Cancer, Then a Calling, for "e-Patient Dave"

Motivated: Dave deBronkart explains the e-patient movement to an audience in Holland.
Mirella Boot

BUSINESS

How a brush with death turned a small-time tech worker into a champion of electronic medicine.

• BY ANTONIO REGALADO

Audio »

There's the patient every doctor dreads—the one who shows up holding a sheaf of printouts from the Internet. And then there is Dave deBronkart.

Better known as "e-Patient Dave," deBronkart has become the Web's best-known advocate of participatory medicine, storming Twitter and stages in Washington and abroad as a motivational speaker who tells patients to get online, get access to their medical records, and take charge of their health decisions. His most famous line: "Gimme me my damn data!"

DeBronkart, who is 61, became a patient advocate after a diagnosis of metastatic kidney cancer in 2007. Given 24 weeks to live, he hit the Web and eventually received a little-used treatment, IL-2. The treatment ended up curing him. Now, as the idea of electronic medicine wins attention in the United States, deBronkart has emerged as an important technology critic.

TR business editor Antonio Regalado spoke with deBronkart about how online patient advocacy is changing medicine.

TR: Before there was e-Patient Dave, who was there?

DeBronkart: I was a two-bit geek, working in Web marketing and analytics.

So can you give me a definition of what an e-patient is?

"E-patient" is a term that was coined in the 1990s by Tom Ferguson, an MD who saw that the vast majority of what we do when we get sick is self-care, and the main limiting factor on how much you can do is how much information you have. When the Internet came along, Ferguson began to identify people who were doing things like finding information online, meeting up with others, and genuinely creating value in health care on the Internet. And so he coined this term e-patient, [for] "equipped, enabled, empowered, and engaged." I immediately saw myself as a specimen of what he was talking about. I had a blog called The New Life of Patient Dave, and I just renamed myself e-Patient Dave.

What are you advocating for?

The forces of economics have run out of control compared to what consumers need. Just think—we have 50 million Americans that have no health insurance. So now we are being left to make these decisions on our own, and I assert that we can't do that unless we have access to our medical records.

How did cancer change your thinking?

I had a cancer that is usually fatal. Samuel Johnson in the 1700s supposedly said that nothing focuses the mind like the knowledge that one is to be hanged in a fortnight. So it got my attention. Totally. Like, "There is nothing I am more interested in than what might prolong my life." That got me to spend all my waking hours looking for assistance, support, information, and so on. I joined a patient community online that had high-quality information and also had empathy, which is a major thing that most people don't appreciate.

What kinds of changes need to happen in the health-care industry?

No physician, no nurse, can possibly perform to the best of their trained potential if they don't have all the relevant information at the point where the care is being done.

People talk about how in Las Vegas, if you are there at the dice table, you run out of money and go to the credit window—they know everything about you. They know how many times you've been late on payments in the last five years. But if you have a heart attack because you hit it big at the dice table and go to the emergency room, they know nothing about you. What I know is possible is that if we can have that information presented in an organized fashion, in a clear user interface, to the health-care provider, it will improve value. 

What has been the response to your advocacy for e-patienthood?

It's funny, because the last thing I thought was that it would be getting global attraction, global attention, but it has. Most of what I talk about is U.S. health care, with its own unique problems. But the message has spread to all kinds of other countries. My message is to let patients help. And that is what has some real traction, much to the surprise of many people in the medical profession. Many patients really want to be given an active role in making health care better.

Why do you say that is a surprise to the medical profession?

There are many doctors, well-meaning (and some jerks), who have been trained specifically that patients are passive lumps who don't want to take care of themselves and don't want to do anything. They think, "You just have to do the best you can given that these are inert and sometimes resisting objects."

You became a little famous after trying to use Google Health, a program that let patients track their own health care. What are your thoughts on personal health records?

The personal health record, commonly known as a PHR, is a concept that is going through a big evolution and just starting to mature. A lot of PHR products, and you can find a slew of them, are idiot-level or just initial experimentation. We just don't have easy tools. The medical industry has computerized to a certain extent, but the vast majority of what they have done is to automate billing. That makes perfect sense for business purposes but produces crap when it comes to clinical reality.

I looked at your blog, but I can't figure out what PHR you use now.

