Monday, April 13, 2020

A reality check on economists as plumbers

I have already written about economists as plumbers here, here, here, here, and here. Economists are plumbers only to the extent that instructors of plumbing courses in a polytechnic can be trusted with actual plumbing for your house.

In her now famous Economist as Plumber speech delivered at the annual AEA meeting in January 2017, Esther Duflo posited her own straw man case and scorned at the officials of the Health Department of the Government of Kerala, 
Their best idea is to reform the public primary health care system in order to make it more attractive to customers (who for the most part seek their health care in the private sector, like elsewhere in India), and to instate better practices of prevention, management, and treatment. They would try out a new organization of the health care sector. Nurses, volunteers from the local governments, and doctors would work seamlessly in a health team that would be in charge of keeping the population healthy, with a heavy focus on encouraging lifestyle changes and preventative activities. They are currently planning to try the system in 152 health centers. 
Though the Additional Chief Secretary (top bureaucrat) in charge of health had invited us to the meeting, he was called away to deal with a doctors’ strike around the time the conversation turned to the specifics of the reform. He handed us over to a retired professor and a retired doctor, who have been charged with designing the specifics of the policy. This in itself is symptomatic: top policy makers usually have absolutely no time for figuring out the details of a policy plan, and delegate it to “experts.” In our conversation, we started to push on some specific questions on the model that they had in mind: why would patients pay attention to a nurse, given that until now they have only taken doctors seriously? Were they really sure that if the nurse started to take blood pressure and fill prescriptions, this would give her the authority she would need to dispense advice? Or that doctors would be willing and able to signal that nurses were to be respected, in a system that has always been heavily hierarchical? For that matter, did the planners really think it was going to be possible for health care professionals to spend a lot more time on public health and prevention when there were only two doctors for every 30,000 people?
What was striking was, not only did they not have any answer to these questions, but they showed no real interest in even entertaining them. Whenever we asked them to spell out what they thought their policy lever was (as opposed to their aspiration), the stock answer was that they did not really have one, that the local governments and medical officers could not be forced to do anything. May be a village committee would need to decide to organize yoga classes, but another one would not, so there was really no way to find out what really worked. This was entirely beside the point, since the presence (or absence) yoga class would have been an outcome of what they could do at the central government (train local governments in the fundamental of public health for example). But they seemed to have no understanding of a causal chain going from policy design to implementation and final outcome. Their position oscillated between presenting the illusion of the perfect system, and presenting the illusion of complete powerlessness in the face of local power and initiative.
We tried, and failed, to engage them on the details of policy. Not only did they have no understanding of plumbing issues, there was not even a realization that plumbing was an issue at all. When the top bureaucrat popped in and was appraised of the conversation it was decided that we would be shown some details. We went away to another meeting and came back after three hours. They had set up the projector, a sign that things were about to get serious. They displayed a power point with each of the new UN Sustainable Development Goals, and a list of proposals to achieve them in Kerala. These amounted to a long, meritorious, and likely totally vacuous, wish list (30 minutes of exercise per day mandatory in all schools, awareness of obesity to be built in communities, etc.). Interest- ingly enough, it had nothing to do with the health care reform that we had discussed that morning. It appeared that the details would have to wait for another day.

I have since learned to avoid these kinds of meetings in general, but this encounter reminded me of my early days as a plumber. It turns out that most policy makers, and most bureaucrats, are not very good plumbers.
Now this is what the actors in the story had to clarify,
Former additional chief secretary (health) Rajeev Sadanandan, who invited Banerjee and Duflo to Kerala and who in Duflo's paper is simply called 'top bureaucrat', said there could be other reasons why Duflo was upset. “It is not as if the officials here did not understand what she and others asked. It is just that local level planners felt that their technique was not suitable to measure the outcomes of Aardram,” Rajeev said. In short, there were ideological differences. “And Duflo and Banerjee were told that Kerala cannot adopt their methodology to assess the outcome of Aardram. They probably would have felt bad"... “She does not know how Kerala functions. Moreover, the people who interacted with Banerjee, Duflo and Gita Gopinath were part of the team that evolved the Aardram Mission,” he said. On their part, the Kerala team was not particularly enthused by Banerjee's and Duflo's randomised trial method. They felt it was a bit too rigid, and removed from reality. “The question was is it possible to break health into discrete activities whose effects can be segregated from related factors and studied separately,” Rajeev said...
Dr B Ekbal, a neurologist and Planning Board member... feels that Duflo had misunderstood the Aardram Mission. She seems to be under the impression that nurses would function as quasi doctors under the mission... Dr Ekbal said at no stage in the planning of Aardram Mission had the planners thought of asking nurses to take over even the least important functions of doctors, leave alone filling prescriptions. “At the most they will do a preliminary assessment of the patient, and even this is usual practice. Nonetheless, we have increased the number of nurses to four in a family health centre,” Dr Ekbal said... (On SDGs) “It is strange she called our goals vacuous when some of them included bringing down infant mortality rate to 8 from 12 and neonatal mortality from 7 to 5 by 2020,” Dr Ekbal said.
Needless to say, while the speech went viral (to further entrench a self-serving narrative), the clarification hardly got any mention.

Clearly the plumbers understood neither the government program nor the context. Instead she constructed a straw man stereotype to caricature government officials, one which tarred everyone with the same brush, and reinforced an entrenched narrative to a completely disconnected academic audience, and one which presented the compelling raison d'etre for their own active engagement with public policy. It was a classic make-believe world!

