presentation
• Panel 2 George Drusano Presentation
• Panel 2 Scott Emerson Presentation
• Panel 3 Daniel Benjamin Presentation
• Panel 3 Edward Cox Presentation
• Panel 3 John Rex examples
• Panel 3 John Rex Presentation
• Panel 4 Helen Boucher Presentation

       

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].

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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.

       

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Antibacterial drugs are a critical component of the nation’s public health armamentarium, and have saved millions of lives by preventing and treating a range of bacterial infections. However, antibacterial drug development has been hampered by challenges unique to the antibacterial drug market, which have stifled innovation and left patients and providers with fewer options to treat increasingly resistant infections. One consequence of the dwindling antibacterial drug pipeline has been a reduction in effective oral antibacterial drug treatment options, which are particularly important in the ambulatory and transitional care contexts. Recent proposals to re-invigorate the antibacterial pipeline are geared towards serious infections treated in the inpatient setting, which may lead to a greater focus on intravenous therapies. However, addressing both current and future needs in the infectious diseases space will require a balanced mix of both oral and parenteral antibacterial drugs.

In cooperation with the U.S. Food and Drug Administration (FDA), the Engelberg Center for Health Care Reform at Brookings held an expert workshop on November 20, 2014, to identify the most promising strategies to support oral antibacterial drug development. Participating stakeholders included experts from the drug development and health care industries, the clinical community, government, and academia. These stakeholders shared their insights on potential regulatory, scientific, and economic strategies to reinvigorate the oral antibacterial drug pipeline. 

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On February 29, the Africa Security Initiative at Brookings held a discussion on Nigeria, nine months after the inauguration of President Muhammadu Buhari, the country’s first president to take office in a peaceful transition of power from one party to another. President Buhari, who previously ruled Nigeria in the mid-1980s after a military coup, inherits a country facing burgeoning population, low oil prices for its top export, and the Boko Haram extremist insurgency in the northeast. Buhari also inherited other problems such as unrest in the country’s delta and southeast regions, and a culture of corruption and human rights abuse and impunity throughout much of the country’s armed forces and police.

Less than a year into his presidency, Buhari has made progress in reforming the military, sacking some military leaders and injecting a bit more energy into the counter-Boko Haram campaign. But has he chosen the right priorities for Nigeria and fundamentally headed in the right direction, and what has been the impact on civilians, particularly in the northeastern part of the country? What additional role, if any, could the United States and the broader international community play to support additional reform?

We convened a panel to discuss these subjects. The panel, made up of independent experts with deep knowledge ranging from human rights to economics and finance to broader political and security sector reform, included EJ Hogendoorn of the International Crisis Group, Madeline Rose from Mercy Corps, Mausi Segun of Human Rights Watch, and Amadou Sy from The Brookings Institution. Senior Fellow Michael O’Hanlon, who directs the Africa Security Initiative at Brookings, moderated the discussion.

 

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• Examining the current state of Nigeria

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After decades of neglect, Latin American governments are increasingly focusing on urban slums. What often spurs their policy interventions is a desire to counter violent criminality leaking out from the poor marginalized slums controlled by gangs into the city centers the better-off residents want to keep safe. But tackling the socioeconomic dynamics of slums -- the trap of poverty, discrimination, lack of public goods and social services, and rule by nonstate actors -- is not only complex, but also costly. Governments, elites, and middle classes tend not to want to spend resources on slums. Effective policies have to be sustained for decades, and political will and tax revenues for such complex state-building are frequently scarce.

Focusing on a discreet intervention – providing low-cost housing – becomes tempting. Rarely is it sufficient. The condition of the buildings alone is not what makes a slum a slum. Moving residents from slums to better low-cost housing has encountered systematic challenges not just in Latin America, but also in other places where it has been tried, such as Kenya. Instead, policies need to focus on broader community dynamics, including public safety, legal job creation with sufficient income, human capital development, and robust connectivity of slums to economically-thriving areas, something residents of the latter often don’t want.

