Last month, the Center for Medicare and Medicaid Services (CMS) reported first-year results from the Medicare Shared Saving Accountable Care Organization Program (MSSP). As noted in a previous post, shifting to an accountable care model is a long-term, multi-year transition that requires major overhauls to care delivery processes, technology systems, operations, and governance, as well as coordinating efforts with new partners and payers. Participants in the MSSP program are also taking much more responsibility and risk when it comes to the effectiveness and quality of care delivered.
Given these complexities, it is no surprise that MSSP’s first year results (released January 30, 2014) were mixed. The good news? Of the 114 ACOs in the program, 54 of the ACOs saved money and 29 saved enough money to receive bonus payments. The 54 ACOs that saved money produced shared net savings of $126 million, while Medicare will see $128 million in total trust fund savings.
At the time, CMS did not provide additional information about the ACOs with savings versus those without. While a more complete understanding of their characteristics and actions will be necessary to understand what drives ACO success, the recent disclosure of the 29 ACOs that received bonus payments allows us to offer some preliminary interpretations:
1. Physician-owned practices are NOT disadvantaged.
When the program was launched, there was much skepticism among policy experts as to whether physician-only ACOs could generate cost savings. After all, they accounted for only a small fraction of the total health care utilization, and many wondered if primary care providers could reduce costs without the active partnership of a hospital system. They also lacked the capital, operational sophistication, and staff resources of larger well-capitalized hospital-sponsored ACOs. Their smaller size also indicated they would have to demonstrate savings at a higher level (the “minimum savings rate” or MSR) to receive shared savings payments.
However, 21 of the 29 successful ACOs were physician-led. While the difference is not statistically significant, 29% of the physician-led ACOs achieved savings greater than their MSR, versus 20% of the remaining participants (mainly hospital-sponsored). The reason why is unclear. However, it’s possible that physician-led ACOs tend to me more nimble in execution, or perhaps the “one foot in two canoes” problem is less acute for primary care providers than hospitals. For example, improvements in care coordination, chronic disease management, and prevention result in more primary care services, whereas hospitals must contend with “demand destruction” on their fee-for-service lines of business if they reduce procedures, admissions and emergency department visits.
2. Is it working? The “Underpowered” Advanced Payment Pilot
If asked the most common barrier to a successful ACO transition, physician-led ACOs will usually reference the lack of financial resources to adopt necessary technology or practice transformation assistance / infrastructure. While the MSSP program is a permanent program administered through the Center for Medicare, the Center for Medicare and Medicaid Innovation (CMMI) gave 35 small and rural ACOs (including 20 of the 114 ACOs for which Year One results are now available) upfront and monthly payments as part of an Advanced Payment Model. Six of the 20 (30%) Advanced Payment ACOs achieved shared savings, comparable to the 15/53 (28%) of other physician-led ACOs. The problem is, with such small numbers the true difference between the two groups may actually be significant, but there are not enough Advanced Payment ACOs to compare the two groups.
CMS recently released a Request for Information about ways to support clinical transformation in small practices, to encourage participation in alternative payment models. CMMI has not indicated whether any participants will be added to the Advanced Payment pilot, but we believe it should be considered in order to generate more evidence on how to best assist smaller ACOs.
3. It’s easier to cut costs if you start high
While individual ACO benchmarks have not yet been released (something we strongly encourage), there is some evidence that ACOs in the highest cost states are more likely to be achieve shared savings. The states with the most expensive (risk adjusted and standardized) regions for Medicare are Florida, Louisiana, Mississippi, and Texas. ACOs in these states account for 25 of the 114 ACOs (22%) but include 10 (34%) of the 29 ACOs with shared savings (p~ 0.07). While reducing costs in high-cost areas is an important policy objective, achieving physician participation in alternative payment models nationwide may require CMS to consider modifications to the baseline calculation formulas in the next round of ACO rulemaking (expected this fall).
It remains to be seen if these trends continue as more experience with the program accumulates, but the first year results from MSSP suggests Medicare ACOs are on the right track and with prudent evolution, can continue to move providers closer to greater accountability for health care costs and quality.Authors
- Farzad Mostashari
- Ross White
As we mark the third anniversary of Japan’s Triple Disaster, questions still linger as to what Japan and the world have learned from the earthquake, tsunami, and nuclear accident that hit Japan on March 11, 2011 killing close to 20,000 people, tearing apart the Tohoku region, and displacing for the long-term close to 270,000 persons, who till this day remain in temporary housing.
Some of the lessons learned were discussed by a panel of experts who gathered at Brookings last May to identify lessons in Japan’s experience for disaster prevention and mitigation. The lessons these experts drew from Japan’s Triple Disaster are indeed far-ranging: from the inclusion of infrequent but worst case scenarios for earthquakes and tsunamis in national planning, the benefits of proactively integrating NGOs into disaster response strategies (Randy Martin, panel 1), the need to make contingency plans in case local governments are decimated and relief requests have to be coordinated at other levels of the administrative structure, and the sheer efficiency of low-tech solutions such as sirens in tsunami warning systems. One of the most telling lessons was that national response strategies are frequently designed to respond to the previous mega disaster and so may be ill-equipped to deal with new challenges. For example, the challenge for medical teams during the Kobe earthquake was to deal with the vast number of trauma injuries, but the 3/11 earthquake required a very different response when most of the victims died in the immediate aftermath from the tsunami and a difficult determination was required about whether to send medical teams to areas affected by radiation from the Fukushima nuclear plant.
The Triple Disaster also confirmed the need for governments in developed as well as developing countries to consider the extent to which their laws and policies are prepared for disasters. For example, in Japan’s Triple Disaster, as well as Hurricane Katrina in the U.S. and the 2011 Christchurch earthquake in New Zealand, governments were not prepared to deal with the influx of offers of foreign assistance. International disaster response law is a way to ensure that international relief can flow quickly – and appropriately – when disasters occur.
The international humanitarian community was reminded by Japan’s Triple Disaster that children are not the only vulnerable group in disasters and that the elderly have particular needs which should be addressed. Evacuating people from areas which are unsafe is always a difficult undertaking but the deliberate efforts to keep communities together in evacuations after the 3/11 Triple Disaster undoubtedly minimized some of the social dislocation which often occurs. Another lesson from 3/11 is that providing accurate information can be as important as aid delivery. While by all accounts, Japan’s immediate relief efforts to the earthquake and tsunami were impressive in both scope and speed, its response was sadly lacking when it came to providing reliable and timely information about the damaged Fukushima reactors.
In fact, the most poignant lesson in Japan’s case relates to Fukushima – not to the devastation of either the earthquake or the tsunami. For humanitarian actors working in other countries, there is a clear lesson to pay attention to the prospects for nuclear/industrial/technological accidents triggered by natural hazards. Few relief agencies are prepared for (or even thinking about) such scenarios. And for Japan, the lesson is still undrawn: what will be the future of nuclear energy? The cleanup at Fukushima still leaves much to be desired, the new Nuclear Regulation Authority has issued tougher safety guidelines, but the deadlines to complete reactor checks have been missed, and the government has not yet answered the most fundamental question in the minds of most citizens: what will be the role of nuclear power in the country’s energy mix? This will be a defining lesson for Japan and the world.Authors
Those who cannot remember the past are condemned to repeat it.
The world has been littered with many financial crises over the centuries, yet many a time these lessons are ignored, and crises recur. Indeed, there are many clear lessons on the causes of past crises, the severity of their consequences, and how future crises can be prevented or better managed when they occur.
This applies to the 2007-09 global financial crisis that brought colossal disruptions in asset and credit markets, massive erosions of wealth, and unprecedented numbers of bankruptcies. Six years after the crisis began, its lingering effects are still visible in advanced and emerging markets alike. It is, therefore, a good time to take stock.
A new book, “Financial Crises: Causes, Consequences, and Policy Responses” (which I co-edited with M. Ayhan Kose, Luc Laeven, and Fabian Valencia), does exactly that: it provides a comprehensive overview of research on financial crises and surveys policy lessons in the context of a wide range of crises, including banking, balance of payments, and sovereign debt crises. We present four key insights.