You're sharp. At present I don't keep a PHR. I actually don't have an immediate use for one. Nothing that particularly needs tracking!

What will the e-patient movement mean to the health-care industry?

Health care is the only industry I know of where the definition of quality—and therefore of value—isn't centered around what people want. There is an idea that value consists of doing more medically or biologically amazing things. So we have situations like where you have three times as many proton-beam cancer treatment devices in a city than there is market need for. Costs keep escalating, and value doesn't.

We are headed to a situation where consumers and employers are saying "To hell with this, we need value for our spending." When people begin buying only things that are clearly valuable, the people selling high-priced medicine are going to be saying, "Wait a minute, what happened?" They have no idea why they suck, why the things that they have always valued in their ecosystems and their culture are not actually of any concern to the ultimate consumer. I say the high-cost providers are pricing themselves out of the market.

Is being an e-patient advocate a good business for you?

A good business? It's a hard business. It's hard because there is no mass market for what I have to say. I am a pioneer—not in a glorious sense, but in the sense of hacking my way through the underbrush. But I like speaking new ideas and seeing people's minds go, "Wow, I never thought about that." I like that we are getting a response.

A Simple Way to Boost Battery Storage

Battery binder: This microscopy image shows a silicon electrode before charging (left) and after 32 cycles. A new binder keeps the particles close together.
Lawrence Berkeley National Laboratory

ENERGY

A stretchy binder material that's compatible with existing factories could help electric cars and portable electronics go 30 percent longer.

• BY KATHERINE BOURZAC

Audio »

Lithium-ion battery electrodes bound together by a new highly conductive material have a much greater storage capacity—a development that could eventually increase the range of electric cars and the life of smart-phone batteries without increasing their cost. Unlike many high-capacity electrodes developed over the last few years, these can be made using the equipment already found in today's battery factories.

The key is a stretchy, highly conductive polymer binder that can be used to hold together silicon, tin, and other materials that can store a lot of energy but that are ordinarily unstable. Researchers at the Lawrence Berkeley National Laboratory painstakingly engineered this new polymer binder and used it to make a silicon anode for a rechargeable lithium-ion battery with a storage capacity 30 percent greater than those on the market today. It's also more stable over time than previously developed electrodes.

When a lithium-ion battery is charged, lithium ions are taken up by one of the electrodes, called the anode. The more lithium the anode can hold, the more energy the battery can store. Silicon is one of the most promising anode materials: it can store 10 times more lithium than graphite, which is used to make the anodes in the lithium-ion batteries on the market today. "Graphite soaks up lithium like a sponge, holding its shape, but silicon is more like a balloon," says Gao Liu, a researcher at the Berkeley Lab's Environmental Energy Technologies Division.

However, because the silicon anodes swell and shrink, changing in volume by three or four times as they're charged and discharged, the capacity of the battery fades over time. "After a few rounds of charge and discharge, pretty soon the silicon particles are not in touch with each other," which means the anode can't conduct electricity, says Liu.

One approach to the problem is to structure these anodes in a totally different way, for example growing shaggy arrays of silicon nanowires that can bend, swell, and move around as lithium enters and exits. This approach is being commercialized by Amprius, a startup in Palo Alto, California. But growing nanowires requires new processes that aren't normally used in battery manufacturing.

Today's anodes are made by painting a solvent-based slurry of graphite particles held together with a binder, a simple process that keeps costs low. The Berkeley researchers believe the key to making new battery materials like silicon work is to stick with this manufacturing process. That meant coming up with a rubbery binder that would stick to silicon particles, remain highly conductive in the harsh environment of the anode, and stretch and contract as the anode swells and deflates.

Most work on advanced batteries has focused on the active materials, but "we have pushed these materials to the limit," says Yury Gogotsi, professor of materials science and engineering at Drexel University. "Now what's limiting us are the binders."

Reading through papers on silicon battery binders, Liu noticed that researchers were making "fatal mistakes"—choosing polymers that lose their conductivity in the kinds of conditions found in an anode, for example. He worked with theoretical chemists to come up with a list of polymers with the right electrical properties for the job. Once they found one, they altered it to make it much stickier. Once they developed and characterized this new material, they were able to make silicon anodes using conventional processes, and test them in batteries.