Paradoxically, real estate dynamics can have pernicious effects. If broader pacification does take hold and public safety in slums increases, some slum areas can become desirable real estate with vast development possibilities. Developers may well seek to buy the land by offering “better” low-cost housing to slum residents to get them to move. Since many slum residents do not have title to their residences, forced displacement also occurs, albeit under the cloak of being nice to the poor.

Instead of being limited to the provision of alternative residences, policies to address slums need to be about inclusion, economic growth, safety, and connectivity of slums with the thriving city parts, and accountability of city-governance authorities.

This commentary was originally published by the Inter-American Dialogue’s Latin America Advisor. 

      

Nigeria is facing a confluence of troubles: dramatically reduced oil prices have pummeled a country that depends on oil exports for two-thirds of its national revenues; the Boko Haram insurgency continues to wreak havoc particularly in the north of the country, where suicide bombings (many of which are now carried out by kidnapped girls) have killed hundreds; and corruption remains a drain on the country, which ranked 136th out of 168 countries on Transparency International’s 2015 Corruptions Perceptions Index.

But amidst this, Nigeria completed its first peaceful transition of power nine months ago—to Muhammadu Buhari, who has since made some progress in reforming the military, sacking corrupt leaders, and injecting energy into the counter-Boko Haram campaign. 

On February 29, the Africa Security Initiative at Brookings hosted a discussion on the current state of Nigeria, featuring EJ Hogendoorn of the International Crisis Group, Madeline Rose of Mercy Corps, Mausi Segun of Human Rights Watch, and Amadou Sy from Brookings. Brookings’s Mike O’Hanlon moderated the conversation.

As O’Hanlon argued at the start, Nigeria is one of the most important countries in the world, but appears little in policy debates. Nigeria is sub-Saharan Africa’s largest economy, and security risks emanating in the country can have spillover effects. All of the participants stressed that Nigeria should factor more centrally in conversations about international security, economic development, and humanitarian issues.

Nigeria’s ups and downs

O’Hanlon started by framing three overlapping challenges in Nigeria:

• The struggle against Boko Haram, which is more complicated than a pure terror group, but has also pledged loyalty to ISIS.
• The question of reform, to include the army, the police, and the entire government.
• The state of the economy, since Nigerian livelihoods need to be improved if there is any hope to handle the first two situations. 

Hogendoorn praised the peaceful transition of power to President Buhari, calling it a “stunning achievement” for the country and those who helped from the outside. However, the problems facing Nigeria—namely the insurgency in the Niger Delta, declining oil prices, and corruption and government mismanagement (at state and federal levels)—are large, he said. He argued that declining oil prices and income are impacting the government’s ability to fulfill promises, and that state governments are powerful and difficult to reform. He praised some anti-corruption institutions in Nigeria, as well as a number of effective governors who have changed corruption situation dramatically over a short period of time. But in the end, he said, it comes down to good leadership. The Nigerian people must demand accountability. 

Rose detailed how things have changed in Nigeria since Mercy Corps became heavily involved in the area in 2012. Mercy Corps’ main missions there include violence reduction, education, and creating opportunity for young girls, as well as humanitarian response. While there has been progress on chronic violence in Nigeria, particularly in the northeast of the country, Rose stressed that there is much to be done. She concluded that there is not enough attention to the human element of the crisis. For example, Rose noted that displacement is common across the Northeast. The displaced are mainly women and children. In the displaced groups, the eldest becomes de facto head of household—sometimes forcing leading adolescent girls to turn to selling sex for food or money for food. Rose called on the government to address this. 

Segun agreed that the focus needs to change regarding crisis response in Nigeria. In the past, the focus has been almost entirely on a military response. This has not been a workable plan, she said, partly because the “military operates above the law.” The reforms in Nigeria must have a social component, Segun argued. Lack of access to opportunity, economic problems, and desertification of major water bodies have all combined to drive farmers and fisherman from the Northeast and into the heart of the conflict. 