- It is hard, but possible, to reduce the incidence of financial crises. Crises can have domestic or external origins and can stem from problems in the balance sheets of private or public sectors. Analyses collected in the book shows that proximate causes of crises include weak supervision and regulation, poorly timed and designed forms of financial liberalization, underpriced deposit insurance, and poorly designed safety nets. Addressing these issues, which is currently being done in many countries through new regulations, improved supervision and other institutional reforms, is therefore of key importance.
- It is hard, but not impossible, to predict crises. Because crises are driven by a variety of factors, it remains a puzzle why they occur in the first place, and predicting where and when they may strike is tricky. However, irrespective of their specific origins, financial crises are often preceded by booms in credit and asset markets, notably housing markets. Given these associations, many have recognized the need to be wary about such booms. Designing and using macroprudential policies to help mitigate these booms has therefore become a welcome priority for policymakers.
- Financial crises often exact large economic costs. A crisis is commonly an amalgam of sharp drops in credit and asset prices, a severe reduction in the supply of external financing, and large-scale balance sheet problems. Analyses in the book show that these disruptions in financial markets often have severe macroeconomic consequences. Notably, recessions with large output losses are common across the various types of crises. The real effects of crises are also quite persistent. While growth eventually returns to its pre-crisis rate, output tends to stay depressed for an extended period of time, especially following banking crises, with no catch-up, on average, to the pre-crisis trend in the medium term.
- Policies can make a big difference. The timing, mix, and depth of policy measures can greatly determine the real costs of crises. On the one hand, expansionary macroeconomic policies can help avoid an even sharper contraction in activity and can allow banks to recover more quickly and renew lending. On the other hand, such policies may discourage more active restructuring – of financial institutions, corporations, and households – and structural reforms, with the risk of prolonging the crisis and depressing growth further into the future. The use of guarantees on bank liabilities can contain liquidity pressures on banks upfront, but come with substantial fiscal contingencies. In contrast, direct capital injections impact the public purse upfront, but some resources can be recovered when public shareholdings are returned to private hands. Striking the right balance, or not, among these various policies, restructurings, and reforms can determine the overall fiscal and economic costs of a crisis.
Prevention is better than a cure
The book presents a wealth of valuable lessons on how to better monitor and reform economies and financial systems to avoid crises and provides an overview of critical policy areas. But it covers more than these insights – it also introduces a comprehensive database covering various types of crises and has lessons from sovereign debt restructuring episodes. And, given that much remains to be explored, the book also provides a guide for future research.
The table is set, and the cards are stacked. President Putin’s Russia will soon formally annex an appendage of Ukraine called Crimea, thanks to a referendum now scheduled for March 16, 2014--a result already denounced by the West as “illegal” and a “violation of international law.” But in this respect, Putin’s victory will almost certainly be pyrrhic, likely to be seen in retrospect as the first step in the ultimate demise of his regime.
After the spectacular success of his Sochi Olympics and the subsequent rise in his personal popularity, partly as a result of his ultra-nationalistic policy toward the Ukraine crisis, such a conclusion might seem, at best, to be problematic, even dead wrong. But let’s think about it.
Putin is acting like a modern Tsar, a Peter the Great striding across the steppes of eastern Europe like a leader determined to get his way: he wanted Crimea, and he took it. He may even decide that he wants the eastern half of Ukraine, and he has already established a pretext for taking it, too. And, who knows? He may play hardball and seize all of Ukraine, including Kiev, arguing fancifully that he had to protect frightened Russians from marauding bands of neo-fascist hooligans. Who would or could stop him? In the short time, no one and nothing.
Germany’s Angela Merkel, after a recent conversation with Putin, told aides that she was “not sure he was in touch with reality,” that he seemed to be “in another world.” But Putin is not “in another world”; he is very much in his world, but it is an old-fashioned KGB world of narrow nationalism and limited vision. Putin is really an egotistical, stubborn autocrat, who wants it both ways: he craves global attention and legitimacy and yet feels he can act in defiance of global rules, laws and etiquette, and get away with it.
What Putin apparently forgets is that Russia is no longer the Russia of Peter the Great, with its pinnacle of nobility ruling ignorant peasant masses, nor even the Russia of Josef Stalin, where communism was the false god of popular dictatorship. Today Russia is in a different place, struggling to find its way in a new world of instant communication and hyped expectations, where an action in the Black Sea can have immediate consequences along the Potomac. It is a Russia still absorbed with its age-old dilemma of east versus west, of the pull of traditional authoritarianism versus the rising appeal of democracy and the open marketplace of goods and ideas. It is a Russia slowly recognizing that with the exception of energy production, which produces the profits and pays the bills, it is a backward country likely to remain backward unless it catches up to the west in industrial production, artistic creativity and quick, unafraid, open-minded management of its interactions with the rest of the world.
When Russia triggered the Ukraine crisis, its stock market cratered, the ruble fell to new lows and Russia’s emerging middle class cannot help but wonder whether Putin is following a sensible policy. They lost a lot of money. Putin also has to worry now about America’s use of its new shale gas boom as a way of influencing the market in Europe. The U.S. is on the edge of supplanting Russia as the world’s biggest producer of natural gas. In a short time the U.S. will be in a good position to help Ukraine (and Europe) fight Russia’s dominant control of its natural gas supplies. Who loses in this fight? Russia’s economy loses, and Russian diplomacy will have to find a new way of managing its relations with the West.
When Russian thugs, following Putin’s orders, beat up Pussy Riot performers at the Olympics; when liberal, anti-Putin politicians get thrown into prison or house arrest for criticizing Putin’s policies, which only encourages others to stand up and complain; when Russian oligarchs find they need special visas to travel to western Europe and the United States because of global outrage at Putin’s policy in Ukraine; when middle class Russian businessmen run into newly imposed banking rules and regulations, imposed after Putin seized Crimea, frustrating their ability to trade and make money; when young Russians, students and intellectuals, now used to living in an open Internet world, find that the outside world is cutting them off because of Putin’s policy in Ukraine—when all of these problems surface, creating newer problems, they will collectively raise serious questions about the wisdom of Putin’s policies, not just in Ukraine but in Russia itself, and begin to undermine the solidity of his regime. I impose no timetable on this process, but it will happen.
Putinism in a growing anachronism in modern times. Putin may think of himself as a 21st century Peter the Great, but he has a lot of Leonid Brezhnev in him too. It took the Politburo two years to kick Nikita Khrushchev out of power after his Cuban missile crisis miscalculation, and it may take the Russian people that much time to change their leader. But Putin’s days are numbered, and it is his own fault.Authors
With these fighting words, Bilawal Bhutto Zardari did something no other Pakistani politician has done: publicly defy the Taliban (Tehreek-i-Taliban Pakistan or TTP):
“I want to tell the terrorists that Sindh will…be the battleground where we will fight and save our Islam…The grandson of Shaheed Zulfiqar Ali Bhutto, the son of...Benazir Bhutto, wants to tell you that Islam’s message is of humanity, of serving the people...Through Sindh Festival we have shown the world we are alive, and hand in hand with the contemporary world.”
The venue for Bilawal Bhutto throwing down the gauntlet to the “barbarians who want to take us back to the Stone Age” was the closing ceremony of the 15 day Sindh Festival that the young Bhutto organized in order to “save our heritage and culture…” and reclaim the social and cultural space Pakistan has ceded to the extremists.
A cultural festival might seem an odd venue for such a political act, but culture is where the rubber meets the road in the battle against extremism in Pakistan. Once home to the largest performing arts festival in the world, the Peerzada family’s World Performing Arts Festival in Lahore, Pakistan has seen music, dance and theater come under attack to the point that in 2010 three-layered police security with seven brigades was required for Pakistani children to perform a school play.
