Priority setting

Reviving Philadelphia: Using the Hud Section 108 Program to Create a Loan Pool for Economic Development, 1993 – 2000

Author
Hilary Duff
Focus Area(s)
Country of Reform
Translations
Abstract

In 1995, Philadelphia, a city on the East Coast of the United States, pioneered a unique use of a long-running federal loan program to bolster economic development and create jobs for low-income communities. Conceived by elected officials and economic development staff and championed by an ambitious mayor, the novel approach employed a lesser-known component of the US Department of Housing and Urban Development’s Community Development Block Grant program known as a Section 108 loan guarantee. Philadelphia established the nation’s first citywide loan pool funded by the Section 108 program and became a model for other communities wishing to undertake similar projects. This case is the first in a series on financing local housing and economic development initiatives.

Hilary Duff drafted this case study based on interviews and research conducted in Philadelphia during November and December 2022. This case is part of a series about using the U.S. Department of Housing and Urban Development’s Community Development Block Grant program effectively. The views expressed in the case study do not necessarily represent those of the Department of Housing and Urban Development. Case published in April 2023.

A Solid Start for Every Child: The Netherlands Integrates Medical and Social Care, 2009 - 2022

Author
Leon Schreiber
Focus Area(s)
Core Challenge
Country of Reform
Abstract

Despite having a sophisticated health-care system and spending more on health care than do most countries in the world, by the early 2010s the Netherlands experienced some of the poorest perinatal-health outcomes in the European Union. Birth-related complications among women and infants were driven primarily by economic and social inequality. For example, women living in the country’s low-income neighborhoods were up to four times more likely to die during childbirth than the Dutch average. In partnership with university researchers, the municipalities of Rotterdam, Groningen, and Tilburg began tackling the problem. After discovering that the growing disparities in perinatal health outcomes were driven in large part by social and economic challenges rather than by purely medical factors, the cities set out to build integrated, multisectoral teams­—local coalitions—that brought together service providers working in both the health-care and social domains. To tailor care to an individual patient’s own circumstances, the coalitions transcended the traditional boundaries that separated physicians, midwives, municipal officials, social workers, and other service providers. They worked to integrate their records and come to agreement on ways to monitor progress, and they designed referral systems and procedural road maps to deal with specific and individual client problems. In 2018, the national Ministry of Health, Welfare and Sport expanded the use of such local coalitions to reduce early-childhood health disparities in municipalities throughout the country. By early 2022, 275 of the Netherlands’ 345 municipalities were participating in the program, dubbed Solid Start, and the new national government pledged to expand the program to every municipality in the country.

 

Leon Schreiber drafted this case study based on interviews conducted between September 2021 and April 2022. Case published May 2022. This case study was supported by Bernard van Leer Foundation as part of a policy learning initiative. Please note that the Solid Start program described in the case is not an instance of the foundation’s Urban95 strategy, which features in several other ISS case studies that are part of the learning project.

Seizing Opportunities, Strengthening Synergies: Lima Frames a Collective Strategy to Advance Early Childhood Development, 2019–2021

Author
Miguelángel Verde
Focus Area(s)
Country of Reform
Abstract

Jorge Muñoz had long championed efforts to improve the lives of children in his relatively well-off district of Peru’s capital city, Lima. In 2019, he had a chance to take some of his ideas to scale. As newly elected mayor of metropolitan Lima, a city of almost 11 million, he oversaw basic services for about a third of the country’s population. At the time, a fifth of Peru’s population lived in poverty, and one in three people lived in informal settlements, where supporting families to give infants and toddlers a healthy start on life presented many challenges. The mayor directed the metropolitan government’s Social Development Department and a small interdisciplinary team of architects and social scientists (1) to identify lessons learned from pilot projects, (2) to establish new ways of assisting infants and young children, and (3) to coordinate to get the job done. When the COVID-19 pandemic broke out in the capital city in 2020, the metropolitan government and its team continued this work, using some of their newly created systems to respond to the larger challenge of caring for vulnerable populations during months of emergency lockdown measures. The national government labeled Lima’s program, which engaged residents in project development, as a promising model for helping local governments implement a countrywide strategy for the promotion of early childhood development.

Miguelángel Verde drafted this case study with the help of Tyler McBrien based on interviews conducted in Lima, Peru, during 2020 and 2021. Case published August 2021. The Bernard van Leer Foundation supported this case study to foster early-stage policy learning.