Sy returned to the importance of economic interests in resolving the crises in Nigeria. He reminded the audience that the country is the largest economy of sub-Saharan Africa, and that is important for the entire continent. Since two-thirds of the government revenue comes from oil, the oil shock has dealt a huge blow. But there is hope for Nigeria, Sy noted. One reason is stimulus via investment outside the oil sector. There has been an increase in infrastructure spending, as well as on human development (namely in education and health). In both cases, he said the biggest issue will be implementation. Sy gave four recommendations to the Nigerian government: 1) increase infrastructure expenditure, 2) make government more lean and cost-effective, 3) increase taxation in non-oil revenue items, and 4) reduce corruption. 

Overall, the participants expressed cautious hope for Nigeria despite the problems it faces. The government there still has a long list of to-do’s, but there is reason to believe that it is on the right general track.

      

Editors’ Note: It is time to establish a regional reconstruction strategy for the Middle East, argues Sultan Barakat, that involves collective vision, broad participation, smart security, equality, and other key elements.This post originally appeared in Huffington Post.

The World Bank is hosting its annual Fragility Forum this week with the aim of making progress on the post-2015 Sustainable Development Goals. This week has also seen a fragile ceasefire in Syria, potentially landmark elections in Iran, and a violent clash between Jordanian security and so-called Islamic State members. Together these developments have prompted me to reassess what needs to be done to resolve the issues of conflict and fragility in the Middle East.

For the Middle East, the starting point should be to move away from any process that reinforces the image of the West devising solutions and proposing "new" visions to the region. Such approaches are reminiscent of the Sykes-Picot agreement or the neoconservatives' "grand strategy" of the early 2000s and do not appreciate that the Middle East has changed fundamentally since 2011. The region, at all levels, now expects to be treated with dignity and to be the driving force behind its own development.

It is high time to pull together to establish a "Regional Reconstruction Strategy" that can address all sorts of violence, not just Islamist-related conflict. The region needs an ever-evolving strategy that maintains a holistic, problem-solving outlook while drawing on various forms of intervention (e.g. community driven development, inter-regional development projects, targeted counterinsurgency operations, stabilization, statebuilding, etc.) without being straightjacketed by any one toolkit or template. Novel approaches rooted in genuine regional leadership, broad participation, youth engagement, and the utilization of technology will increasingly need to be applied. The pillars of such a strategy should be a collective regional vision, effective local participation, smart security, reconciliation and justice, equity, reconstruction and development, and capacity.

Collective Vision: With the aspirations of the Arab Spring unrealized and many countries descending into sectarianism, what is needed now is a collective vision that goes beyond national borders. This would include pooling the region's resources, specifically all the ingredients for large-scale development, such as human resources, an educated population, capital, mobility, and nature. We could then look to the day when region-wide development is synergistic and not predatory or a zero-sum game. What Morocco has achieved with solar energy is a shining example—a visionary investment has addressed regional developmental and environmental challenges, stimulated employment, and raised confidence that hi-tech and innovative sectors can thrive in the Middle East. Such a broad vision is crucial if the region is to leapfrog into the twenty-first century and not remain in a vicious cycle of conflict and failed development.

Key to an inclusive and non-adversarial vision will be both accepting and embracing Islam as a majority religion while building on human security as an area of common ground. For this to happen some real changes are required in places such as Iran and Saudi Arabia—which would enable both to exercise their regional leadership in coalescing a constructive collective vision rather than perpetuating sectarian hostility.

Broad Participation: It is important that the regional vision recognizes that development requires an active civil society, a free media, and rooting action and ideas at the local level and with popular participation. The process of engaging in a region-wide consultation where contributions are coming from schools, villages, city halls, political parties, unions, and many other civic forums can help the region start dreaming about what it wants to look like in the 50 years to come.

Smart Security: Instead of a collective vision for development we have one for defense, formed with the excuse of the Islamic State group. All appreciate that a minimum level of security is important for implementing reconstruction, but a lack of security cannot be a pretext to do nothing. Experience has shown that delaying reconstruction efforts pushes people down the slope of conflict and violence and leads to dependence on humanitarian assistance. The region needs to find ways of better understanding the granular texture of security at local and regional levels so that strategies can be developed in which localized insecurity does not hold back development in other areas. This could support "spot reconstruction" efforts that create exemplars of what a degree of stability combined with reconstruction intervention can achieve in the midst of larger instability.

