2 d’abr. 2018

wrong pockets problem and pay for success

The wrong pockets problem: a situation in which we would have better outcomes if one institution or sector invested money, but because the primary benefit accrues to another institution or sector there is no incentive to make that investment. This problem describes a situation where the entity that bears the cost of implementing a practice including an evidence based best practice does not receive a commensurate benefit. Because the costs outweigh the benefits for that implementing governmental actor, projects in the public interest do not receive sufficient resources. Thus, project investment is suboptimal, and overall social welfare is in equilibrium suboptimal. Sustained inefficiency is the norm.

This wrong pockets problem particularly affects prevention programs, whether they are behavior modification programs, public health programs, structural prevention programs, or broad policy changes. Despite a growing body of empirical evidence rigorously demonstrating the effectiveness of many programs across numerous social services, advances in the implementation of evidence-based practices has been slow.

Pay for success (PFS) tries to solve the worng pockets problem: It is an innovative financing mechanism that shifts financial risk from a traditional funder—usually government—to a new investor, who provides up-front capital to scale an evidence-based social program to improve outcomes for a vulnerable population. If an independent evaluation shows that the program achieved agreed-upon outcomes, then the investment is repaid by the traditional funder. If not, the investor takes the loss.

Key drivers of the model:
  • Pay for outcomes: With PFS, the government only pays for new programs if they meet agreed-upon results, shifting away from traditional outputs-focused funding that does not account for whether a program is having the intended impact;
  • Scale evidence-based policymaking: PFS funds tests of potential social programs, amplifies the evidence-base around promising programs, and scales proven programs with a strong evidence base, allowing governments to invest in what is working;
  • Shifts risk to new actors: Setting up a new program is risky for governments, both financially and politically. PFS shifts that risk to an outside funder and bypasses typical bureaucratic challenges.
Examples of pay for success financing: The Social impact bonds (SIBs)

Some interesting articles by Urban institute:
Social impact bons in health:
photo: LIFE; Peter Stackpole (1958)

16 de març 2018

International women's day: Women on Boards

Some research and data related to women on Boards.

Why the Influence of Women on Boards Still Lags
Almost all Fortune 500 executive boards now include at least one woman (and many have two or three). Female board members have doubled since 2006, and while these gains are promising, they are slowing. Research indicates women aren’t making more rapid inroads on corporate boards because very few have been promoted to a post that would give them influence beyond their seat at the table

Authors: Kimberly A. Whitler and Deborah A. Henretta

Slow Progress for Women on Spanish Board
Women's representation on the boards of Spain's listed companies climbed by 15 percent during the year 2017. That increase brought the total to 258 female directors, who now occupy just over 19 percent of 1,347 board seats.

While significant ground was gained, the current situation still falls short of the 30 percent representation recommended by the Good Governance Code of Spain's National Securities Market Commission (CNMV) for the year 2020.

Authors: IESE and Atrevia 

Still looking for room at the top: Ten years of research on women in the workplace
In 2017, on average, women accounted for 17 percent of corporate-board members and 12 percent of executive-committee members in the top 50 listed G-20 companies. Even more worrying, perhaps, is that many people are content with the status quo. According to Women in the Workplace 2017 study, almost 50 percent of men think that it is sufficient when just one in ten senior leaders in their company is a woman. One-third of women agree.

Authors: McKinsey and Company

photo: (*) Photosolde.

24 de febr. 2018

Performance culture in hospitals: if you are good in one dimension you'll probably will be good in the rest

Nils Gutacker and Andrew Street using a sample of 95955 patients treated in 252 hospitals during  april 2009 and march 2012 on hip replacement surgery in the English National Health Service, explored the performance of the hospitals. They use four performance indicators: 1) Post operative health status (post OHS); 2) Length of stay (LOS); 3) Waiting time >18 weeks; 4) 28-day emergency readmission.

Using a multidimensional model and a dominance criteria they show us that there are a significance correlation between them.

  • Hospitals with shorter LOS also realise better post operative health status (the fast track or enhanced recovery).
  • Hospitals that have a lower proportion of patients waiting more than 18 weeks to be admitted also have a shorter LOS
  • Hospitals with better post OHS also tend to have a lower proportion of patients waiting for more 18 weeks
  • The emergency readmission within 28 days has a negative impact on health status
They also classified the hospitals in three categories: dominant (perform well), dominated (perform poorly) and non-comparable in overall performance effects: All dominant hospitals are private Independent Sector Treatment Centres (ISTCs), and all dominated hospitals are public NHS.
  • Volume outcome are not important in explaining overall performance differences between them. 
  • Dominant providers operates in a more competitive markets (in a quality competition in-price regulated market). 
  • Dominant providers have economies of scope. Good overall performance is associated with more concentrated delivery system. 
  • ISTCs don't cherry pick healthier cases to treat or “dump” complex cases back into the NHS.
Providers to perform better in one dimension have an excellent performance on another. This means that some providers have a better performance culture than others and this are better for patients.

Access to the article (pdf): Multidimensional performance assessment of public sector organisations using dominance criteria (Health Economics 2017)

photo: Light: (*) Photosolde.

11 de febr. 2018

Alan Maynard arrived at York when I was born

Alan Maynard was the greatest influencer in the field of health economics.

Alan arrived at York as a graduate student in economics in 1967, when I was born. In 1978 he created York’s MSc in health economics, and in 1983 he founded the Centre for Health Economics (CHE), where he was Director until 1995. CHE has had a major influence on health policy and the development of health economics, and continues to flourish.

He was founding editor of Health Economics, now a leading journal in the field, and later had a hand in creating two other thriving institutions: the York Health Economics Consortium and the Centre for Reviews and Dissemination.

