WORKING PAPER 23 - October 21, 2020
KEYWORDS: poverty-related and neglected diseases (PRNDs), aggregator mechanism, research and development, clinical trials, antimicrobial resistance, infectious diseases, COVID-19, AIDS, Tuberculosis, Malaria, public funding for R&D, vaccine, public health
There have been significant improvements in recent years in the early stage development of products for poverty-related and neglected diseases (PRNDs). However, there are still major challenges in the funding of late-stage clinical trials of candidate products for these diseases. For vaccine development specifically, Rappuoli and colleagues recently concluded that “these improvements in the early development process have revealed a new, and possibly more perilous, Valley of Death in the late vaccine development phase.” There are three major challenges in conducting phase III trials for PRND product development. First, such trials are expensive and companies often shy away from investing in them because there is no commercial market for most PRNDs. Second, there is poor coordination on late-stage trials across R&D initiatives. At present, there is no overarching global mechanism that is “steering the ship”—there is no universally agreed upon process for prioritizing R&D investments for PRNDs, for selecting the most promising candidates, or for coordinating the multiple, overlapping research programs worldwide. The result is duplication, waste, and ultimately delays in the development of products. Third, current R&D efforts for PRNDs are “top-down”—they are controlled by high-income countries (HICs) and have generally done poorly at including decision-makers from high-burden countries. It is policymakers in low- and middle-income countries (LMICs) who are in the trenches when it comes to controlling PRNDs—yet they are often not at the table when it comes to deciding on what gets funded, where research is conducted, who gets access to intellectual property, and where and how the technologies end up being manufactured. All these steps need to be “globalized” if we are to develop and deploy new control tools.
WORKING PAPER 22 - May 20, 2020
KEYWORDS: Diplomacy, Sustainable Development Goals, universities, American diplomacy, human behavior, collaboration model, science diplomacy, Vietnam, ozone agreement, Monsanto, black swan
This paper based on Ambassador W. Robert Pearson’s inaugural lecture of the DUCIGS/Rethinking Diplomacy Program at Duke University focuses on how the combination of the disciplines of diplomacy and science plays an important role in facilitating the solution of complex issues. The author introduces a “collaboration model” for modern problem solving of complex problems, including those where good science is a key factor, with many stakeholders. In this model, diplomacy can act as the “facilitator” or the “mediator” to manage that process. In order to succeed with a “collaboration model,” five elements are required: (1) involvement of all the essential stakeholders (those that could make or break an agreement), (2) consensus definition of the problem, (3) sufficient common interests to generate a productive dialogue, (4) a shared commitment by the stakeholders to finding a solution, and (5) successful post-agreement implementation that stands the test of time. Examples of successful stories include the international Ozone Agreement and the agreement on the UN Sustainable Development Goals. The author concludes that in today’s world all science is also politics. Knowing what is needed to solve a problem is not enough. Knowing how to persuade the broader public, businesses and governments to do what is needed requires knowing the best way to make that happen. The best way to help make that happen is to use the best tools of diplomacy. Science and diplomacy thus become indispensable partners for human progress.
WORKING PAPER 21 - April 21, 2020
KEYWORDS: transition, graduation, foreign aid, health aid, development assistance for health, Aid for Health, multilateral donor, bilateral donor, the World Bank, USAID, PEPFAR, DFID, JICA
Many donors are reconsidering their approach to providing health aid to countries that are viewed as becoming increasingly capable of self-financing their own development. To better understand this phenomenon, we analyzed the transition approaches adopted by six key global health donors, three multilateral and three bilateral, who provided nearly 75% of all disbursed official development assistance for health in 2016. We conducted a desk-based review and triangulated our findings with semi-structured key informant interviews.
We found: 1) there is no consensus on the terminology used to describe the transition process;
2) donors vary in terms of the formality of their policies, the indicators used to allocate resources and/or trigger transition, and the timeline/duration of transition; 3) some donors view the unit of transition at the sector or program level rather than the country level; and 4) donors provide varying degrees of support before, during, and after transition.