Reconciliation and Justice: No long-term investment in reconstruction can be protected without genuine reconciliation across the region. Twenty years ago the main fault line was Israel-Palestine. Today, there are many additional fault lines that need to be addressed, including Muslim-Christian tensions, tensions between displaced and host communities, and tensions between Sunni and Shiite communities. The most fundamental way to initiate reconciliation is to make sure that the rule of law applies to all and that everyone has access to justice regardless of the mechanism. On this a lot can be built on local and traditional systems for achieving justice and reconciliation.

Equity: A common mistake with reconstruction is that it proceeds without sufficient regulation and monitoring to ensure that benefits are equitably distributed. This region has repeatedly seen how easily reconstruction "lords" (most of whom were previously warlords) can emerge to line their pockets at the expense of the general public, thus perpetuating that country's crisis. World Bank arguments for the private sector to take the lead in reconstruction in Afghanistan and elsewhere have done nothing but strengthen this model. Assad's efforts to liberalize Syria's economy prior to 2011 led to the further enrichment of a corrupt elite, contributing to what we see today. Going forward, reconstruction efforts must take into consideration the poorest and least capable—so that nobody is left out.

Reconstruction and Development: There is an urgent need to find new ways of inducing development through international engagement with the region. The current instability has shifted spending toward security and away from the basics of development. As a result, some of the most important development indicators—freedom of expression, women's participation, poverty, quality of education—have taken a step back. All this is happening when the region is facing financial challenges due to severely reduced oil prices. This may prove to be an opportunity as some countries needed a good wake-up call to the pernicious effects of a model of capital development in which billions of dollars are invested in the West, generating jobs and stabilizing economies thousands of miles away at the expense of the region. If the West wants to help the region it should seek to focus minds within the Arab world on the value of investment in addressing regional problems in a mutually beneficial way. Ultimately a more stable region will lead to more prosperous neighbors both in the East and the West.

Building Capacity: To do this we must invest enormous amounts in fostering sustainable capacity at regional, national, and local levels. It is essential to invest in education at all levels, in particular going beyond primary education to support the young men and women that will become leaders with the conviction and capabilities to rebuild the region. In a rush to capture development, we have focused on the hard sciences, engineering, business studies, and computer science while ignoring our own culture, languages, and history. We must correct this imbalance, and it is time we develop our ideas in our own language and not rely on translation.

For all this to happen, fragility must be addressed within a coherent regional vision, not individual national plans. It would be constructive if the international community and donors would try to view the region as a whole—as one canvas in which to facilitate cross-border mobility of population, capital, ideas, and labor—and encourage regional responsibility with different countries leading in their areas of competency. International partners can support this with new and innovative forms of funding that utilize collateral guarantees from the region, not just individual countries. If we can embrace a truly regional approach, there may be a day when we elevate human dignity and human development above petty politics and sectarianism.

      

Editor's note: This article is part of a series marking International Women's Day, on March 8, 2016. Read the latest from Global scholars on bridging the gender inequality gap, women’s well-being, and gender-sensitive policies in sub-Saharan Africa. 

This Tuesday, March 8, marks the first International Women’s Day since world leaders agreed last September to launch the Sustainable Development Goals (SDGs) for 2030. A more rounded conception of gender equality marks one of the SDGs’ most important improvements compared to their predecessor Millennium Development Goals (MDGs). Two SDG targets help to illustrate the broadening geopolitical recognition of the challenges. They also help to underscore how much progress is still required.

A new target: Eliminating child marriage

The inclusion of SDG target 5.3 adds one of the most important new priorities to the global policy agenda: to “eliminate all harmful practices, such as child, early and forced marriage, and female genital mutilation.” Until only a few years ago, the child marriage portion of this target had received only scant international attention. The driving force advancing the issue has been Girls Not Brides, a fast-gelling coalition that now includes more than 550 civil society organizations from over 70 countries. The initiative was first spearheaded by Mabel van Oranje, the dynamic international policy entrepreneur.