The Berkeley group's anodes have been tested in over 650 charging cycles. They maintain a storage capacity of 1,400 milliamp hours per gram—much greater than the 300 or so stored by conventional anodes. Full batteries incorporating the anodes store about 30 percent more total energy than a commercial lithium-ion battery. Typically, battery capacity increases by about 5 percent a year, Liu notes. He says they've tested the binder in other battery anodes, including those made of tin, that have similar potential and problems, and that it should work for any such materials.

The storage capacity of these batteries is nearly as good as those made from pure silicon nanowires with no binders, says Yi Cui, professor of materials science and engineering at Stanford and one of the founders of Amprius. That's impressive, he says, considering that the binder doesn't store any lithium.

Liu's group is now collaborating with researchers at 3M on the anode research. 3M is scaling up production of silicon-based battery materials designed to not expand quite so much during charging, says Kevin Eberman, who is developing battery materials products at 3M Electronics in St. Paul, Minnesota. But to make them work, a good binder is key. The company is providing the Berkeley group with materials to test. Liu says the Berkeley group has patented the binders, and is in talks with a few companies about ways to commercialize them.

Geothermal energy: an under tapped, climate-friendly resource

SUBMITTED BY DAVID LAWRENCE 

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A few years ago I had the pleasure of swimming in a big, heated pool. Outdoors. In winter. It sounds like an unaffordable luxury, and in most places, it is. But in Iceland, you can swim all year round in geothermal swimming pools. Iceland sits on the boundary of the Eurasian and North American tectonic plates, which are slowly pulling apart, giving it extraordinary geothermal resources. Besides year-round outdoor swimming, this renewable resource provides heat, hot water, and electricity.

According to Iceland's National Energy Authority, about 25 percent of the country’s electricity was generated by geothermal power plants (2008 data). The benefits sound like an environmental fairy tale: pollution is almost nil, operating costs are low, power generation is constant, and it’s completely renewable.

Given that there are geothermic regions all over the world (think Pacific Rim), you’d expect that geothermal power plants would be under construction everywhere. But surprisingly according to Katherine Baragona, an infrastructure finance specialist at the World Bank, geothermal power doesn’t attract as much interest as solar or wind power.In an article inHandshake, a journal on public-private partnerships, she points out that what is preventing more financing in this area are the upfront costs of a geothermal power plant. They are very high, making it hard to attract investors. There’s also nervousness about causing a man-made disaster by triggering an earthquake. Given that potential scale of climate-related disasters (for example, submerging the Maldives or a chunk of Bangladesh), I don’t understand the worry — human activity sets off tremors all the time.

In the article, Baragona is optimistic about geothermal’s prospects. Anyone who’s gone swimming in an outdoor geothermal swimming pool will probably agree. The amount of heat inside the earth is incredible; if we can tap into just a fraction of it, we can use energy without worrying about its impact on the environment.

Recent developments are promising. Last month, Indonesia, which has the world’s largest geothermal reserves,  took a step in this direction with support from the World Bank, which agreed to lend $300 million to build geothermal plants there. There may not be much demand for heated swimming pools in Indonesia, but the new power plants will go a long way towards helping the country meet its energy needs in a sustainable way.

It seems to me that every country with geothermal potential should get busy developing it. It may be pricey in the short run, but generations of people will benefit from cheap, clean power with readily available technology. Why wait for solar and wind technology to catch up when you can tap into geothermal resources right now?

This post is the first of a series on PPPs and climate change. You can read more on this topic in the latest issue of Handshake, IFC’s journal on PPPs.

On the Front Line of Climate Change....Buildings!

SUBMITTED BY DAVID LAWRENCE 

 

Efforts to fight climate change tend to focus on emissions, usually dirty ones, like vehicle exhaust or the toxic belching of coal-fired power plants. A blast of diesel fumes in your face is a good reminder that these things are bad for both people and the planet. So it’s no surprise that we zero in on cheerful, clean solutions, like solar power and zippy electric cars.

But anyone who has lived in the former Soviet Union knows that buildings can also be incredibly wasteful, hemorrhaging heat in gushing torrents. Winter after freezing winter, I stuffed cotton into gaps in the window frame to block out the cold. And I was always astonished that people—including me—could only regulate temperatures in overheated apartments by opening their windows in subzero conditions.