Our findings suggest that more explicit transition approaches and greater definitional clarity are needed. Donors should avoid a “one size fits all” approach—a lack of flexibility puts countries at risk. Evidence should be generated and shared on which transition modalities work best and under which circumstances. Donors should communicate with each other and avoid transitioning at the same time. As more low-income countries transition to middle-income status, transitions away from donor support for health will become an increasingly important phenomenon to understand.
WORKING PAPER 20 - April 14, 2020
KEYWORDS: COVID-19, pandemic, vaccine, infectious diseases, research and development, clinical trials
The SARS-CoV-2 virus, which causes COVID-19, has quickly spread worldwide. On January 30, 2020, the WHO declared COVID-19 to be a Public Health Emergency of International Concern and advised all governments to prepare for transmission in their countries. On March 11, 2020, the WHO declared that it had become a pandemic. There is uncertainty about what will happen next, e.g., the pandemic could involve multiple simultaneous epidemics of COVID-19 over 1-3 years, and/or SARS-CoV-2 could become a globally endemic virus. In this paper, we begin by arguing that the rapid development and scale-up of COVID-19 vaccines has become critical to reducing the morbidity, mortality, and economic damage associated with a pandemic. We show that new funding for COVID-19 vaccine development is required for all development stages and we estimate how much funding is needed. We examine ways to mobilize such funding and explore potential funding vehicles, including CEPI, the Coalition for Epidemic Preparedness Innovations, as well as the governance of such vehicles. Finally, we highlight issues such as vaccine manufacturing, intellectual property, global access, regulatory approval, and ethical and trial design considerations in conducting trials in the midst of the COVID-19 outbreak.
WORKING PAPER 19 - March 12, 2020
KEYWORDS: China, South China Sea, bargaining, multilateral, institution, international, order, territorial, disputes, claimant, UNCLOS, power, accountability
Why have the bargaining strategies of the interested states in South China Sea (SCS) territorial disputes changed over time? To date, scholarship has analyzed states’ overall strategies towards the SCS, domestic determinants of bargaining strategies, and China’s remarkable growth and unique position in the world system. But what about international constraints on crisis bargaining? This paper will argue that China’s willingness to engage in restrained negotiating behavior during the bargaining process is constrained by the degree to which it is accountable to the international institutional status quo and the financial system that supports it. China’s decision to exercise restraint in bargaining passes through two analytical dimensions: an assessment of its power relative to neighbors and an analysis of the costs and benefits of defying multilateral institutions. My theory predicts unrestrained, more aggressive bargaining when relative power is high and the state in question is decreasingly accountable to international multilateral institutions. Using case studies and historical sources, this paper finds that restraint in bargaining behavior in the South China Sea from the 1970s to the present is directly related to relative power and the extent to which China’s behavior is constrained by its accountability to international multilateral institutions. These findings are applicable to academics and policymakers considering the engagement between countries and the world order.
WORKING PAPER 18 - February 8, 2020
KEYWORDS: Ethiopia, health financing, aid, resource mobilization, Sub-Saharan Africa
In this paper, we discuss Ethiopia’s approach to health delivery, trends in health financing trends, focusing on the financing arrangements and expenditure management systems through which health funding is allocated from various internal and external sources. The paper reviews Ethiopia’s public financial management system to identify challenges and opportunities to improve domestic resource mobilization for health and resource allocation within the health sector. With the imminent transition away from external donor support that Ethiopia faces due to economic growth, the paper explores the sources of fiscal space for health in Ethiopia to sustain progress in the health sector through a deep dive of the sources of health financing through tax and non-tax revenues, additional borrowing, future aid prospects, and better fiscal discipline and expenditure efficiency.
