Sam Watson’s journal round-up for 25th February 2019

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Democracy does cause growth. Journal of Political Economy [RePEc] Published January 2019

Citizens of a country with a democratic system of government are able to affect change in its governors and influence policy. This threat of voting out the poorly performing from power provides an incentive for the government to legislate in a way that benefits the population. However, democracy is certainly no guarantee of good governance, economic growth, or population health as many events in the last ten years will testify. Similarly, non-democracies can also enact policy that benefits the people. A benevolent dictator is not faced with the same need to satisfy voters and can enact politically challenging but beneficial policies. People often point to China as a key example of this. So there remains the question as to whether democracy per se has any tangible economic or health benefits.

In a past discussion of an article on democratic reform and child health, I concluded that “Democratic reform is neither a sufficient nor necessary condition for improvements in child mortality.” Nevertheless democracy may still be beneficial, on average, given the in-built safeguards against poor leaders. This paper, which has been doing the rounds for years as a working paper, is another examination of the question of the impact of becoming democratic. Principally the article is focused on economic growth, but health and education outcomes feature (very) briefly. The concern I have with the article mentioned at the beginning of this paragraph and with this newly published article are that they do not consider in great detail why democratisation occurred. As much political science work points out, democratic reform can be demanded in poor economic conditions due to poor governance. For these endogenous changes economic growth causes democracy. Whereas in other countries democracy could come about in a more exogenous manner. Lumping them all in together may be misleading.

While the authors of this paper provide pages after pages of different regression specifications, including auto-regressive models and instrumental variables models, I remain unconvinced. For example, the instrument relies on ‘waves’ of transitions: a country is more likely to shift politically if its regional neighbours do, like the Arab Spring. But neither economic nor political conditions in a given country are independent of its neighbours. In somewhat of a rebuttal, Ruiz Pozuelo and other authors conducted a survey to try to identify and separate out those countries which transitioned to democracy endogenously and exogenously (from economic conditions). Their work suggests that the countries that transitioned exogenously did not experience growth benefits. Taken together this shows the importance of theory to guide empirical work, and not the other way round.

Effect of Novartis Access on availability and price of non-communicable disease medicines in Kenya: a cluster-randomised controlled trial. Lancet: Global Health Published February 2019

Access to medicines is one of the key barriers to achieving universal health care. The cost-effectiveness threshold for many low income countries rules out many potentially beneficial medicines. This is in part driven though by the high prices charged by pharmaceutical countries to purchase medicine, which often do not discriminate between purchasers with high and low abilities to pay. Novartis launched a scheme – Novartis Access – to provide access to medicines to low and middle income countries at a price of US$1 per treatment per month. This article presents a cluster randomised trial of this scheme in eight counties of Kenya.

The trial provided access to four treatment counties and used four counties as controls. Individuals selected at random within the counties with non-communicable diseases and pharmacies were the principal units within the counties at which outcomes were analysed. Given the small number of clusters, a covariate-constrained randomisation procedure was used, which generates randomisation that ensures a decent balance of covariates between arms. However, the analysis does not control for the covariates used in the constrained randomisation, which can lead to lower power and incorrect type one error rates. This problem is emphasized by the use of statistical significance to decide on what was and was not affected by the Novartis Access program. While practically all the drugs investigated show an improved availability, only the two with p<0.05 are reported to have improved. Given the very small sample of clusters, this is a tricky distinction to make! Significance aside, the programme appears to have had some success in improving access to diabetes and asthma medication, but not quite as much as hoped. Introductory microeconomics though would show how savings are not all passed on to the consumer.

Credits

Does political reform really reduce child mortality?

Measuring causal effects is a tricky business. But, it’s necessary if we want to appropriately design effective policies and interventions. Many things are not amenable to manipulation in an experiment and so we rely upon a toolbox of statistical tools to try to identify the effect of interest. These methods are often ingenious, finding sophisticated ways of exploiting different types of variation, but they are essentially uninterpretable without an underlying causal theory. To illustrate this, let’s consider a paper that was featured a few weeks ago in the journal round-up: Effect of democratic reforms on child mortality: a synthetic control analysis.