 

The problem isn’t limited to former Soviet countries, or to windows. In arecent article in the PPP journal, Handshake, Prashant Kapoor, a Green Building specialist at IFC, points out that nearly half of all energy produced globally is used to heat, cool or ventilate buildings. Since we spend so much of our lives indoors, the opportunities to find ways to cut energy use in buildings are vast.

Making buildings greener seems to be getting more and more attention. The Economistrecently reported that growing grass on city rooftops, a part of Chicago’s Climate Action Plan, greatly reduces the energy needed to cool the building in summer. In Seattle, the Bullitt Foundation is building the greenest building on earth, which will use solar energy to generate electricity and heat (as well as process its own waste). And in London,a new fundwill offer low-cost loans to improve energy efficiency in public buildings.

The idea behind green buildings is that savings in energy and fuel costs can pay for itself over time, saving money in the long run while reducing both carbon emissions and pollution. It sounds like a winner. But I also love the idea of buildings being self-sufficient, not relying on a central grid or anyone else for energy, heating and lighting. The more a building can do for itself, the less costly infrastructure we need to build.

Mr Kapoor points out that simple energy efficiency measures, such as low-energy light bulbs, smart thermostats or better insulation, can reduce power costs by up to a third. This can save people a lot of money, and as The Economist points out, lead to significant savings in buildings that are active around the clock, like airports, hospitals or police stations.

That’s where public-private partnerships (PPPs) come in. Governments can do a lot to encourage greener buildings by making energy-efficiency a requirement in PPP transactions. Since PPPs are used more and more often for airports, hospitals and schools, this should be an easily achievable goal that will save governments a lot of money.

Mr Kapoor lists many reasons why there hasn’t been more progress. But I think the growing pressure to reduce carbon emissions, as well as hard economics, will change that.Handshake  mentions examples—the main airport in the Maldives and hospitals in Mexico. But if the idea catches on, especially in the cold countries of the former Soviet Union, I think we’ll see a real difference.

The India Paradox: Promoting Competitive Industries in a High-Growth Country

SUBMITTED BY IVAN ROSSIGNOL, CO-AUTHORS: PARTH SHRI TEWARI, ROSANNA CHAN 

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India’s economic growth rate in the past decade has been nothing short of spectacular.  With its GDP growth around 7 to 9 percent per year, India is the second-fastest-growing large economy in the world.  However, the country’s manufacturing sector accounts for a dismal 17 percent of its employment opportunities, as compared to 60 percent in agriculture and 23 percent in services.[1]This summer, the World Bank’s Indian Visiting Scholars Program* invited two leading academics from Harvard University to visit India and to articulate potential pathways to sustain the country’s growth trajectory. These 2 scholars are Ricardo Hausmann, Professor of Economic Development at the John F. Kennedy School of Government and Director of Harvard’s Center of International Development and Dani Rodrik, Professor of International Political Economy at the Kennedy School. While there, they interacted with the private sector and key policymakers, including senior officials of the Department of Industrial Policy and Promotion, the Planning Commission, and the Ministry of Finance.

Monkeys…and India’s economic structure and growth

Hausmann argues that diversification in the economic structure, and not necessarily specialization, may be a crucial factor for accelerating growth in India.  He observes that rich economies produce many products whereas developing economies produce few products that are also made in rich economies. This relationship exists not only between countries, but also between cities within a country.

The obvious question arises: If each product requires specific sets of capabilities, how can resource- and skill-constrained developing countries diversify? Hausmann suggests leveraging existing capabilities to develop new products that, in turn, allow for the development of more capabilities, and the production of more new products, and so on. The novel analogy he makes is that of a monkey leaping from tree to tree in the forest of potential products of the world. The closer the tree is, the easier the leap. The successful value-chain upgrade from low-value-adding business process offshoring to higher-end “knowledge process outsourcing” is a case in point.