Maynard matters. Critical thinking on health policy
This edited volume is a book with two parts:

Part One of the book consists of a set of short pieces written by Alan’s colleagues, celebrating his contributions to different areas of academic and public life. Part Two contains a selection of Alan’s work.
As Tony Culyer says you will meet seven Maynards in these pages:

  1. The health economics pioneer: cost-effectiveness studies, health service inequalities and economics of mental health, an analytical approach to health service design and management.
  2. The high class journalist: Innumerable think pieces in the Health Service Journal. Often scathing, often ironic, often right, NEVER dull.
  3. The high class academic: Founding editor of a great journal: Health Economics.
  4. The policy wonk: His impact on family doctor fund-holding, the creation of NICE, workforce contracting.
  5. The academic manager: Founding director of the Centre for Health Economics
  6. The teacher: Insightful, amusing (often hilarious) but wise and caring too. Never without a box of Kleenex for those who found the going tough.
  7. The NHS chair: York Hospital NHS Foundation Trust for 12 years, Vale of York NHS Commissioning Group 2012-15.

photos: York daffodils. Heslington Hall by W. Monkhouse (1860)

22 de des. 2017

hospital performance and managerial education

Managerial Education and Management in Healthcare (2017). In this article Nicholas Bloom et al investigate the link between hospital performance and managerial education by collecting a large database of management practices and skills in 2000 hospitals across nine countries.

They document:
  • A large variation of management practices within each country
  • The index “better management” is positively associated with improved clinical outcomes such as survival rates from AMI.
  • There's evidence that a hospital’s proximity to a university which supplies joint business and clinical education is associated with a higher management practice score (and better clinical outcomes).
  • The bundle of managerial and clinical skills has an impact on hospital management quality.
  • Management matters for hospital performance and that the supply of managerial human capital may be a way of improving hospital productivity.
  • Given the enormous pressure health systems are under, this may be a complementary way of dealing with health demands in addition to the usual recipe of greater medical inputs.

The correlations they describe are only suggestive as they do not have panel data or experimental evidence to track out causal impacts. Such evidence from either randomized control trials or natural experiments is an obvious next step in their agenda.

painting: Blue star (2016)

12 de nov. 2017

Ideas are becoming more expensive to find.

In Are Ideas Getting Harder to Find? (NBER Working Paper No. 23782), Nicholas Bloom, Charles I. Jones, John Van Reenen, and Michael Webb argue that, to maintain a given rate of economic growth, resources devoted to research must increase over time.

In many growth models, economic growth arises from people creating ideas, and the long-run growth rate is the product of two terms: the effective number of researchers and their research productivity.

The authors present a wide range of evidence from various industries, products, and firms showing that research effort is rising substantially while research productivity is declining sharply. They cite both aggregate evidence and measures of R&D productivity in specific industries, in particular computers, agriculture, and medicine.

A good example is Moore’s Law. The number of researchers required today to achieve the famous doubling every two years of the density of computer chips is more than 18 times larger than the number required in the early 1970s. Across a broad range of case studies at various levels of (dis)aggregation, they find that ideas — and in particular the exponential growth they imply — are getting harder and harder to find. Exponential growth results from the large increases in research effort that offset its declining productivity.

They argue that a single-minded focus on the quantity of undiscovered ideas is unhelpful. It is not just how many ideas for productivity growth are left, but what it would cost to get them out of the ground – and, crucially, how much we’re prepared to spend to do it. For a long time, geologists have been forecasting ‘peak oil’, only to be surprised by new deep-sea discoveries and shale oil. We, likewise, see a continuing stream of innovations. But, just as newer oil sources are increasingly costly to extract, coming up with new ideas is getting more expensive. There have been technological improvements, but these require the devotion of ever-growing amounts of resources to the research process to maintain steady rates of improvement

These days, pushing the frontier of knowledge out requires mastering an ever-larger body of knowledge, meaning that students have to stay longer in university, and researchers increasingly work in larger teams whose members are more specialised. This all pushes up costs. Returning to the oil metaphor, we are digging deeper into a trickier part of the rock.

Access to the article (pdf): Are Ideas Getting Harder to Find?
Commentary from the authors: Ideas aren’t running out, but they are getting more expensive to find

photo: Until our two activists and our members of the Catalonia Cabinet could come back to Catalonia and will be released from jail I'll publish a dark photo.

24 d’oct. 2017

Community resilience

Resilience is defined as the capacity of any dynamic system to anticipate and adapt
successfully to difficulties.
  • Individual resilience is the process of, capacity for, or outcome of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.
  • Community resilience is the ability of communities to withstand and recover from community stressors as well as to learn from past stressors to strengthen future response and recovery efforts.
What is a community stressor? A community stressor is an event that negatively impacts a community physically, emotionally, or economically. Stressors differ by communities, but examples include:
  • Weather-related disasters (e.g., hurricanes or severe snowstorms)
  • Economic downturns or high poverty rates
  • Gun violence or drug-related crimes
  • Environmental issues (e.g., climate change or global warming)

Two interesting articles
1. A toolkit to teach people about community resilience so that they can then educate others about resilience and resilience building. RAND TOOLKIT COMMUNITY RESILIENCE

2. Spanish paper from Juan de Dios Uriarte Arciniega (Universidad Pais Vasco and Ex-director Academia de la Ertzaintza). LA PERSPECTIVA COMUNITARIA DE LA RESILIENCIA

I think Catalan and Spanish people are not prepared to the adverse effects that they will occur soon and they have not been doing anything to build a community resilience.
Me as an individual also I'm not prepared. I'm afraid.

(*) Photosolde: Les parque __________________________________________________________________