Yet, despite the Pakistani Taliban’s campaign of violence, resulting in an estimated 50,000 Pakistani deaths since 2001, they have not killed the country’s resilient arts and culture. The Karachi and Lahore Literary Festivals draw 10,000 attendees per day. Pakistan’s visual artists are world renown; Imran Quareschi occupied the coveted Metropolitan Museum rooftop exhibition space last summer. The fusion of traditional and pop Pakistan music made popular by the Coke Studio and Nescafé Basement television shows streams from the windows of Pakistan’s famous painted trucks as well as university hallways.
So, in fact, the Sindh Festival, which celebrated Pakistan’s rich, diverse culture—past and present—provided the perfect platform for Bilawal Bhutto’s message of reclaiming Pakistan’s cultural and social spaces, and its identity. Opening at the Hindu site Mohenjo-Daro, the world’s oldest planned urban landscape, the jam-packed festival program, which included a film festival, a celebration of Basant, or a kite flying festival (banned by the government), and a Valentine’s night concert of Ghazals (traditional love poems), drew hundreds daily. In today’s Pakistan, simply providing a venue and a reason for people to gather outside their homes is an act of defiance and courage.
With wisdom beyond his 25 years, Bilawal Bhutto understands that fighting the Taliban means fighting for the soul of Pakistan, that this fight begins with Pakistani identity and that Pakistani identity is grounded in its culture.
Bhutto’s launching a cultural festival struck a “dagger into the heart of the extremist project,” to quote Sherry Rehman, former ambassador of Pakistan to the United States and informal advisor to Bilawal Bhutto. The act of launching the festival, on top of his fierce condemnation of the Taliban—labeling them “barbarians who want to send Pakistan back to the Stone Age”—set Bhutto apart from the conciliatory behavior of the Sharif government and Imran Khan, a frequent Taliban apologist.
While the Festival ran and Bhutto berated the Taliban, the Sharif government opened peace talks with the extremists, only to be suspended in the wake of a spike in violence against soldiers, police and civilians. In response, Sharif and even Imran Khan called for military action against the Taliban.
The planned major attack in Waziristan, which received support across all political parties, evidently had credulity within the TTP. They announced a month-long ceasefire, a move that led the government to cancel the planned air strikes. But the shaky foundation for peace talks was shattered again when militants attacked the district court complex in Islamabad, although the TTP denied responsibility.
In contrast to the government’s ‘on again off again’ approach to peace talks, Bilawal Bhutto criticized those who support negotiations with the Taliban as “obliging terrorists”. Invoking the mothers of martyred soldiers and policemen, and referencing his own mother’s murder, Bhutto condemned talks with the Taliban as “bowing down” to “miscreants and killers”.
Only time will tell whether Bhutto’s impassioned words at the Sindh Festival Closing Ceremony will have lasting impact, but according to the recently arrived Ambassador to the U.S. Jalil Abbas Jilani, Bhutto’s speech has sparked a reaction among Pakistani politicians, causing them to re-assess their positions vis a vis the TTP.
But neither a military campaign nor peace talks will eliminate the incipient fundamentalism spreading through Pakistani society. This crops up in astonishing ways. For example, Khaadi, the upscale fabric and clothing store, has been forced to tailor its designs to cater to the fundamentalist beliefs of its manual workforce. Two designs for this season—one with small Chinese figures and another with birds—had to be eliminated: the workforce refused to print the figurative patterns because they believed they were “haram,” or forbidden by Islamic law.
Bilawal Bhutto has his work cut out for him. Whether his assertion that “the colours of our heritage and culture are so deep and bright that no tsunami of terrorism will ever be able to wash it away” will prove true or not remains to be seen. To gain acceptance beyond Pakistan People’s Party loyalists, he will have to prove his seriousness by spending more time in Pakistan than Dubai, and by demonstrating his willingness to attack core problems of corruption, poverty, poor education and inadequate delivery of basic services. Or, he could cut his teeth on something less ambitious—and fight to restore YouTube, banned for five years in Pakistan.
What is clear from Bilawal Bhutto’s contentious and courageous debut at his cultural festival is that he alone in Pakistani politics is willing to take on the Taliban. And he has done it while celebrating the music dance, art, kite flying and other aspects of Pakistani culture the Taliban would like to eradicate.Authors
On gender equality – it is no secret that the Pacific Islands is lagging.
The region is home to some of the world’s highest domestic violence rates. Economic empowerment of women in many countries, particularly in Melanesia, is desperately low. Women lack access to finance, land, jobs and income. In my country, Solomon Islands, there is only one woman in parliament, and there are none in Vanuatu and Federated States of Micronesia – a country which has never yet seen a woman elected.
Over the past few years, the long-term fiscal situation has improved. With the passage of the American Taxpayer Relief Act of 2012 (in early January, 2013), the Budget Control Act of 2011, the subsequent imposition of sequestration, and slowdowns in projections of health care expenditures, there have been a variety of sources of improvement. In addition, the slow but steady economic recovery has helped reduce the short-term deficit. Policy makers are clearly fatigued from dealing with the issue.
Yet, the fiscal problem is not gone. First, ignoring projections for the future, the current debt-GDP ratio is far higher than at any time in U.S. history except for a brief period around World War II. While there is little mystery why the debt-GDP ratio grew substantially over the last six years – largely the recession and, to a smaller extent, countercyclical measures – today’s higher debt-GDP ratio leaves less “fiscal space” for future policy.
Second, while we clearly face no imminent budget crisis, our new projections suggest the 10-year budget outlook remains tenuous and is worse than it was last year, primarily due to changes in economic projections.
There is no “smoking gun” in the 10-year projections, “just” a continuing imbalance between spending and taxes. All federal spending other than net interest is projected to fall as a share of GDP over the next decade. Net interest is projected to rise by 2.0 percent of GDP to its highest share of GDP in history.
Notably, there is no suggestion in the projections that the debt-GDP ratio will fall. In the past, when the U.S. has run up big debts, typically in wartime, the debt-GDP ratio has subsequently been cut in half over a period of about 10-15 years. Under current projections, the debt-GDP ratio will rise, not fall; the only question is how fast. Moreover, even if seemingly everything goes right – with respect to the economy and keeping the fiscal house in order – deficits and debt will rise, not fall, and we still face the prospect of a high and rising debt-GDP ratio by the end of the next decade.
And, of course, fiscal problems worsen after the next 10 years. Results over the longer term depend very much on one’s choice of forecasts, in particular regarding the growth in health care spending. Nevertheless, under the most optimistic of the health care spending scenarios we employ, the debt-GDP ratio will rise to 100 percent in 2032 and 200 percent by 2054 and then continue to increase after that. All told, to keep the 2040 debt-GDP ratio at its current level, 72 percent, in 2040, would require immediate and permanent policy adjustments – reductions in spending or increases in taxes – of 1.9 percent of GDP relative to current policy. The achievement of more ambitious future debt-GDP targets, a delay in the initiation of adjustment, or the realization of more pessimistic fiscal outcomes will necessitate even larger policy responses.Authors
Taxpayer use of itemized deductions varies widely by location, according to a new analysis of 2007 IRS data. In about one in ten counties, 11 percent or fewer taxpayers itemize while in another 10 percent at least 38 percent of taxpayers claim deductions. In a handful of counties, more than half of taxpayers itemize. In general, taxpayers in high-cost, high-tax counties located along the coasts are far more likely to itemize than those in living in in the middle of the country (see map).
About one in three tax filers itemizes. The largest itemized deductions are for mortgage interest, state and local taxes, and gifts to charity. Others include certain medical expenses, job-related expenses, and casualty and theft losses. The Pease provision limits itemized deductions for upper-income taxpayers.Interactive
The variation in itemized deductions depends on many factors, but is driven by differences in income. For example, taxpayers with higher incomes own more expensive homes and carry larger mortgages and thus pay more in mortgage interest. Some live in states and counties with higher taxes. Taxpayers with higher incomes tend to give larger gifts to charity, and they tend to cluster along the east and west coasts.