Actually, the four paragraphs quoted above have several other factually incorrect things, leave aside the deeply questionable subjective conclusions. The speech itself, especially on the other India examples, is littered with similar or graver problems. 

Never mind that the actors and the context is about arguably one of the more impressive global development success in general and especially in health sector. Further, the derisively described officials themselves are all among the most respected and deeply experienced professionals. 

Anyways, fast forward to the times of Covid 19. Pretty much the same set of actors within the same Kerala government, using exactly the derided decentralised model and approach, are today globally acclaimed for their impressive work. This has several links to stories documenting the success till date of the Kerala model of Covid response. And this from the Washington Post,
Even though Kerala was the first state to report a coronavirus case in late January, the number of new cases in the first week of April dropped 30 percent from the previous week... The success in Kerala could prove instructive for the Indian government, which has largely shut down the country to stop the spread of the contagion... The state faced a potentially disastrous challenge: a disproportionately high number of foreign arrivals... Its challenges are plenty — from high population density to poor health care facilities — but experts say Kerala’s proactive measures like early detection and broad social support measures could serve as a model for the rest of the country... Kerala’s approach was effective because it was “both strict and humane,” said Shahid Jameel, a virologist and infectious disease expert... “Aggressive testing, isolating, tracing and treating — those are ways of containing an outbreak,” said Jameel, who is also the CEO of Wellcome Trust, a health research foundation. Henk Bekedam, the World Health Organization’s representative in India, attributed Kerala’s “prompt response” to its past “experience and investment” in emergency preparedness and pointed to measures such as district monitoring, risk communication and community engagement. 
Some of the things in the article itself is exaggerated - for example, Kerala did not do any mass testing, but only followed the standard Government of India protocols - symptomatic people with travel or contact history, health workers with symptoms, all hospitalised patients with severe acute respiratory illness (fever, cough etc), and asymptomatic direct and high-risk contacts of a confirmed patient (once between days 5 and 14 of having come in contact). 

Incidentally, when the same set of officials come up with this lockdown exit strategy (it is a 36 page detailed plumbing document), which is perhaps the only document of its kind available now anywhere in the world, and has become the reference document for others, what do the plumbers come up with? Sample the "nine steps" prescription,
First, try to make sure that every household has at least one person who knows the key symptoms of the disease. Second, spread the awareness that some people will get infected despite their best efforts; we want to avoid ostracism and concealment. Honest reporting is key. Third, offer multiple ways to report; a hotline, the ANM, the Asha, etc. Fourth, consider training the rural health practitioners (including the unqualified) in the detection of those symptoms and reporting them to the relevant authorities. Fifth, make sure that those reports are collated quickly so that we know where the new hotspots might be and more generally, focus on coordination of the evidence from across the country so that broad trends can be identified. Sixth, in each state create a large mobile team of health professionals, doctors and nurses, with testing kits and, ideally, ventilators and other equipment. The idea is a part of this team will be quickly deployed wherever the number of reports seems to be growing fast (including in nearby areas in other states)... Seventh, to build this team and make sure it has access to the necessary equipment, require all health professionals (and not just those who work for the government) to be available for call up where needed and give the teams the right to make use of all hospitals, private and public, as needed. Eighth, be much, much bolder with the social transfers schemes... Finally, be prepared to continue this “war effort” until the vaccine comes on line. Then vaccinate as many people as possible. And start to upgrade the healthcare system — let us be better prepared for the next time.
I'll not comment on this, but leave it to perceptive readers to make sense of it. Except to say this - the median official in any district could have come up with something much more practical, relevant, scalably actionable, and likely to be effective. 

If only real plumbing was as easy as it is misunderstood to be!

It is indeed something to introspect that, instead of scaremongering with models and peddling mass lockdowns and impossibilities like mass testing, none of the experts have anything constructive to offer by way of  practical and actionable suggestions to governments on calibrated exits, social distancing, management of migration, more optimal testing protocols, re-starting of business activities, managing epidemic relapses, and so on.

Interestingly, the role of experts in the US has been much more constructive and relevant. Sample this summary of the choices available and the debate surrounding them. When will the international development plumbers think about surfacing such debates for developing countries?

When faced with real world problems and solving them in real time, the "bureaucrat", "retired professor", and "retired doctor", along with several others, have done a remarkable job, one which is a model for others, and not just in India, to emulate. 

Ultimately, plumbing is about getting stuff done. And that requires people who have experience of doing stuff, not mere knowledge of concepts and frameworks. As mentioned in the beginning, teaching plumbing courses is not enough to make good plumbers!

Update 1 (18.04.2020)

Another example of plumbers just cutting and pasting which are already being done, many since the beginning in many districts, and passing off as novel suggestions. And what have not been done have a practical reason for not being done. If only Covid 19 fighting had such low-hanging fruits!


A Vasudevan said...

This is a great post. I liked it immensely. It is impossible to do mass testing in a country with such a huge population.
Kerala has set a standard. It has to sustain it in the weeks to come.
And the State deserves all support, material, financial as well as moral.
The randomized trial method is not a good way of handling health care strategies and issues. Unfortunately, economists who get international recognition just do not want to hear any objections to what they do and would like to be heard and revered. This is the hubris part of it.

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