The greater the area of the forest that an economy occupies, the more diversified it is, and thus the greater the opportunities are for growth. So how does this inform industrial development? Like entering a forest with a map to navigate the various vegetation zones, Hausmann’s methodology can be used in some cases as a frame of reference to analyze so-called “product spaces” and to offer a roadmap for policymakers and entrepreneurs to identify strategic “tree leaps” towards new products. That, in turn, helps a country develop its capabilities and occupy greater areas of the product space.

From products to people: how does industry development relate to employment?

For his part, Rodrik argues that apart from developing new products, shifts in production structure contribute to overall productivity improvements that are needed for growth. 

Drawing comparisons across countries, Rodrik finds that successful countries have been able to channel labor resources to productive sectors, as well as develop sectors that absorb the type of labor that is available (for example South Korea, Taiwan and Brazil in certain industries). In India, the majority of labor is unskilled.  The challenge, says Rodrik, is twofold: to have policies that are aimed at allocating labor resources to productive sectors and developing additional sectors that will also absorb this labor.  He emphasizes that this would not only involve examining labor-market rigidities but would also involve maintaining a competitive exchange rate. In Rodrik’s view, today’s real debate is not whether to have an industrial policy but how to improve the contribution of industry to inclusive development. It cannot be a top-down process. It must be a process of collaboration, coordination, and dialogue with the private sector.  

The take away:  Industrial policy 2.0?

No matter how much we try to shy away from it, industrial policy is very much alive in countries like India, at both the central and the state levels. The question is how to go about it to avoid the trap of “picking winners.” While Hausmann and Rodrik championed different aspects of how industrial policy could help facilitate economic growth – one at the product-space level and the other on the exchange-rate and labor-rigidity aggregate level – both of them emphasized the importance of communication and coordination between the private sector and policymakers.  Indeed, it is important to create a process that is not political and involves collaboration, dialogue and feedback mechanisms.  As Rodrik puts it, a collaborative process should be one where government processes are embedded in, and not “in bed with,” the private sector, for it to be responsive and conducive to private-sector growth.

[1]Component parts of the labor force by occupation. CIA World Factbooks 18 December 2003 to 18 December 2008

*Enhancing Dialogue through the Visiting Scholar's Program The Finance and Private Sector Development Network of the World Bank Group, through the Competitive Industries Practice, has been working on enhancing the policy dialogue by linking world-class knowledge to Indian policymakers. FPD brings leading academic thinkers to look at these issues in the Indian context 

Related links:
Link to Hausmann’s presentation
Link to Rodrik’s presentations: I, II, III, IV

Old School or New School, the Question is the Same: How can development institutions make measurement core to their business?

SUBMITTED BY NIGEL TWOSE, CO-AUTHORS: JODI NELSON 

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Firms maximize their profits by developing strategy with targets, tracking progress, and using incentives to drive achievement. Without the natural feedback of the market, how can we use this approach to drive toward results for the poor? 

One of us works for the International Finance Corporation (IFC) – an old school Bretton Woods institution with years of experience building systems to track results across countries. The other one of us works for the Bill & Melinda Gates Foundation, an entrepreneurial organization that is much newer on the block, without some of the systems that come with fifty years of development work but also without the preconceptions. We come to the table with a desire to learn from each other’s experience. We hope this first blog will pique input from colleagues around the world, similarly passionate about the power of data to improve our business.

Our main concern is how to make relevant, credible, transparent and actionable measurement the powerful tool it needs to be in our organizations. We are convinced that private sector practices that link strategy, results, information and performance incentives hold promise, but also aware that there exist significant challenges to successfully using them. In our two very different institutions, we grapple with three similar questions about how to resolve this tension. 

Question #1: How do we ensure data about results are used to increase effectiveness?

There is no doubt that the last 5-10 years have witnessed enormous progress in the understanding and practice of evaluating development effectiveness. Although there remains philosophical debate about how evaluation is best done, we believe that the simple fact that it is supported at the highest levels of institutions such as DFID, USAID and the World Bank, debated among practitioners and academics, funded and pursued passionately indicates progress.