At a practical level, ending child marriage faces at least two major challenges. First, it is largescale. Every year, an estimated 15 million girls around the world are married before the age of 18. Second, it is highly complex. There are no simple solutions to addressing cultural practices with deep roots. Impressively, Girls Not Brides has already published a thoughtful theory of change to inform policy conversations, accompanied by a menu of recommended indicators for measuring progress. Regardless of whether this specific theory turns out to be correct, the coalition deserves significant credit for advancing public discussions toward practical action and outcomes. One can only hope that every constituency that lobbied for an SDG target presents similarly considered proposals soon. The advocates for ending child marriage have already registered some early gains. In 2015, four countries raised the age of marriage to 18: Chad, Guatemala, Ireland, and Malawi.

A renewed target: Protecting mothers’ lives

The SDGs are also carrying forward the previous MDG priority of maternal health. Target 3.1 aims as follows: “By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.” Formally this falls under Goal 3 for health and wellbeing, but it certainly represents a gender equality objective too. Part of that is by definition; mothers are female. Part of it is driven by the need to overcome gender bias; male decision-makers at all levels might overlook key health issues with which they have no direct personal experience.

As of the early 2000s, maternal mortality was too often considered a topic only for specialist discussions. One of the MDG movement’s most important contributions was to elevate the issue to the center stage of global policy. For example, former Canadian Prime Minister Stephen Harper made it a centerpiece among his own foreign policy priorities, including at the G-8 Muskoka summit he hosted in 2010.

Figure 1 shows an initial estimate of the gains across developing countries since 2000, as measured by maternal mortality ratios (MMR). The solid line indicates the actual rate of progress. The dotted lines indicate how things would have looked if previous pre-MDG trends had continued as of 1990-2000 and 1996-2001, respectively. (This is the same basic counterfactual methodology I have previously used for child mortality trends here and here, noting that maternal mortality data remain considerably less precise and subject to ongoing updates in estimation.)

The graph shows that developing countries’ average MMR dropped from approximately 424 deaths per 100,000 live births in 1990, down to 364 in 2000, and further to 233 in 2015. That works out to a 36 percent decline over the past 15 years alone, driven by acceleration in progress during the mid-2000s. Importantly, the value in 2015 was also at least 12 percent lower than it would have been under pre-MDG rates of progress—287 under 1990-2000 trends and 266 under 1996-2001 trends.

Figure 1: Developing country progress on maternal mortality, 1990-2015

A long road ahead

Whereas the MDGs focused on developing countries, the SDGs apply universally to all countries. In that spirit, and slightly different from the previous graph, Figure 2 shows an estimate of the current global MMR trajectory for 2030, extrapolating the rates of progress from 2005 to 2015. Drawing from available data for 174 countries with a current population of 200,000 or more, the world’s MMR is on course to drop from approximately 216 in 2015 to 163 in 2030. This would mark a 25 percent improvement, but falls far short of the global MMR target of 70. (These calculations follow a similar methodology to my assessment last year of under-5 mortality trajectories.)

Figure 2: Global maternal mortality - current trajectory to 2030

The mothers of nations

Although the SDG for maternal mortality is set at a global level (unlike the country-level target 3.2 for child mortality), it is worth assessing how many individual countries are trailing the MMR benchmark of 70. The geographic nature of the global challenge is underscored in Figure 3. It lists the number of countries with MMR above 70 across the respective years 2000, 2015, and—on current trajectory—2030. As of 2000, 90 countries still had MMRs greater than 70. By 2015, this was down to 77 countries. By 2030, on current rates of progress, the relevant figure drops only slightly to 68 countries.

Most notably, the figure for sub-Saharan Africa remains unchanged between 2015 and 2030, at 44 countries, even though most of the region is already experiencing major mortality declines. Rwanda, for example, saw its MMR plummet from 1,020 in 2000 to 290 by 2015. It is on track to reach 106 by 2030. Meanwhile, Sierra Leone saw a decline from 2,650 in 2000 to 1,360 in 2015, on a path toward 768 in 2030. The challenge is not a lack of progress. Instead, it is simply that these countries have huge ground to cover to reach the ambitious goal. On current trajectory, 11 African countries are on course to have MMRs of 500 or greater in 2030.