WORKING PAPER 17 - January 28, 2020
KEYWORDS: middle income trap, economic growth, creative destruction
Since we coined the term in 2006, “the middle income trap” has been the subject of scores of investigations. The investigators have generally tried to answer one of two questions: Is there evidence to support the existence of the trap, and what can middle-income countries do to spring free of it? The evidence in support of its existence has been mixed, and the policy discussions have—to put it bluntly—been largely unhelpful. But our original proposition was that of the possibility of a trap, not its inevitability. We were more convinced of the absence of a functional theory of economic growth for middle-income economies. Solow-Swan models that stressed capital accumulation and exogenous technological change did well to explain growth in low-income countries, and Lucas-Romer models emphasizing learning and endogenous technical change identified the main drivers of growth in advanced economies and explained why capital and knowhow did not easily flow to poorer economies. Neither class of models has, to our knowledge, satisfactorily explained successful transitions from one type of growth to the other. In this paper, we propose that Schumpeterian models proposed by Aghion, Howitt and others that stress creative destruction and institutional change could provide the analytical foundations for understanding middle-income economies better. We present evidence that is consistent with the main predictions of this approach, and discuss its key policy implications, especially effective competition regimes, mechanisms to maintain social mobility, and adept management of economic crises.
WORKING PAPER 16 - January 13, 2020
KEYWORDS: Networks, Social Capital, Community Participation, Local Governance, India
Social networks and social capital have been a central discussion point for academicians and policy makers alike since last few decades. Intersecting literature on networks and applied areas stresses upon homophily effect operating through social categories of gender, caste and occupation play a crucial role in individual behaviour across health and related networks in the society. On the other hand, literature talks of social capital playing a vital role for the individual and collective society in various spheres of their lives. This empirical research triangulates the theories of social capital, social networks and community participation to study the role of networks in community participation in the context of local governance in rural society. We use indicators such as household network size as proxy to social capital, attendance and vocal participation as proxy to community participation while using the popular network concepts of peer-effect and homophily effect through logit models to assess the role of network-based social capital in community participation.
WORKING PAPER 15 - September 6, 2019
KEYWORDS: Global Public Goods, International Collective Action for Health, Global Action Plan, Aid for Health, World Health Organization, World Bank Group, Gavi, Vaccine Alliance, Global Fund to Fight AIDS, Tuberculosis, Malaria
Twelve multilateral health and development organizations have signed on to a joint Global Action Plan for Healthy Lives and Well-being for All (the Global Action Plan). The Global Action Plan includes a call for signatory organizations to align efforts to strengthen the provision of global public goods (GPGs) for health. In this paper, we examined multilateral support for GPGs for health, focusing on the four largest multilateral health organizations — Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the World Bank; and the World Health Organization. Our analysis aimed to understand how these organizations define GPGs for health and support such goods. Taking a cross-cutting view of the four organizations, it also aimed to lay out the steps these organizations could take to align their support for GPGs for health to deliver on the Global Action Plan.
To conduct this analysis, we conducted a desk-based review including relevant academic and grey literature, strategy and finance documents, and grants and projects databases. We also conducted 46 key informant interviews with senior leadership among these organizations as well as individuals from think tanks and academia who have expertise in GPGs for health and/or our multilateral agencies of focus.
Overall, we found that these four organizations lack an explicit GPGs for health strategy and they do not use a common definition of GPGs for health. All four are supporting GPGs for health in some form, through a variety of mechanisms, and it would be valuable to assess which of these are working the most effectively. A long-term, sustained financing mechanism for GPGs for health, and an overarching governance mechanism, will ultimately be needed.
WORKING PAPER 14 - December 16, 2019
KEYWORDS: BRI, imperialism, Chinese Tribute Order, soft power, imperialism of nation-states, debt, environment
I seek to grasp the genealogy of China’s Belt and Road (BRI) in relation both to the imperial Chinese world order and the historical sequence of forms of global domination, i.e., modern imperialism, the ‘imperialism of nation-states’ during the inter-war and Cold War period as well as the post-Cold War notion of ‘soft power’. While we may think of BRI as poised uncertainly between the logics of the older imperial Chinese order and the more recent logic impelled by capitalist nation-states, there are significant novelties in the new Chinese order, mostly in relation to debt, the environment and digital technology which constitute new realms of power not easily dominated by a hegemon.