 

 

Bridging the Divide: Coalition Building for Early Childhood Development in Istanbul, 2016 – 2020

Author
Leon Schreiber and Gordon LaForge
Focus Area(s)
Country of Reform
Abstract

By the mid-2010s, Istanbul, the biggest city in Turkey, had developed a reputation as a bustling concrete jungle notoriously unfriendly to the 1.2 million children aged four years and younger who lived there. As part of a decade-long construction boom, multistory skyscrapers increasingly replaced green spaces and parks throughout the city. But such insufficient consideration for the developmental needs of young children was not confined to the design of public and urban spaces: in many Istanbul homes, parents worked hard to put food on the table and had little time to consider how to give their young children the best possible start in life. In February 2016, a coalition of policy research organizations and private enterprises launched an ambitious effort to persuade officials in Istanbul’s 39 districts to begin taking the needs of young children seriously. The group drew on help from a network of prominent Turkish universities and partnered with four district municipalities that agreed to join a program called Istanbul95, supported by the Bernard van Leer Foundation, a Dutch foundation. The group created a digital-mapping tool to help locate vulnerable children, conducted regular home visits to support hundreds of families, and designed new prototypes for child-friendly public spaces. This effort to embed principles of early childhood development into the work of Turkish local governments passed a milestone when, in 2019, the major metropolitan area governments of Istanbul and İzmir also agreed to join, a key step toward reaching many more children.

Leon Schreiber and Gordon LaForge drafted this case study based on interviews conducted in Istanbul in June and July 2020. Case published November 2020. The Bernard van Leer Foundation supported this case study to foster early-stage policy learning.

 

Learning To Be Smart: Using Data and Technology to Improve Services in Kansas City, Missouri, 2009 – 2019

Author
Tyler McBrien
Focus Area(s)
Country of Reform
Abstract

When Troy Schulte took over as interim city manager of Kansas City, Missouri, in 2009, the local economy was struggling and the government faced hard choices about how to use scarce resources. With a slashed budget and a diminished workforce, Schulte had to figure out how to deliver city services without reducing quality. Together with a small team of employees, he began to create a culture of data-driven decision making in municipal offices, to invest selectively in technology, and to give nonprofit organizations and firms an opportunity to develop their own, innovative solutions to city problems by making more information available to them. Schulte found a kindred spirit in Mayor Sly James, who negotiated a public–private partnership with a view to developing what Kansas City’s chief innovation officer called “the smartest 54 blocks in the country” along the city’s new streetcar corridor. As initial efforts came to a close and a new mayor entered office, Schulte and other officials stepped back to assess what they had learned. The new, data-driven culture had yielded positive improvements, whereas the technology-based smart-city initiative had had a more limited impact—at least in the shorter term. The experience generated important lessons about the scale of the benefits that technology could generate in midsize cities and in what kind of time frame.

Tyler McBrien drafted this case study based on interviews conducted in Kansas City, Missouri, in January 2020. Case published March 2020.

 

Making Good on a Promise: Boosting Primary Health Care Funding in Nigeria, 2015 – 2019

Author
Leon Schreiber
Country of Reform
Abstract

During the first decade and a half after Nigeria returned to democracy in 1999, the country struggled to adequately fund its primary health care system. Despite a nearly 10-fold increase in the size of the economy, Nigeria in 2014 was still spending only US$11 per capita on health care—equal to only 6% of total government expenditure and far below regional norms and the nation’s own stated aspiration. As a result, Nigerian citizens were paying 69% of their medical expenses out of pocket, and the cost discouraged many from seeking treatment. A new National Health Act, adopted in 2014 after a decade of delay, raised hopes for a solution by stipulating that at least 1% of the government budget go into a new fund to improve basic services provided at the thousands of primary health care clinics located throughout the country. However, owing to Nigeria’s longstanding neglect of primary health care, there was a real risk that the fund might never become reality. To demonstrate the viability of the program and press for its implementation, the federal health ministry, led by Minister Isaac Adewole, developed operational procedures that spelled out crucial steps to ensure financial accountability and transparency, won international backing for a pilot project that would validate the system, and built a support coalition that spanned the government and civil society. The effort took three years, but in 2018 the Nigerian legislature passed an appropriations bill that for the first time included the 1% allocation for the fund—significantly boosting the resources available to improve the quality and accessibility of primary health care services across Nigeria. Even more significantly, in September 2019, the government declared the fund a statutory allocation that it would automatically renew every year, and clinics in three states began receiving the new resources in November 2019.

Leon Schreiber drafted this case study based on interviews conducted in Abuja, Nigeria, in July and August 2019 with the help of Bunmi Otegbade. Case published November 2019.