Figure 3: Scoping progress on SDG 3.1

Number of countries with maternal mortality ratios > 70

Women and girls deserve more

Although these two targets for child marriage and maternal mortality embody only a small portion of the SDGs’ broader gender equality imperatives, they reflect crucial aspects of the overall challenge. On the positive side, they provide inspiration for the ways in which long-overlooked issues can rapidly gain political and policy traction. But they also underscore the scale of the task ahead. The global challenges of gender inequality—ranging from discrimination to violence against women to inequalities of opportunity—all require dramatic accelerations in progress. On this International Women’s Day, we all need to recommit to break from business as usual. Our mothers, sisters, daughters, and partners around the world all deserve nothing less. 

Note: The maternal mortality figures presented above have been updated subsequent to the original post in order to correct for a coding error discovered in the original country-weighting calculations for global trajectories.

      

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As Africa's oldest independent country, Ethiopia has a history that is unique in the continent. The country has faced its share of conflict, including a protracted civil war from 1974 through 1991. A land-locked location in Eastern Africa, the country has also been witness to climate catastrophes, — including the drought that killed a half a million people in the 1980s and the threat of a new drought today. Despite being one of Africa's poorest countries, Ethiopia has experienced significant economic growth since the end of the civil war, and a majority of its population is literate. In addition, Ethiopia is a crucial U.S. security partner, particularly when it comes to counterterrorism, in a region plagued by threats.

On April 25, the Africa Security Initiative at Brookings hosted a discussion examining the security situation in Ethiopia, in broader political, economic, and regional context. Panelists included Abye Assefa of St. Lawrence University and Terrence Lyons of George Mason University. Michael O’Hanlon, co-director of the Center for 21st Century Security and Intelligence, moderated.

Video

• The security situation in Ethiopia and how it relates to the broader region

Audio

• The security situation in Ethiopia and how it relates to the broader region

      

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

       

Food safety is not a problem unique to China, though it is certainly one of the country’s most pressing and persistent challenges. On April 28, 2016, the John L. Thornton China Center hosted a public event to discuss food safety in China and what new regulations might mean for consumers and businesses.

Revised food safety law a step in the right direction

China’s revised Food Safety Law, enacted in October 2015, is intended to strengthen the regulation of food companies in China and enhance oversight along the supply chain. The law imposes tougher consequences on violators of food safety regulations. The revised Food Safety Law is a step in the right direction, but improving food safety will require more than just new regulations. Greater inter-agency coordination is needed among the various government entities with regulatory responsibility for food safety, including the China Food and Drug Administration, the Ministry of Agriculture, the National Health and Planning Commission, and the General Administration of Quality Supervision, Inspection and Quarantine.

China has done relatively better in enforcing food safety and quality standards for its food exports than it has for its domestic food market. A disparity between export quality and what is found in local markets is not uncommon in developing countries. But after several large-scale food safety incidents, domestic Chinese consumers are now paying close attention to the quality of their food and are no longer willing to accept such a disparity. Setting and enforcing higher food safety standards domestically is important for maintaining public health and for increasing consumer confidence. The latter will take time but is an indispensable component of the consumption-driven economy that China seeks.

Industry consolidation needed

One of the biggest obstacles facing Chinese food safety regulators is a still-fragmented domestic food industry with many small players. The increase in regulatory requirements and inspections mandated by the new law will raise the costs of doing business and likely lead to industry consolidation, which would help make the domestic Chinese food industry more manageable from a regulatory perspective. Emerging trends that see consumers buying food products from small and perhaps unverified retailers online actually make the jobs of regulators more difficult. This is because products are harder to trace—and, if there is a problem, to recall—when transactions occur through nontraditional retail channels. Traceability is critical to ensuring food safety because it allows problematic food items to be identified. The responsible firm can then correct the situation and each actor in the supply chain can be held accountable.