A large number of countries have undergone democratic reform over the last 20 years. This article aimed to estimate how that reform has impacted upon child mortality. To do this a synthetic control method was used.

Synthetic control

The synthetic control method was formalised by Alberto Abadie, Alexis Diamond, and Jens Hainmueller in an article in the Journal of the American Statistical Association. It’s particularly useful in the situation where there is one area or cluster or country that has undergone a change, and multiple potential countries or clusters to act as controls that did not undergo the change. The eponymous synthetic control is a weighted average of the potential control sites where the weights have been chosen to best replicate the pre-intervention trend in the intervention site. The example given by Abadie and colleagues is estimation of the impact of tobacco control reform in California on tobacco consumption. The other US states are all potential controls. Bayesian synthetic control methods have also been established (by a team at Google), which we will make use of later.

The synthetic control method therefore seems appropriate to analyse the impact of democratic reform in a given country. Measurement of democratic reform was based on a change in the Polity2 index that rates the degree of autocracy/democracy in countries; a switch in the index from negative to positive (the index runs from -10 to 10) was considered ‘democratic reform’. Of the 60 countries identified as having reformed, 33 met the inclusion criteria, and 24 counterfactuals were able to be constructed. The primary outcome is the relative reduction in child mortality after ten years; the results from the 24 countries are shown in the histogram below (Figure 1). It would seem that, on average, democratic reform seems to reduce child mortality.

demo1

Figure 1. Histogram of results from the 24 included countries from Pieters et al.

Causes

Perhaps one of the factors that have limited research in the area of political economy and health is the complexity of the relationships between the various macro, micro, economic, and political effects. For example, on the basis of the evidence presented above, we would still not be able to say whether, for a given country, introducing democratic reform would have any impact on child mortality. Let’s consider a couple of examples to explore why.

figure

Figure 2. Results from synthetic control analyses of the impact of democratic change on child mortality. Data from UN Inter-agency Group for Child Mortality Estimation.

Mozambique

Mozambique was engaged in a civil war between 1977 and 1992 as the communist Frelimo battled the anti-communist Renamo for control of the country. At the cessation of hostilities in 1993, wide sweeping reforms were enacted by Joaquim Chissano, and an election was held. We can consider 1993 as the year of democratic reform and conduct our own synthetic control analysis (using the aforementioned Bayesian approach). The results are shown in the figure above (Figure 2). Clearly, there is a significant reduction, but is this due to democratic reform or simply the end of civil war? A counterfactual approach is used as the theory of causation behind much statistical inference. Had an autocratic regime followed the civil war would there have still been declines in child mortality? I would conjecture that there would have been. Democratic reform in this case is either not a cause or a redundant cause.

Zambia

Kenneth Kuanda was removed as the president of Zambia in 1991. Following this, reforms for multiparty democracy were enacted. Figure 2 above reports the estimated impact upon child mortality. A decline is clearly evident, however, this decline does not start until 2003, when the copper price tripled (Figure 3 below; copper constitutes 88% of Zambia’s exports) and GDP per capita almost doubled. Again, whether democratic reform can be inferred as a cause in this instance is questionable, especially when reduced to questions of counterfactuals.

copper

Figure 3. Copper price per metric ton (US$). Data from IMF Cross Country Macroeconomic Statistics Database.

South Africa

The apartheid regime was ousted in 1994 following election of the ANC in South Africa. This regime change opened up the political institutions to the majority of South Africans who had previously been excluded. However, as Figure 2 above shows, this reform appeared to have little impact on child mortality. Indeed, South African healthcare still faces significant challenges, and large structural inequalities in access to quality healthcare persist even today. Taken together, this illustrates that democratic reform is not a sufficient condition for improvement of population health.