Reducing Inequality by Focusing on the Very Young: Boa Vista, Brazil, Deepens Its Investment in Early Childhood Development, 2017 – 2019

Author
Bill Steiden
Focus Area(s)
Country of Reform
Abstract

Narrowing the gap between rich and poor was a top priority for Teresa Surita, five-time mayor of Boa Vista, Brazil. Surita had long viewed early childhood development services as crucial for improving life chances and attaining that goal, and she had partnered with several programs to expand parent coaching and other opportunities. As her fifth term began in 2017, she turned to a program called Urban95, which called for making a top priority the needs of young children and their families in all of the city’s planning and programs. Building on work the city had already done, Surita and her department heads undertook projects that included adapting a neighborhood to the needs of young children and their caregivers and building a cutting-edge data dashboard and alert system designed to ensure citizens would get help when they needed it. The city sought to keep those efforts on track while also extending assistance to families among the refugees fleeing deprivation and violence in neighboring Venezuela. As the term of the initial phase drew to a close in September 2019, municipal officials began to take stock of progress and results. Despite some philosophical disagreements and some uncertainties about the future of vital federal funding, the city was on track to achieve its project goals. 

Bill Steiden drafted this case study based on interviews conducted in Boa Vista and Sao Paulo, Brazil, in July and August 2019. Case published October 2019. The Bernard van Leer Foundation supported this case study to foster early-stage policy learning.

 

Easing the Burden of Care: Planning and Budgeting for Health in Vietnam, 2005 – 2015

Author
ISS Staff
Country of Reform
Abstract

In 2005, Vietnam’s legislature voted to develop a new health insurance system that would reduce most citizens’ out-of-pocket health-care costs and instructed the health ministry to take steps to make care more accessible, more affordable, and more effective—especially for those who lived in remote, mountainous regions. One of the challenges was how to manage scarce resources in order to constrain soaring costs. Another was how to coordinate with provinces and local governments (districts and communes)—which controlled much of the country’s health-care spending—in order to achieve national priorities, such as improved preventive care. During the next several years, the health ministry’s Department of Planning and Finance worked with those subnational units to improve the financial information system, hone strategies and plans, and align activities. By 2014, Vietnam’s government had more than tripled its per-capita health-care spending—to US$48.82 in 2014 from US$15.52 per capita in 2005, in current US dollars—a rate of growth that outpaced the average in both low-income and lower-middle-income countries. Although the ministry still struggled to keep patients’ costs down, the share of out-of-pocket spending fell to 45% in 2015 from 67% in 2005, according to government figures.

ISS staff members drafted this case study based on interviews conducted in Hanoi, Vietnam by Simon Engler and Huong Dang in May, June, and August 2018. Case published in May 2019. This case is part of an ISS series on linking health priorities to the budget process.

Best-Laid Plans: Ethiopia Aligns Health Care with National Goals, 2014-2018

Author
Gordon LaForge
Country of Reform
Abstract

Ethiopia’s Federal Ministry of Health was struggling to meet its goals in 2014 despite impressive gains in the health of its citizens during the previous 20 years. A new minister and his leadership team reached out for ideas by engaging Ethiopia’s regions, districts, and communities—an essential step in a large and ethnically diverse society. They then developed an ambitious transformation program to help realize the government’s national aspirations for health care, including commitments made to achieving the Millennium Development Goals. To bring their vision to fruition, however, the minister and his team had to link priorities to the budget process and use the health budget as a management tool. The ministries of health and finance matched goals and targets to available resources and worked to create actionable plans. And health officials took steps to build cooperation and extend coordination at every level of government in Ethiopia’s federal system. Technical and capacity constraints—plus unexpected political upheaval beginning in late 2015—slowed implementation, but in 2018 a new administration was taking steps to address those challenges.

Gordon LaForge drafted this case study based on interviews conducted in Addis Ababa, Ethiopia, in October 2018. Case published January 2019.

To view a short version of the case, please click here

When Curbing Spending Becomes the Top Priority: Colombia Tries to Balance Health Needs and Fiscal Capacity, 2013-2017

Author
Gordon LaForge
Country of Reform
Abstract

In 2012, Colombia’s public health system was headed for bankruptcy. The country had made significant progress on important public health priorities: expanding immunizations, reducing infant mortality, and attaining near-universal insurance coverage. But a Constitutional Court ruling that the government had to pay for almost all health services and technologies for those it subsidized, combined with rising pharmaceutical prices, was pushing the budget into deficit. Economist Alejandro Gaviria became minister of health and social protection amid that simmering crisis. To contain spiraling costs while enabling the sector to focus on some of its priorities, he worked to create new legislation that would limit the services the government would cover, regulate the drug market, and adjust an incentive structure that had lowered accountability and encouraged excess. In parallel, budget officials in the health ministry, the Ministry of Finance and Public Credit, and the National Planning Department tried to improve financial management of the system in order to increase efficiency and reduce costs. In the end, some of Gaviria’s efforts paid off and the ministry averted immediate insolvency, but as of 2018, the viability of Colombia’s health-care system remained in doubt even as health indicators improved.

Gordon LaForge drafted this case study based on interviews conducted in Bogota, Colombia in September 2018. Case published November 2018.

To view a short version of the case, please click here