The problem is that the current discourse about evaluation theory and design doesn’t touch on the more daunting challenge of how to integrate measurement into decision making. Simply put, the most elegant evaluation design is irrelevant if the findings are never used. In this way, the true “gold standard” is the use of data rather than a specific way to collect it. Moreover, in both of our organizations, impact evaluation produces a small portion of the type of regular information people need to track progress and make decisions. High level strategies to alleviate poverty through business growth, farmer productivity, access to financial services and other means are built on diverse types of investments, grants, organizations, partnerships and contexts and therefore diverse types of information. Technically, we know how hard it is to “sum up” results data of varying quality and to track them as indicators on management scorecards and dashboards. Still, the real institutional need is to find a way to do exactly this: provide decision makers responsible for allocating resources with digestible information that they use. We find very little in the current debates and policy discussions to help us to chart a course to do this. 

Question #2: How can we use incentives to drive results and use of data?

Results-based approaches have been in and out of development for a while. Bilateral donors turned to tougher contractual tools as a means to buy and ensure outcomes from implementing partners some ten years back. Performance-based incentives (PBI) or pay-for-performance (P4P) is showing up today in discussions on development financing. DFID has adopted such an approach to allocate its aid budget. The Results Based Financing for Health (RBF) effort of the World Bank, Norwegian government and DFID seeks to use results-based financing to improve healthcare in developing countries. 

Despite these and other efforts to incentivize changed behavior among NGOs, governments and others, we don’t use performance-based incentives in our own organizations. Experience working in development reminds us how difficult it is to control for complexity. We understand, too, that measuring change is not the same as being able to attribute it to individual action and that it is hard to be held accountable for something that is both complex and beyond our control. Nevertheless, we wonder if we’ve disregarded too quickly lessons of professional accountability from the private sector. Private sector leaders are held accountable to increased revenue and sales despite their lack of direct control. If we are willing to hold our grantees, partners and national service providers up to this test, can we also hold ourselves accountable for targeting results, measuring progress and using the data to become increasingly effective?

Question #3: How can we assure that the “client” is center stage in our efforts to plan for and measure results?

Aspirations to assure that the people on the receiving end of development are central to its planning and measurement are not new. The arguments supporting participatory development date back to the 1970s and even the most mainstream institutions adopted its tenets in the 1990s. And yet, by the beginning of the century, twenty years of practice were characterized as an emperor with no clothes – the feared “New Tyranny” of orthodoxy without enough proof of the value added (Participation: The New Tyranny? by Bill Cooke and Uma Kothari, 2001). It’s no surprise that the pendulum has swung to the opposite pole today – rigorous positivist evaluation design as the sole focus of our dialogue and efforts to solve the broader measurement challenges we still face.
 
Although we applaud the emphasis on scientific methods, we lament the faddism of evaluation practice and the fact that we aren’t all focused on a more diverse set of problems to solve. People, communities and grantee and partner organizations remain essential to all of our efforts. Esther Duflo and Abijhit Banerjee’s recent book Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty pushes us to see the connection between individuals and our efforts to help them, but how do we apply this kind of thinking to fit the scale and scope of high level strategies designed and implemented by large donor organizations? Foundations survey their grantees and IFC surveys its clients to assess the quality of their relationships. But how do we connect the dots between what we learn and how we do and improve our work in a way that avoids the mistakes of participatory and experimental fads?

We could go on and on to list and pose the questions that motivate our 1:1 conversations of late. Please join us – we’d love to broaden the conversation and hear your ideas.

Managing garbage to save the planet

SUBMITTED BY DAVID LAWRENCE
The world bank 

 

The plight of refugees is in the news all the time, mostly as a result of war. But recently, I saw a post in Dot Earth, a New York Times blog, about a documentary calledClimate Refugees. It suggests that climate change will lead to massive refugee problems, mainly as a result of flooding. Disasters in New Orleans, Bangladesh and Myanmar offer a glimpse of what might come.

The Maldives, an island nation in the Indian Ocean, is at special risk: most of it is only 1 - 1.5 meters above sea level. If global warming leads to rising sea levels, the country could be submerged. Consequently, the government aims to make the country carbon-neutral by 2020.

I don’t think that a carbon-neutral Maldives will stop global warming, but it’s done a good job demonstrating steps that governments and the private sector can take to reduce carbon output. Recently, it set up a public-private partnership to manage waste on the island of Thilafushi, where most of the country’s garbage was dumped and burned off. When the project is completed, this toxic island will have a state-of-the-art waste management system that includes a 2.7MW power plant that will replace existing diesel plants, saving 12,000 tons of carbon emissions annually.