Not only does the share of taxpayers who itemize vary greatly from county-to-county, so does the amount they claim. Among those taxpayers itemizing, the median county-level deduction was $18,590 in 2007. However, in 10 percent of counties, taxpayers itemized an average of $16,640 or less, while in another 10 percent they deducted an average of $22,990 or more. In about 1 percent, taxpayers deducted an average in excess of $35,020.
Where do the biggest itemizers live? Not surprisingly in high-cost, high-income urban counties located in southern California and the corridor between Washington, DC and Boston, and around major inland cities such as Chicago and Denver. Inland and rural counties tend to benefit less from itemization.Authors
Henry Kissinger argues in a Washington Post op-ed today that Finlandization would be a good solution for Ukraine. The country would be free to choose its own domestic political system, and be free to associate itself with Western Europe economically and politically. It would refrain from NATO membership.
Kissinger’s approach is far more sensible than many of the others that people propose, from the hard-liners who want to threaten Russia with military force to the various “magic bullet” solutions that assume the West can gain leverage over Russia through economic sanctions or reducing gas supplies.
Have no doubt: Finlandization would be a great solution for Ukraine. Who wouldn’t want to be a Finland? It’s one of the three or four most prosperous, modern, and globally integrated countries in the world today. It’s Western in every respect. It’s an EU member. It is not in NATO. But it’s proudly independent.
Unfortunately, Ukraine is not and cannot be a Finland. It’s far too weak, poor, unstable, and corrupt. Finland’s per capita GDP is over $47,000. Ukraine’s is less than $4,000. Finland is the third least corrupt country in the world; Ukraine is 144th (out of 177). (Ukraine’s score on the Corruption Perception Index was more than three standard deviations below Finland’s.)
Finlandization is a utopian goal for Ukraine. It might be a good goal to strive for, but only if the West and the Ukrainians approach it realistically. Finlandization is not something the Russians would just give to Ukraine. The Ukrainians — not the West — would have to earn it. That would be a lengthy, painful process. Russia can and undoubtedly will punish Ukraine for a long time to come. We can’t protect Ukraine from most of what Putin can do. We don’t have the money, the will, or the patience. It’s a big mistake if we pretend we can. We'll lose face, and the Ukrainian people will suffer for nothing.
Finland had to be united and strong in its approach. It had to be determined enough to resist not only Soviet pressure but also efforts by some Western policymakers who, far from the front lines of the Cold War, disparaged the Finnish stance and coined the term “Finlandization” as a synonym for weak-kneed capitulationism.
Finally, we should remember that part of the price of Finland’s own Finlandization was to cede a big chunk of its western Karelia province to the Soviet Union.Authors
There are a trillion reasons to care about who owns emerging market debt. That’s how much money global investors have poured into in these government bonds in recent years —$1 trillion. Who owns it, for how long and why it changes over time can shed light on the risks; a sudden reversal of money flowing out of a country can hurt. Shifts in the investor base also can have implications for a government’s borrowing costs.
What investors do next is a big question for emerging markets, and our new analysis takes some of the guesswork out of who owns your debt. The more you know your investors, the better you understand the potential risks and how to deal with them.
Some of the facts
We compiled comparable and standardized estimates of the investor base of emerging markets’ government debt using the same approach we designed last year to track who owns advanced economy government debt.
We use data from 24 emerging market countries and we’ve made it available for anyone interested in further research (Figure 1). The data covers the period from 2004 through June 2013.
By our estimates, half a trillion dollars in foreign investment poured into emerging market government bonds from 2010 until 2012 alone, most of it from foreign financial institutions that aren’t banks (large institutional investors, hedge funds, sovereign wealth funds). These investors held about $800 billion of the debt—80 percent of the total—at end-2012.
We also calculate that foreign central banks held about $40 to $80 billion of the debt, and their holdings appear to be concentrated in seven countries: Brazil, China, Indonesia, Poland, Malaysia, Mexico and South Africa.
Why this money poured in to emerging market economies over the last decade is partly related to improvements in public debt management. In particular, emerging markets have extended the maturity of their debt profile, cut down issuance of floating rate debt, and reduced foreign currency debt. This made their public balance sheet more resilient to exchange rate and interest rate shocks, and reduced risks on the supply-side of government debt. Partly as a result, foreign interest in emerging market government debt rose sharply in recent years.
Rising foreign participation in emerging market government debt markets creates opportunities and new risks, notably on the demand side. Rising foreign participation in government debt markets can help reduce borrowing costs and spread risks more broadly among investors, but it can also raise external funding risks for countries. Moreover, having a view of investors across countries is essential for understanding the dynamics of global demand for government debt. Changes in global investor’s allocations among countries are important because they can affect many countries all at once.
Before, during and after the global financial crisis
We found that foreign investors distinguished among emerging market economies in three distinct periods—before, during and after the global financial crisis. Before the crisis, they showed moderate differentiation among countries: some received inflows while others faced outflows. As it usually happens, this differentiation became much sharper during the crisis. However, during the third period (2010–12), we found that foreign flows became almost always positive and much less differentiated (Figure 2).
Part of these inflows can be explained by improving economic fundamentals in a number of emerging markets in this period. Five emerging markets reached or regained investment grade status during 2010–12: Colombia, Indonesia, Latvia, Romania, and Uruguay. Most emerging markets weathered the crisis well, with a relatively quick return to high growth. This may have raised expectations of currency appreciation in emerging markets, attracting further demand from foreign investors. At the same time, even countries whose credit ratings deteriorated or did not improve during this period continued to receive inflows against the background of near-zero interest rates in advanced economies.
Emerging markets can prepare
Last year we developed a framework to examine how potential sudden stops in foreign money may impact government debt markets. In our new analysis, we’ve run illustrative scenarios to see what might happen under different circumstances. We designed these to assess the impact of a shock, not to predict the likelihood of one.
The scenarios show that, for a given level of foreign participation in government bond markets, countries with the following characteristics would be less sensitive to external funding risks:
- lower debt-to-GDP ratio
- lower gross financing needs
- more developed domestic financial systems
- larger liquidity buffers to protect against external shocks.
So the scenarios illustrate the importance of extending the maturity of government debt, developing a local investor base, and maintaining liquidity buffers to mitigate the potential harm from a sudden outflow of foreign funding. Countries that had these mitigating measures, such as Mexico and Poland, faced less pressure on bonds yields during the summer of 2013, despite having higher foreign ownership of government debt.
For all these reasons, emerging markets need to carefully track who owns their debt and for how long. They need to beef up their communications with their investor base to understand their needs.
Understanding the benefits and risks of foreign ownership in emerging market debt is key. Is there some perfect mix of domestic and foreign investors? Stay tuned for the upcoming analysis in the next issue of the Global Financial Stability Report for more on that.
Available in: Español | عربي
Noranna busy at work: A true-blooded Moro, she is among the many witnesses to the struggle around her. As a child, she saw how conflict affected the lives of the people in their community in Maguindanao – lack of social services, slow development progress and displaced families.
In Mindanao, southern Philippines, the decades-long search for long lasting peace has been hindered by many challenges and natural calamities. This has led to a situation where young professionals are learning a type of development work that deals with the effects of various conflicts.
The Bangsamoro Development Agency or BDA, provides more than work opportunities for residents of Mindanao. Bangsamoro basically means “Moro nation,” a term currently used to describe the Muslim-majority areas in Mindanao – its peoples, culture and ethnic groups.
Recent talk about deflation in the euro area has evoked two kinds of reactions. On one side are those who worry about the associated prospect of prolonged recession. On the other are those who see the risk as overblown. This blog and the video below sift through both sides of the debate to argue the following:
- Although inflation—headline and core—has fallen and stayed well below the ECB’s 2% price stability mandate, so far there is no sign of classic deflation, i.e., of widespread, self-feeding, price declines.
- But even ultra low inflation—let us call it “lowflation”—can be problematic for the euro area as a whole and for financially stressed countries, where it implies higher real debt stocks and real interest rates, less relative price adjustment, and greater unemployment.
- Along with Japan’s experience, which saw deflation worm itself into the system, this argues for a more pre-emptive approach by the ECB.