Zimbabwe

Finally, consider Zimbabwe, which became more autocratic in 1986 following a deal between Zanu and Zapu. If democratic reform improves child mortality then it seems reasonable that autocratic changes would worsen child mortality. Figure 2 above reports the synthetic control results for Zimbabwe. No change is evident.

What can we conclude?

Democratic reform is neither a sufficient nor necessary condition for improvements in child mortality. We cannot understand the evidence without an underlying theory. The study discussed here is a good data analysis; decent analyses in this area should be encouraged. But, the theory should come before the data.

Credits

Conference round-up: Medicine, Markets and Morals Network Meeting Three

Last October saw the first meeting of the Medicine, Markets and Morals Network. Today and yesterday I attended their third and final (for now) meeting in London. The network brings together researchers from across the social sciences and humanities to discuss issues relating to resource allocation in health care. A book is planned and the website will be maintained, so hopefully the Network has a future and will produce something more permanent. For now, here are some of the overarching themes that I saw being discussed at the conference.

To deliberate or not to deliberate?

I don’t know what it is about philosophers that enables them to talk so well without slides. The conference started with a prime example in the shape of Jonathan Wolff discussing alternative approaches to valuing health care. Should we consider preferences, experienced utility or capabilities? And whose? Jo suggested that there is no single best approach and argued in favour of a discursive, deliberative approach.

This became a recurring subject for the event, to which we returned on the final day with Ruben Andreas Sakowsky arguing that deliberative evaluation is a better way of eliciting individual preferences. To this end, he suggested that we ‘upgrade’ the way we do discrete choice experiments. Leah Rand argued that we need to upgrade the notion of ‘accountability for reasonableness’, which is at the heart of decision-making processes in health care. Leah argued that there is a need to ensure legitimacy in the process of decision-making and a requirement for fair consideration of reasons.

But deliberative processes present challenges. Do people know enough to make informed decisions about the allocation of health care resources? If they don’t then there is still an argument to be made that in a democracy it is the views of these people that should be acted upon. But can deliberation still be meaningful if the people involved have no understanding of the context or implications of their decisions?

Information – particularly who has it and which bits of it matter – was the major theme of the conference for me. I think a lot of what we discussed related to the incompatibility of evidence-based policy and democracy. I’ll come back to that later, once I’ve discussed some of the other speakers’ talks.

Systems, structures and marketisation

Another major subject was the Health and Social Care Act 2012 (HSCA). Richard Taunt discussed the HSCA, noting the tendency for people to view the apparent fiasco as undemocratic. Richard argued that this is not the case, but rather issues like this have “no salience in electoral politics”. Even if people say that NHS policy will determine which way they vote, in reality votes don’t correspond to what people say is important. One option is to build sustainable development into democracy, such as has been tried with the Well-being of Future Generations (Wales) Act or the Finnish ‘Committee for the Future’. But, Richard argued, we already have the Health Select Committee and plenty of think tanks; ‘upgrading democracy’ should not be about structures. Rather, we should focus on encouraging the right kinds of behaviours, such as humility and continual learning.

Later in the day, Allyson Pollock presented a quite different story about the Health and Social Care Act; as providing the mechanisms for the deconstruction of the NHS. Allyson explained that the Act does away with the duty to provide universal health care according to need, and that the closure of hospitals is the evidence of this possibility being realised. The risk presented was that we might end up with a US-style system of health care funding and provision.

Therese Feiler presented a theological basis for the use of economics-type thinking in health care, which took us all out of our comfort zone; a great thing! Therese suggested that the use of diagnosis-related groups (DRGs) is a part of the process of the commodification of health care.

Mary Guy discussed the legal situation in the UK and The Netherlands regarding the application of competition law to health care, which is key to the potential for marketisation of the NHS. The take home message is that whether or not the NHS could be subject to competition law (in its current organisation) is still to be decided in the courts.