The Chinese government is already supporting initiatives that aggregate production units at the farm level. These farmer production bases enable farmers to coordinate food production and marketing to larger retailers. Participating farms have been provided with safe pesticides and guidelines on pesticide application; they are also able to sell to large retailers directly. These direct farmer-retailer relationships allow for greater traceability and facilitate the spot-checking that is necessary for verification. This model holds promise for improving food safety, especially as it pertains to pesticide application, but it will need to be scaled up to have a meaningful impact on China’s domestic food market.

What can China learn from other countries?

Since China is not alone in facing food safety challenges, it can learn lessons from the experiences of other countries. According to Vivian Hoffmann of the International Food Policy Research Institute, “there are many ways in which the public sector can harness the capacity and energy of the private sector to make food safety regulation more efficient.” For instance, China could consider greater co-regulation, which is a strategy that involves the private sector in regulation. Allowing firms to give input when regulators are setting standards can help prevent situations where unattainable standards are either crippling for companies or just ignored altogether. Hoffman is clear to note that allowing firms to give input does not mean compromising on consumer safety. Rather, it would create a more transparent process that would allow companies time to work up to higher standards if necessary. Private companies could be involved in testing their own products, but verification testing would still be needed.

Open communication with consumers is also important. The risk-based approach to food safety, which is the international norm and which China has also adopted, entails a particular challenge: Sometimes what consumers think is the most dangerous aspect of the food supply is different from scientists’ perceptions and knowledge of risk. For example, scientists may focus on biological contaminants while consumers worry about pesticides and additives. The concerns of consumers should be taken into account when setting priorities, but experts also need to explain why their concerns may be different. Communication and transparency are essential for bridging this disconnect. Chenglin Liu of St. Mary’s School of Law similarly stresses transparency as a key ingredient in improving China’s food safety situation. Broader capacity building efforts—as it relates to rule of law, an independent judiciary, and independent journalism—will help improve the enforcement of regulations.

The country’s revised Food Safety Law is a step in the right direction, but it is not enough to resolve China’s food safety woes. Regulatory enforcement remains a challenge. Fortunately, it is by no means an insurmountable one. Vigilant consumers will continue to demand higher-quality and more-traceable food products, a trend that puts increasing pressure on regulators to enforce high standards and that also presents great opportunities for proactive businesses.

       

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.

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• Download the full paper (PDF)

       

In 2010, Africa’s leaders gathered at the African Union in Addis Ababa to celebrate 50 years of independence. In Washington, President Barack Obama marked the occasion by hosting a town hall meeting of young African leaders from nearly 50 countries.

What looked at the time to be a curious way to mark a significant moment in the continent’s history was in fact the genesis of what could become the most innovative Obama initiative in Africa. 

When asked during the session by a young woman from Mali why he had convened such a meeting, Obama said that he wanted “to communicate directly to people who may not assume that the old ways of doing business in Africa are the ways that Africa has to do business.” The president added that he wanted the young leaders to meet each other, to develop a network of like-minded people working for a better future, and to reinforce each other’s goals and aspirations.

That town hall marked the launch of the Young African Leaders Initiative (YALI). Over the next two years, YALI engaged Africa’s youth, principally through events coordinated by U.S. embassies throughout the region. Then, during a speech in 2013 in South Africa, Obama announced the establishment of the Washington Fellowship. Subsequently renamed the Mandela Washington Fellowship (MWF), the program initially was designed to bring 500 young leaders to the U.S. for six weeks of executive leadership training at U.S. universities and four days in Washington to meet with each other, leaders in the administration, and to have a town hall with the president. In 2016, the program was increased to 1,000 fellows.

The fellows

When USAID put the application online for the first class of fellows in December 2013, the response was extraordinary. Nearly 50,000 applied for 500 slots. Similar numbers have applied for the two subsequent classes. Over the course of three classes of fellows, there have been 119,000 applications for 2,000 openings.