Mario Draghi has described deflation in the euro area as a situation where price level declines occur (1) across a significant number of countries; (2) across a significant number of goods; and (3) in a self-fulfilling way.
By this definition, the term “deflation” is arguably overstatement.
First, on geographical scope, recent price changes have been positive in all but 3 countries (versus 12 countries as recently as 2009).
Second, regarding incidence across goods and services, outright price declines account for only a fifth of the HICP basket — not a high share and, again, no more than in 2009, when the event passed without deflationary consequence.
Third, is there is a “self-fulfilling” dynamic in the sense that expected future inflation is dragging down current inflation? Here the answer is less obvious. If by expected future inflation we mean longer term rates, then the answer is no: expected inflation 5-10 years out is flat and so could not possibly be the cause of falling current inflation. But if we consider 2-4 year ahead expected inflation, the horizon relevant for many spending decisions and wage negotiations, these are falling and could be affecting current inflation. That said, actual inflation stabilized in February at 0.8%.
In the current European context, even very low inflation can scupper the nascent recovery and pressure the most fragile countries.Problem #1
Both deflation and less-than-previously-expected inflation increase the real burden of existing debt and the real interest rate that borrowers pay. As it happens, the countries with deflation/low inflation, marked red in the chart below, also happen to be the ones with already higher debt burdens (private + public) and real rates, and include all the countries that have been under market pressure during the crisis.
While deflation/lower inflation in high debt countries is painful to them, at least it improves relative prices, and hence exports and current account sustainability. Unfortunately, when inflation turns low everywhere in the euro area, each unit of deflation/low inflation endured by indebted countries delivers less price adjustment relative to the surplus countries. Or put another way, each point of relative price adjustment must be bought at the cost of greater debt deflation.Problem #3
When demand drops and nominal wages are sticky, the hit to unemployment is cushioned by any on-going inflation, which effectively lowers the real wages that firms pay. That cushion is now badly needed. In Spain, we see in the next chart that, after the crisis, the wage distribution slammed against the zero-barrier, with 30% of the distribution concentrated there. Given sticky nominal wages, near zero inflation in Spain is not helping to resolve the severe unemployment problem there.
There are at least two.Lesson #1
One should not take too much comfort in the fact that long-term inflation expectations are positive (over 2% in the euro area). Long-term inflation expectations on the eve of three deflationary episodes in Japan were also reassuringly positive. But nearer-term expectations turned more pessimistic, feeding into spending and wage decisions and delivering actual deflation. Long-term expectations adjusted too little and too slowly to be a useful guide to monetary policy. The takeaway: not-so-long-term inflation expectations, which we saw are falling in the euro area, also need to be given due consideration.
One needs to act forcefully before deflation sets in. As shown below, the Bank of Japan was relatively slow in lowering policy rates and ratcheting up base money. In the event, it had to resort to ever-increasing stimulus once deflation set in (shaded grey areas in the second chart). Two decades on, that effort is still ongoing.
You can have too much of a good thing, including low inflation. Very low inflation may benefit important segments of the population, notably net savers. But in the current context of widespread indebtedness problems, it is working to the detriment of recovery in the euro area, especially in the more fragile countries, where it is thwarting efforts to reduce debt, regain competitiveness and tackle unemployment. The ECB must be sure that policies are equal to the tasks of reversing the downward drift in inflation and forestalling the risk of a slide into deflation. It should thus consider further cuts in the policy rate and, more importantly, look for ways to substantially increase its balance sheet, be it through targeted LTROs or quantitative easing (public and private asset purchases).
Germany’s Chancellor Angela Merkel, rarely one to engage in flights of fancy, finished a telephone conversation with Russian President Vladimir Putin about the crisis in Ukraine, and then, turning to several of her aides, she said that “she was not sure he was in touch with reality.” The Russian leader, she added, seemed to be “in another world.”
And therein lies a possible source of dangerous misunderstanding, or no understanding, between the leader of Russia, on the one hand, and those of the western nations, including the United States, on the other. Just what does Putin have in mind? This is the central question.
Having gobbled up Crimea, is he now planning to invade the generally pro-Russian eastern half of Ukraine, and split the country in two? Has he indeed lost “touch with reality”? Or, more likely, has he now concluded, pursuing his own cold logic, that he can recapture a large portion of Russia’s former imperial glory by moving aggressively against Ukraine—and doing so with relative impunity? Who, or what, is going to stop him?
Putin is not mad, and he is not in “another world.” He is very much in his own world, which is for him a very realistic world of a new, frothy, determined Russian nationalism. Indeed, he is master of this world.
Now that he has gambled—and won—on a successful, terror-free Olympics, creating a global image of a slick and modern Russia and inspiring ordinary Russians to be proud of their country once again (and polls show they are), he figured it was time to take on the chronic, nagging problem of Ukraine: put simply, whither Ukraine?—east or west?
That question may haunt politicians and pundits in the west, but it does not trouble Putin. He knows the answer: for hundreds of years, Ukraine was part of the Tsarist and Stalinist empires, and it will remain in Russia’s sphere of influence. That is his reading of history, and that is his policy. When it seemed last November as though Ukraine might slip out of Russia’s tight economic and political embrace, and accept a loose form of membership in the European Union, Putin acted swiftly to smash this possibility. He offered then President Yanukovich a $15 billion loan, plus a cut in gas prices, to tie Ukraine to the east, to Russia, thus effectively squashing the illusion of many Ukrainians that they were on the edge of genuine independence through formal association with the west. Putin wanted no part of that.
In despair, Ukrainians organized widespread demonstrations in central Kiev. Anger deepened, as casualties mounted. Finally, protest leaders met with Yanukovich, a Russian emissary appointed by Putin, and the foreign ministers of Poland, Germany and France. They all agreed that Yanukovich would remain in power until December, when new elections would be held under international inspection.
Within 48 hours, the deal collapsed, Yanukovich fled, and the Ukrainian parliament appointed a new and inexperienced government, which was greeted with guarded optimism in the west and obvious disapproval in Moscow. Over the next few days, top Russian officials, fearing they were losing their grip over Ukraine, began to blast the new Ukrainian leaders as “ultranationalists” and even “fascists.” Prime Minister Medvedev described conditions in Kiev as “lawless” and “extremely unstable.” It will end, he predicted, “in a new revolution…and bloodshed.” It seemed as if Medvedev was seeding the ground for a Russian military intervention.
Last weekend, the Russians acted with uncharacteristic precision, suggesting lots of advance planning. They took control of Crimea, a strategic appendage hanging precariously from Ukraine into the Black Sea, where Russia has maintained a major naval base for many years. And, in addition, the Russians seemed to have their eye on the eastern half of Ukraine, where pro- and anti-Russian protesters were in frequent and bloody combat. The Kremlin, in a special statement, said that “any further spread of violence to eastern Ukraine and Crimea” would give Russia “the right to protect its interests and the Russian-speaking population of those regions.”
Though stridently nationalistic and proud of the occasionally restless Russian masses, Putin is also a Russian leader fearful of popular unrest. When tens of thousands of Russians objected to his election a few years ago, he let them demonstrate until the demonstrations became too blatantly anti-him, and then he stopped them. Putin hated the Chechen uprising and crushed it. He distrusts the rising Islamist rattling in nearby Dagestan, and aggressive Russian action there is considered likely, and soon. And, obviously, Putin is prepared to use additional military force, if necessary, to keep Ukraine in his bailiwick.
What can the West do? It can condemn Russia for “blatant aggression.” Its leaders can threaten to boycott the G-8 meeting scheduled for June in Sochi, of all places; it can even threaten to kick Russia out of the G-8. It can impose a number of business sanctions on Russia. It may even produce an economic package to help Ukraine, but big enough? With strict conditions? And while this collective western response to his moves against Ukraine may all end up hurting Russia economically, it will not change Putin’s mind about his controversial war-like policy in Ukraine.