Rudolf Klein gave a notably lo-fi talk on the need to ration expectations rather than treatments or procedures. He argued that the NHS agenda is determined by the state of the economy. While the NHS Mandate (which we were all encouraged to read) lists many goals, the top item on the list of NHS ‘must-do’s relates to financial stability. The question is, what are we willing to sacrifice from the long list of NHS goals? (There was support in the room for allowing longer A&E waiting times.) And what about the cost of transparency and statistics in order to maintain ‘anticipative accountability’, which is held to be very important? Can we sacrifice some of these costly processes which in turn help create more goals for the NHS mandate?

Evidence, narratives and democracy

Chris Newdick argued that bioethics hasn’t done us much good, in that the focus on autonomy has bolstered neoliberalism. He discussed the notion of public health ethics and asked why community is not the starting point for the ethical debate rather than the individual. In this sense, has the neoliberal agenda been more successful in the debate about health care, as well as more broadly?

I think this brings us back to the issue of information. The idea that autonomy and/or the free market is paramount is an a priori notion. The invisible hand is a nice story, and people are compelled by it. Evidence, on the other hand (the visible hand), is not compelling. One can always find evidence to support a claim and as such the non-expert may be inclined to distrust all evidence. A compelling story is more difficult to disregard.

In his closing remarks, Cam Donaldson mentioned Robert Evans’s notion of zombie policies. These are not usually evidence-based zombies but about stories. Cam presented Alan Williams’s old argument about the distinctiveness of health care as akin to a duck-billed platypus. This provides a nice analogy, but it still depends on evidence. This is why we see the ‘health care is just another good’ argument coming back time and time again; recently in the broccoli debate in the US.

The problem is that the basis for publicly provided health care requires a lot of thought and a lot of foundational understanding of how things work in a particular economic, political, legal, historical and ethical context. For example, to know that health care is not broccoli you need to understand moral hazard (etc), and that this has been observed. There is evidence. However, in order to support neoliberalism and a free market in health care you don’t need any of that. All you need is basic intuition and a compelling heuristic: leave people, institutions and corporations to do as they please and the invisible hand will sort it all out.

This at least partly explains why academics tend to think differently about resource allocation in health care. Rachel Baker and Helen Mason presented their work on eliciting public views about the allocation of resources at the end of life. Using Q methodology (for which we were given a brief tutorial) they have identified three different viewpoints that people tend to adopt. The first group support the notion of value for money, with no special cases; QALY-maximisers would fit into this group. The second believe that life is precious, and they are not likely to accept any restriction of health care due to costs. The third is a more nuanced group that value wider benefits while also acknowledging the importance of opportunity cost.

On the first day we attendees were presented with 18 statements, with 7-point likert scales to elicit our agreement. The same questionnaire was used in a large online survey of a representative sample of the UK. This survey is designed to elicit the prevalence of the different viewpoints. Viewpoint 2 was by far the most common in the general population. Meanwhile, in the room, viewpoint 3 was the leader. As for me, the stats showed that I was the strongest supporter of viewpoint 3. This discrepancy between the public and a group of academics may not come as a surprise, but it is noteworthy. Viewpoint 3 is the most nuanced position. It acknowledges the messyness of health care resource allocation decisions. The findings of the survey suggest to me that the public do not recognise this messyness, or at least employ a simpler decision process that ignores some of the messyness. They may be right to do so, but I suspect not. As academics we know more about what we do not know; we have more known unknowns. The general public on the other hand don’t – and can’t be expected to – understand all of the challenges of resource allocation in health.

One of the very last points to be raised in the concluding discussion was whether homeopathy should be funded on the NHS. Most of us agreed it shouldn’t, but Ruben bravely stuck his neck out and suggested that if people want it then who are we to deny it? I think there’s an analogy to be drawn here between homeopathy and free market health care. We know homeopathy isn’t good for people. We know market forces in health care (broadly speaking) aren’t good for people. But both of these assertions are empirical; dependent on understanding a long history of evidence and fundamental notions of how we determine what is good for people. The public don’t have this understanding. The ‘invisible hand’ and ‘like cures like’ make for far more compelling and easily attainable interpretations of reality. So people will vote for them. But that is not a good thing.