There’s a lot of room for the private sector and governments to tackle climate change. You can read more in the latest issue of Handshake, IFC’s quarterly journal on PPPs.

Money can’t buy citizens’ love, but integrity and performance can

SUBMITTED BY ALEJANDRO GUERRERO RUIZ, CO-AUTHORS: AUDREY SACKS 

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We know very little about governments’ willingness to take risks. Technologies to enhance public sector performance are widely known and available nowadays, but we still can't predict when governments are likely to take risks in the implementation of complex public sector reforms. One prerequisite for any government attempting to implement reforms is that it has sufficient political capital. Governments and politicians seeking trust and legitimacy try to win or buy approval, but they do not always succeed in winning anything approaching legitimacy. We are still grappling with how to objectively measure the extent to which governments are effective and even demonstrate that citizens are good judges in perceiving and distinguishing good-performers from bad-performers, or in translating that perception into political endorsement or trust.

Our argument is that a government that shows early returns from Public Sector Management (PSM) reforms in terms of delivering better public services, showing fairness in the interactions with citizens, and enhancing the quality and performance of its street-level bureaucracy will build the necessary political capital to undertake more far-reaching and politically costly public sector reforms at a later stage. Further, these improvements are likely to increase citizens’ trust in governmental authority and their willingness to comply with government taxes and regulations, which in turn will improve a government’s capacity to become more effective and to evoke deference, which will further enhance the credibility of future reform packages.

Using survey data, we analyze the sources of political capital, specifically trust and legitimating beliefs, in a wide variety of settings: Latin America, Africa, and the Middle East. Our findings suggest that the source of this capital comes from service delivery, bureaucratic competence and honesty and procedural fairness. Across Africa, when evaluating governments, citizens’ perceptions of procedural fairness and the honesty of the bureaucrats swamp governments’ service delivery activities. In Latin America in particular, we found that governments were able to rapidly re-build trust in government institutions at the local level, by focusing on delivering quick improvements in sectors which were very visible and a priority for citizens. For example, these early gains allowed the Mayor of Medellin to gain enough political capital to break with past clientelist politics, and to introduce a new public management framework based on the delivery of services and responsiveness to citizens’ needs. His calculations were right: investing in improving very visible, relevant public goods, and making an extra effort to share the results with citizens paid off. He left office with 90 percent approval, without having to resort to clientelism as usual.

Thus, PSM reforms are more likely to generate short-term positive political returns and longer-term gains for a government if it is able to improve perceptions of its bureaucracy’s competence and the fairness of government procedures. The importance of procedural justice in eliciting support for governments is a strong finding of a large body of research. How we are to promote procedural fairness is compatible with PSM reforms: good public servants and transparency combined with institutional arrangements to provide effective voice and grievance procedures to those who experience discrimination. We also know from experiences around the world that governments are more likely to elicit its citizens’ approval when bureaucrats including teachers, nurses, and agricultural extension agents treat those individuals with whom they interact on a day-to-day basis with dignity and provide services with a manageable amount of red tape and corruption. 

While improving services may not harm an incumbent government’s popularity, enhancing service delivery is unlikely to directly generate any significant short-term political returns for a government. Why is this the case?  Introducing service-enhancing reforms in a clientelist context is costly and may trigger rent-seeking. In addition, because the public has limited information about what exactly the government does and how, individuals may not assign credit to government for service delivery improvements even when the credit is due.  Rather, citizens may be attributing the improvements to other actors including sectarian groups, the private sector; NGOs and community-based groups; religious institutions; traditional leaders; and, donors.  From looking at the results in our two pieces of research, we conclude that politicians will only engage in reforms to improve the provision of public goods when the chances of receiving credit and political capital are high. Therefore, we argue that projects which involve visible government agencies and address citizens’ top priorities will increase the chances that citizens correctly attribute improvements in welfare to the better performance of government.

If this is the case, and politicians are only going to be tempted to follow the risky path of reform when the gains are feasible, then how can the World Bank, other donors and NGOs work with governments to ensure that governments at least receive the credit when it’s fairly due?
 

I want to be... a millionaire.

Youth in Uganda discuss their career goals and aspirations.