Years ago, when Russia was run by a weaker, older leader, namely Leonid Brezhnev, and Russia sent the Red Army into Afghanistan, ostensibly to save a communist government in trouble, the West wailed and President Carter decided to boycott the Moscow Olympics. East-West relations suffered, no doubt, but Brezhnev did not change his reckless policy. He did what he thought he had to do to protect Russian interests and to project Russian power, just as Putin is doing right now.
Unless the West, led by the United States, is prepared to use military power to stop Russian aggression, and that is not in the cards for very good reasons, Ukraine will again be swallowed up in the Russian orbit. Let us then hope that this sad result does not trigger a mindless political exchange between Republicans and Democrats during our November elections this year.Authors
The umpteenth change of government in Italy (the third since late 2011 and the 63rd in 68 years) should arouse more than mere curiosity in Washington. Matteo Renzi, the newly appointed prime minister, has promised to work towards the relaxation of the austerity course that has dominated the EU economic policy during the crisis. The Obama administration, which has consistently argued for the EU to accord preference to growth-oriented policies over austerity, cannot but welcome any move in that direction.
But can Renzi really make a difference and tilt the balance in favor of more flexible fiscal rules?
Over the last few years, upon the insistence of a German-led coalition of ‘thrifty’ countries (e.g., with public finances more or less under control), the EU has adopted a set of rules to prevent deficit spending as an instrument of fiscal policy and to empower the European Commission with greater authority to oversee, assess and sanction national budgetary policies deemed too lax. These are binding commitments which cannot be changed at will, but only via intra-EU negotiation.
Beset by chronic political instability, and with a poor record of economic reform and a huge public debt (over 133 percent of the GDP), Italy is hardly in a position to demand re-negotiation of EU rules. In fact, given its gigantic debt-to-GDP ratio (second only to Greece’s in the EU), Italy is subject to even stricter budgetary constraints.
To its credit, Italy did achieve a remarkable degree of fiscal consolidation under Renzi’s immediate predecessors, Mario Monti and Enrico Letta, and managed to keep its budget deficit within the EU-set 3 percent threshold in both 2012 and 2013. But fiscal restraint has come at the cost of negative-to-zero growth and a dramatic rise in unemployment. As a consequence, public debt has risen, not diminished. Renzi and Pier Carlo Padoan, Italy’s new Economy Minister, will certainly insist on this simple fact when they seek more leeway from the EU. However, their attempt is unlikely to succeed if they fail to reform Italy’s institutional and economic systems.
A key step would be to enact an electoral and constitutional overhaul to avoid continuous changes of government and streamline the decision-making process. Even though the changes would not enter into force until the next electoral cycle, this would be a strong signal that Italy is serious about reform. More importantly, Renzi must commit Italy to a mid- to long-term agenda to stimulate the economy, which has constantly underperformed since the introduction of the euro in 1999. The tax burden should be reduced (particularly for companies and families), labor market regulations made more flexible but also more supportive of the young and the unemployed and the efficiency of the public sector and the judiciary increased.
Italy’s government had best start implementing reforms before it takes on the EU six-month presidency next July. Renzi would then be in a far better position to get the help he needs from the EU and Germany because he could argue that his reforms can only be brought forward if Italy is accorded more lenient terms.
It is critical that Renzi avoid requesting ad hoc moves, as Germany and other austerity champions would see this as potentially undermining EU rules. The Italian government should instead use the EU presidency’s agenda-setting power to shape the debate about the so-called ‘contractual arrangements.’ These are meant to be binding mechanisms by which an EU member state commits to structural reforms in return for as yet unspecified ‘compensation measures.’ Their actual shape should be defined later this year. If the Italian government had already started to implement its agenda, it would have more credibility to insist on a balanced trade-off: reforms in exchange for greater flexibility in the application of the EU budgetary constraints.
Even if Renzi can succeed in keeping his fractious left-right coalition united and overcome domestic opposition to his reform agenda (admittedly, a big ‘if’), there are limits to what he can reasonably achieve. Supporters of austerity command the higher ground in the EU and are likely to agree only to small adjustments. But small adjustments would be better than nothing due not only to their economic impact but also their political value EU governments that are struggling with economic and social problems, such as Italy’s, could point to such adjustments as evidence that the austerity course is being stemmed.
Renzi seems determined to fight off against the wave of popular resentment against the EU that is mounting all across Europe, including in traditionally Europhile Italy, and that is widely expected to favor anti-EU forces at next May’s European Parliament (EP) elections. The Italian electorate, while disillusioned, still sees continued membership in the currency union as a safer bet than the other way round, but is also unwilling to make further sacrifices for the euro’s sake. Renzi’s room for political maneuver is therefore limited: his pro-EU stance can only hold if he is able to de-emphasize the public opinion’s growing association of membership in the eurozone (and, by extension, in the EU) with austerity policies.
Here lies another reason for which the United States should pay attention to Italy. The growth of anti-EU sentiments risks poisoning national debates about the merit of European integration, which could in turn make the EU more difficult to manage economically and also more inward-looking. Such an outcome should be a source of concern for the United States. Renzi’s chance to reverse the austerity course in the EU is minimal. Nevertheless, were he to win some real concessions from his European partners which he could sell to the public, Renzi would contribute to reinvigorating popular support for the EU. In the long-run, this achievement would be far more significant than shaping the EU economic debate, for Italy, Europe and ultimately also for the United States.Authors
Editorial note: This blog was adapted from an article in the March 2014 Health Affairs, "Integrating Correctional And Community Health Care For Formerly Incarcerated People Who Are Eligible For Medicaid."
Under the Affordable Care Act, up to 13 million adults have the opportunity to obtain health insurance coverage through an expansion of the Medicaid program. As many as 2.86 million or 22%, of them will be justice-involved – people who are incarcerated, on probation, or on parole. This expansion is a promising step forward since nearly 90% of individuals released from prison lack health insurance coverage.
However, health insurance coverage alone is not sufficient to effectively link any individual to proper community-based health care. Much like a driver's license does not guarantee access to a vehicle or intricate knowledge of the highway system, an insurance card does not ensure the availability of a provider or a patient’s ability to successfully navigate the health care system.
This is especially true for the justice-involved population.
These individuals are at far greater risk for disease, and have higher rates of physical and behavioral health issues, including infectious disease and substance use. The Bureau of Justice Statistics has reported substance abuse rates in excess of 80%, while nearly 50% of all jail inmates exhibit symptoms of co-occurring mental illness and substance abuse or dependence. Justice-involved people also generally have higher rates of learning disabilities and lower literacy, making it even more difficult to navigate the health care system.
To further complicate their already challenging situation, these individuals also suffer from pervasive social issues, such as poverty, unemployment, unstable housing and homelessness, and varying degrees of personal and family problems. As a result, once they return to the community seeking health care will often rank low on a list of competing priorities, including securing employment and housing, and reestablishing family and community relationships with limited financial resources and social support. Therefore, we must acknowledge that successfully connecting these individuals to health care resources will help mitigate further risk and accommodate their unique spectrum of physical, social and mental health needs.
Further, we must acknowledge that if not addressed the lingering disparity between disease burden and access to care will continue to drive health care costs, worsen health outcomes, and perpetuate the unfortunate marginalization of a high-risk, high-need population. While it is critical to better understand insurance enrollment strategies for prison populations, it is also critical to better anticipate their health care needs and prepare the delivery system to meet those needs efficiently and effectively.
Successful Models of Care
Several care models have been particularly effective in linking justice-involved people to community-based care. Three unifying themes characterize these successful models of care:
- Effectively reach individuals and establish a consistent source of care to improve individual and population health
- Increase access to substance abuse treatment to reduce health care costs
- A link to consistent health care after release from jail results in lower recidivism (or reincarceration), particularly for those with behavioral health care needs (e.g., mental illness, chronic disease)
Project Bridge and the Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS) (Rhode Island): Project Bridge personnel go into prisons, identify HIV-infected inmates before they are released, and link them to a hospital-based clinic for their post-release care. Using an intensive case management system, Project Bridge successfully retained former prisoners in post-release medical care by providing support services for their nonmedical challenges.