The U.S. government kept the qualifications relatively simple. Young men and women from each of sub-Saharan Africa’s 49 countries are eligible to participate, including from countries on which the U.S. has sanctions, such as Sudan, Eritrea, and Zimbabwe. Applicants generally have to be between 25 and 35, proficient in English, possess a proven record of leadership, and have a commitment to return to the continent. Fellows apply for one of three tracks: business and entrepreneurship, civic leadership, or public management.

A review of the program found that in the first cohort, the gender split was 50/50, nearly 40 percent owned a business, and a similar number ran a nonprofit organization. Eighty percent of the class had never traveled to the U.S., and more than half grew up outside capital cities.

The key element of the fellows’ program occurs during the specialized six weeks of leadership training that takes place at nearly 40 universities across the U.S. At the universities, the fellows, in cohorts of 20, are exposed not only to programs tailored specifically for their interests, but to other young Africans who share a passion for making a difference in their communities and countries. For most fellows, meeting other young Africans from different countries is one of YALI’s key benefits, as is forging genuine ties with Americans and U.S. institutions.

The narratives of the 2,000 Mandela Washington Fellows illustrate some of the most compelling stories and realities on the African continent today.

Importantly, the MWF program is cost-efficient, as the average cost of a fellow coming to the U.S. is $24,000. At least half is paid by the participating U.S. universities and a host of companies, including Coca-Cola, IBM, the MasterCard Foundation, AECOM, Microsoft, Intel, McKinsey & Company, GE, and Procter & Gamble, who have made grants or in-kind contributions to the fellowships and the YALI program.

YALI’s broader impact

YALI is having an impact on its participants. An initial assessment by IREX, USAID’s implementing partner, found that over 80 percent of male and female fellows who owned businesses reported an increase in earnings in the year following their fellowship in the U.S. Business fellows also leveraged more than $3 million in new sources of support through loans, grants, equity financing, and in-kind contributions.

Fellows who participated in the civic leadership training reported that the impact of their nonprofit organizations nearly tripled to over 1.6 million beneficiaries, with an average contact per fellow increasing from less than 3,000 to just fewer than 15,000 beneficiaries.

Over 80 percent of the fellows reported that they remained in contact with other fellows during the course of the year, and 70 percent indicated they continued to be involved with their host university. The ongoing connectivity is helped by the three regional conferences in Africa that USAID convenes for program alumni, more than 200 internships on the continent—most sponsored by corporate partners—as well as funding for fellows to attend conferences and other programs after they have returned to Africa.

As part of YALI’s broader reach, USAID created four Regional Leadership Centers (RLCs)—in South Africa, Kenya, Ghana, and Senegal—that offer distance and in-class leadership training to about 3,500 participants annually.

The YALI Network (Figure 1) was established in 2013 as a means to stay connected online to the tens of thousands of young Africans who applied for the fellowship but were not selected as well as others interested in the initiative. The network, which provides access to global leaders in relevant fields and opportunities for collaboration on a range of activities, has attracted nearly 250,000 members. Participants in the RLCs and the YALI Network can earn certificates in various courses, including climate change, women’s empowerment, and the election processs.

Figure 1.

Source: YALI Network

YALI, of course is not without its challenges. Recruiting from 49 countries can be exceedingly difficult, and the quality of Skype and telephone connectivity can vary significantly, which impacts the interview process. Due to the high volume of applicants, embassies have learned that they need more time to review applications. Extra efforts have been needed to accommodate fellows with disabilities. YALI’s biggest challenge, though, is winning the support of African leaders who generally have yet to embrace the program due to its unilateral launch.

What’s next?

YALI is a cost-efficient and effective way to invest in Africa’s future, especially as it concerns deepening trade and commerce with the region, strengthening democratic institutions and empowering civil society. If the next administration continues to invest in the program, YALI could become an enduring legacy program of the Obama administration much like the African Growth and Opportunity Act (AGOA) and the President’s Emergency Program on AIDS Relief (PEPFAR) are, respectively, for the Clinton and Bush administrations. Over time, YALI inevitably would contribute to a new generation of transformative African leadership and deeper ties between the U.S. and Africa in a way that few other programs do.