Transitions Clinic (currently operating in ten U.S. cities): Transitions Clinics are located in neighborhoods with high concentrations of formerly incarcerated people and provide transitional and primary care with case management to former inmates with chronic health needs. The clinics provide referrals to community organizations for necessary social support services, and case management from trained community health workers who were previously incarcerated. The model depends on robust information exchange and has been shown to successfully engage this population in post-release care by addressing both transitional and primary health care needs.
Michigan Prisoner Reentry Initiative Michigan (statewide): This statewide program offers coordinated care for recently released prisoners, specifically by using community health workers to connect former prisoners with serious medical needs to a patient-centered medical home. An analysis of 2,000 people in the program found that the recidivism rate for people who had been on parole for two years fell from 46% in 2007 to 24% in 2012. The state saved an average of $31,000 annually for each prisoner who did not return to prison.
Despite the growing evidence base and the tremendous progress made by these programs, barriers to engaging justice-involved people in consistent health care must be addressed in future public policy. Here we present four recommendations for policymakers, Medicaid agencies, criminal justice institutions, clinicians, and other stakeholders who collectively seek to achieve better care for justice-involved populations.
New competencies: Effective engagement of justice-involved individuals will require new competencies across all settings, and requires a broad understanding of their complex and interrelated health, legal, social, and economic needs. Providers in both criminal justice and community-based health care settings need to be exposed to different competencies across medical and behavioral health fields and understand this population’s simultaneous health, legal, and socioeconomic challenges. Some emerging models of care such as Accountable Care Organizations (ACOs) and patient-centered medical homes are addressing these issues, but efforts should be broadened to include the larger health care delivery system.
Robust collaboration: Effective engagement will also require collaboration between criminal justice personnel, community health care providers, and social support services. The programs mentioned here indicate that linkage to care, information exchange, and coordination between corrections and community health care settings are feasible and cost-effective. Policy makers at the local, state, and federal levels have key roles to play in reducing the barriers necessary to share information and coordinate care across these settings. At a minimum, policy makers need to facilitate the development of partnerships among corrections professionals, health plans, and community providers.
Systemic barriers: Many people who leave the criminal justice system—and their new health care providers— must wait for weeks, if not months, for accurate copies of their medical records. While new systems are attempting to reconcile these issues, regulatory alignments and policy guidance are also needed to ensure the appropriate transfer of information between the criminal justice and community health care domains.
Wide-ranging benefits: Policy makers should recognize the opportunities for cost savings by coordinating services across health care and the correctional health sectors. By reducing barriers to collaboration across clinical and nonclinical settings, we can expect a number of benefits for clinically and socially complex subpopulations.
Overall, we see great potential for collaboration between criminal justice and community-based health care systems. Such collaboration is essential to achieving the clinical and cost objectives of a high-value health care system that serves the greatest possible number of people— including those who have been involved in the criminal justice system. By learning from and building on the evidence and the models of care that have been developed, as well as identifying the necessary elements of their transformation, the nation’s expansion of access can result in better care and overall improvement in other determinants of health among formerly incarcerated people, including employment and recidivism.Authors
- Amy Boutwell
- Brad W. Brockmann
- Kavita Patel
- Josiah D. Rich
In the last decade and a half, the share of women in the National Assembly has been declining. Only one out of nine chairs of National Assembly Committees is female. Women’s representation remains low in key bodies of the Communist Party: the Politburo (two out of 16), the Central Committee and the Secretariat. In Government, the civil service has a large percentage of women but their representation in leadership is small and tends to be at lower levels: 11 percent at the division level, 5 percent at director level and only 3 percent at ministerial level (UNDP, 2012).
But should we be concerned about getting higher levels of women in leadership? Is this just about “political correctness” or can having more women in leadership in business, government and politics benefit Vietnam’s development?
Việt nam đã đạt được những tiến bộ rất đáng khích lệ trong bình đẳng giới như tỉ lệ đi học của trẻ em gái và tỉ lệ của lao động nữ trong lực lượng lao động rất cao. Cuối năm 2013 chúng ta có một tin vui là một nghiên cứu của Grant Thornton, cho thấy phụ nữ Việt nam ngày càng nắm nhiều vị trí lãnh đạo trong các doanh nghiệp. Tỉ lệ nữ trong hội đồng quản trị tại các doanh nghiệp Việt Nam là 30% trong khi tỉ lệ trung bình toàn cầu là 19%. Tỉ lệ đảng viên nữ trong Đảng Cộng sản Việt Nam cũng tăng từ 25% năm 2005 lên 30% năm 2010. Tuy vậy, đa số các vị trí lãnh đạo doanh nghiệp, chính quyền và đời sống chính trị vẫn là nam giới. Xét chung về vai trò của phụ nữ trên các cương vị lãnh đạo thì còn nhiều việc cần làm.
Tỉ lệ nữ trong Quốc hội giảm dần trong thập niên vừa qua. Trong số 9 người đứng đầu các ủy ban của Quốc hội, chỉ có 1 là nữ. Số phụ nữ trong các cơ quan quan trọng nhất của Đảng như Bộ Chính chị, Ban chấp hành trung ương và Ban bí thư còn rất thấp (chỉ có 2 nữ trong số 16 ủy viên Bộ Chính trị). Về phía chính quyền, tuy tỉ lệ nữ công chức lớn, nhưng tỉ lệ lãnh đạo nữ lại khá thấp và ở cấp thấp: tỉ lệ lãnh đạo nữ cấp phòng là 11%, cấp sở là 5% và cấp bộ là 3% (UNDP, 2012).
Câu hỏi đặt ra là liệu chúng ta có nên coi vấn đề có thêm nhiều phụ nữ vào cương vị lãnh đạo là quan trọng không? Cần làm như vậy cho “phải phép” hay liệu việc nhiều phụ nữ tham gia lãnh đạo doanh nghiệp, chính quyền và đời sống chính trị thực sự mang lại lợi ích cho quá trình phát triển của đất nước?
Improving coffee production and quality can help the country's economy, as well as around 2.5 million people who depend on this crop for their livelihood. See photo slideshow
The Productive Partnerships in Agriculture Project (known as PPAP), an ambitious program which is supporting coffee and cocoa farmers in six provinces in Papua New Guinea, just got a new financing boost. After just one year, the project is already reaching 4 percent of the country’s coffee and cocoa growers –18,000 small farmers who are dependent on these two cash crops for their livelihoods. Many more partnerships are in the pipeline.
Through the initiative, several NGOs, co-ops and businesses in coffee and cocoa are all helping deliver vital services to thousands of small farmers – such as training, planting materials, access to demonstration sites and certification schemes, as well as social services like gender, HIV/ AIDS awareness.
The idea is that such support will allow growers to produce more and better quality produce and see higher incomes, with benefits passing to families and communities, while also providing a significant and much-needed boost to the coffee and cocoa industries.
Striking the right balance between relations with the West and relations with Russia has always been Ukraine’s central foreign policy challenge. Ukraine’s leaders have sought to have it both ways: to grow relations with the United States, European Union and NATO while also trying to maintain a stable relationship with Russia.
Kyiv pulled off this balancing act in the 1990s. Its first steps to engage the West did not appear to threaten key Russian interests. Boris Yeltsin accepted Ukraine as an independent state. Vladimir Putin, however, is not Boris Yeltsin, and today’s Russia is not the Russia of the 1990s. The current Russian president wants to prevent Ukraine from slipping too far toward the West, has significant leverage over Kyiv and is prepared to use it. The Russians’ spectacularly ill-timed February 26 decision to launch a snap military exercise is not an encouraging sign, nor are the February 27-28 developments in Crimea.
Ukraine regained its independence following the Soviet Union’s collapse in 1991. While a small minority of ardent Ukrainian nationalists wished that Russia would simply disappear, Kyiv had no realistic divorce option. The Soviet system left the Ukrainian and Russian economies thoroughly intertwined. The Ukrainian energy sector remained hugely dependent on Russia for natural gas, oil and fuel rods for its nuclear reactors.
Historical and cultural links bound the two as well. For most of the 350 years leading up to 1991, Ukraine had been part of Russia’s empire. Breaking up was hard to do. A senior Russian diplomat told me in 1994, “Up here (pointing to his head), I understand Ukraine is an independent country, but down here (this time pointing to his heart), it will need more time.”
Such sentiments—and Russian nationalist claims to Crimea—fueled the Ukrainian leadership’s worries about a domineering Russian neighbor. Kyiv deliberately built relations with the West as a counterbalance. In the mid-1990s, the Ukrainian government concluded a strategic relationship with the United States, a partnership and cooperation agreement with the European Union, and a partnership arrangement with NATO.
These yielded benefits. U.S. participation in a trilateral dialogue with Ukraine and Russia brokered a deal that moved 2,000 nuclear weapons out of Ukraine—on better terms than the Ukrainians could have negotiated bilaterally. Warming relations between Ukraine and NATO prompted Moscow to settle long-standing differences with Kyiv over basing part of the Russian Black Sea Fleet in Crimea.
In the late 1990s, President Leonid Kuchma often described his foreign policy as “multi-vector,” reaching out to Russia, Europe and the United States. Russian officials appeared relatively relaxed about the westward vector. Kuchma expressed interest in joining the European Union, but that was clearly not a realistic prospect any time soon.
With regard to NATO, Kyiv sought cooperation, not membership. At a conference in 1999, Volodymyr Horbulin, secretary of the National Security and Defense Council and Ukraine’s smartest strategic thinker, expressed appreciation for NATO’s “Open Door” policy. Horbulin suggested that Ukraine might someday aspire to membership, but he described that option as plainly out of reach until NATO could command support from a large segment of Ukrainian elite and public opinion.
As for Russia, it was in disarray for much of the 1990s. Boris Yeltsin also made things easier. As erratic as he could be, and though he seemed to have little patience for his Ukrainian counterparts, Yeltsin accepted Ukraine’s sovereignty and independence—and the concomitant right of the country to make its own foreign policy choices. (In December 1991, Yeltsin had joined with his Ukrainian and Belarusian colleagues to proclaim the end of the Soviet Union and establishment of the Commonwealth of Independent States.)
Much changed with the end of the 1990s. Ukraine’s ambitions for its westward vector grew. And Vladimir Putin replaced Yeltsin as Russia’s president in 2000.
Putin has his own ambitions. He does not seek to rebuild the Soviet Union, even though he once famously termed its collapse the greatest geopolitical catastrophe of the 20th century. While perhaps sentimental about the USSR, Putin is a pragmatist.
Putin wants a sphere of influence, which he regards as an important aspect of Moscow’s great-power status. He expects neighboring countries to defer to Russian interests on major issues. Given its size and historical links to Russia, Ukraine is the prime target. Putin has sought—so far without success—to bring Ukraine into the Moscow-led customs union with Belarus and Kazakhstan.
A Ukraine moving toward the West seriously threatens Putin’s geopolitical construct. Moreover, he strives to appear to his domestic political base as a strongman and protector of Russia’s national interests. “Losing” Ukraine would undermine that carefully cultivated image.
Putin thus has responded very differently than Yeltsin to Ukraine’s pursuit of its westward vector. In January 2008, Ukrainian President Victor Yushchenko requested a membership action plan (MAP) from NATO. A few weeks later, Putin stood next to Yushchenko at a Kremlin press conference and calmly threatened to target nuclear missiles on Ukraine. The MAP request failed to win consensus support at the April 2008 NATO summit in Bucharest.
Fast forward to 2013. Ukraine, now under President Victor Yanukovych, neared signature of an association agreement with the European Union, which includes a free trade arrangement. Its full implementation would prepare the ground for a future EU membership bid—and pull Ukraine irretrievably out of Moscow’s orbit.
Putin accordingly cranked up the pressure. Last summer, Russian customs inspectors began to block the import of Ukrainian goods. Kremlin officials threatened all manner of financial ruin should Kyiv go forward with signing the agreement.
The threats worked. Yanukovych suspended the association agreement process and instead accepted Putin’s gifts of a $15 billion credit line and cheaper gas. But the European Union exerts a powerful pull. Tens of thousands took to the streets of Kyiv in November in protest. Stoked by anger over brutal police tactics, the protest swelled to the hundreds of thousands, ultimately bringing down the Yanukovych regime.
The new government in Kyiv supports the EU association agreement. Seen objectively, a Ukraine that is integrating with the European Union and at the same time maintaining a full range of political, economic and commercial relations with Russia should not pose a threat to Moscow. The European Union is not NATO. But Putin views this through his own prism and seems to regard it as a menace.
Unfortunately for Ukraine, the Kremlin has significant leverage over it, including cancellation of the credit line, trade sanctions, a gas price hike and even a gas cut-off. Economic sanctions would hurt the fragile Ukrainian economy, and Russia has resorted to such sanctions in the past. While separatist sentiments in eastern Ukraine are often overstated, the Russians appear already to be exploiting them in Crimea, the one region in Ukraine where ethnic Russians constitute a majority of the population.
This means that Ukraine’s new and untried government faces a more difficult challenge than any of its predecessors in maintaining its East-West foreign policy balance. As Kyiv pursues its relationship with the European Union, it also has to cope with a Russian policy that is designed to add to its burdens, when the government already confronts so many domestic tests.Authors
Given the remarkable winter and snowfall throughout the Northeast and other areas of the country this year, it’s worth taking a moment on a public health message: One of the snow’s biggest killers on the roads has nothing to do with cars sliding on ice or careening out of control. In fact, most of these tragedies occur when cars aren’t moving at all, and the toxin is odorless, tasteless, and silent. A 1996 blizzard, for example, led to an outbreak of 25 poisonings in Philadelphia and New York City, leading to a Centers for Disease Control investigation. The culprit: carbon monoxide.
Last year, I wrote about this problem after four people died in New England after a February snowstorm:
…a 20-year-old man and 18-year-old woman were found dead in their snow covered, stationary car in Meriden, Conn. The same day, a 20-year-old man was found dead in a parked car in Mattapan, Mass. just hours after a teenage boy in Roxbury, Mass. died of the identical condition. Two other children in East Boston almost suffered the same fate, but were rushed to area hospitals and survived.
In each case, someone had left the car running to provide heat, but didn’t realize the tailpipe was blocked up by snow. As a result, the vehicle cabin filled with odorless, invisible carbon monoxide, which poisoned the occupants.
Sadly, this isn’t just a freak occurrence
According to a 2007 report from the National Highway Traffic Safety Administration, 147 people still die each year from accidental carbon monoxide poisoning from cars.
The most insidious feature of carbon monoxide poisoning is that the early symptoms — mild nausea, dizziness, and weakness — are very mild and seem like mere car sickness. Yet during this time, the poison enters the bloodstream, attacks red blood cells, and prevents them from carrying oxygen. The unsuspecting victim is being suffocated gradually from the inside.
2005, Massachusetts passed Nicole’s Law, which requires carbon monoxide detectors in homes (the 7-year-old died when her home’s furnace vent was blocked by snow). And even though the technology for carbon monoxide detection is cheap and easily available, no automaker has yet included it in their cars.
After this was posted, I got an email from 10-year-old Dylan Bemis. Inspired to make a difference, he and a team of nine 5th and 6th grade students at St. Mary Magdalen School in Delaware entered a Lego League competition (they called themselves the Robo Dogs), and designed a solution after reading the article. Here’s a look at their idea, which won first place for “innovative solution” to a problem at the qualifying tournament and regional finals (they just missed making the national finals, held in St. Louis):
I recently shared this diagram with Joshua Sharfstein, the Maryland secretary of health and former deputy commissioner of the U.S. Food and Drug Administration, who replied that he loved seeing the 10-year-olds’ design and later sent out the following tweet:February 27, 2014
Wouldn’t it be great if a manufacturer or public health authority could address the problem? We know at least one group of young people stand ready to help.Authors