Journal articles on the topic 'Economic Structural Adjustment Program (Zimbabwe)'

Since the debt crisis of the 1980s, Philippine economic performance has been an outlier in East Asia, in spite of reform policies that generally have conformed to worldwide norms of trade liberalization and deregulation. In the 20-year period since 1980, the proportion of GDP attributed to manufacturing has declined from 24 to 22 percent. Dependence on commodity exports has declined, and the Philippines' export structure is now less diversified than it was 20 years ago. Market-oriented economic reforms are incomplete, as they are in many other countries, but the Philippines' poor economic performance is mostly a result of macroeconomic instability and low domestic savings, not inadequate reforms. Reform efforts have contributed to political instability, and macroeconomic instability has stifled investment. A model of macroeconomic shortages in domestic, external, and public savings is presented to illustrate the continuing constraints on Philippine economic growth and development.

When Alberto Fujimori campaigned for president of Peru W i n 1990, he ran on a platform in which he promised to institute a moderate program of gradual economic stabilization, including the privatization of certain state-owned enterprises. These promises were instrumental in his scoring an upset victory over writer Mario Vargas Llosa, who had been the odds-on favorite to win just three months earlier — and, thus, to become Peru's third popularly elected president in his country's ten years of continuous democracy.Nevertheless, soon after Alán García relinquished the presidential office, in July 1990, to the newly-elected president, those election promises underwent a dramatic reversal. On the grounds that he had inherited a bankrupt country which left him no alternative (no habia otra cosa que hacef), the new president moved quickly to establish a stabilization program of classic orthodoxy in August 1990 (Fujimori, 1990).

The impact of structural adjustment program on the economic situation in many African countries can not be overemphasised. Over two decades of implementing neo-liberal economic policies by the Bretton Woods institution, it is of great importance to document the lessons learnt. This paper elicits the structural mechanism representing the intended effect of structural adjustment policies and the unintended effects observed from the implementation of the structural adjustment policies. The assumptions and hypotheses implicit in the main structural adjustment policies, as well as the observed unintended effect of the policies are clearly elicited with a causal loop diagram.

This article explores neo-liberal economic development concepts on general and criticism on them in the form of alternatives provided. Actually, the concepts themselves have not been openly accepted by the World Bank and the IMF, while since 1990s both international financial institutions have been for several times forcing the application of the concepts in countries that received loan from the institutions. This topic becomes very important since Indonesia has experienced many economic policies which are forcefully driven or demanded by the IMF or the World Bank. Those kind of policies are, for instance, capital liberalization, trade liberalization, privatization, and structural adjustment program. Neo-liberal development concepts are based on liberal economy ideas only, which consist of free market profit and private asset ownership. The concepts have been applied to many developing countries in the form of structural adjustment program package.Keywords: neo-liberal, structural adjustment, liberalization, economic development

The economic and political crisis which Turkey faced during 1977-1980 was resolved by an orthodox stabilization program adopted early in 1980, immediately followed by conventional structural adjustment measures and the military coup realized on September of the same year. The Turkish experience with orthodox stabilization and structural adjustment incorporates a number of specificities and it will be useful to recall them briefly.First of all, the striking element of continuity in basic economic policy orientation which lasted from 1980 up till 1089 without any significant reversals should be emphasized. The personal role of Turgut Özal as Vice Premier in charge of the economy during 1980-1982 under the military governments and Prime Minister during 1984-1991, was a determining factor in this respect. Reversals and hesitations as observed in Latin American experiences due to differences between rival monetarist schools or between populist and right wing political groupings played practically no role for almost ten years in Turkey. The political pressures which resulted in a switch back to populism in 1989 —a theme to be investigated in this paper— marked, in our view, a drastic shift away from the policy model adopted in 1980.

AbstractThe focus of this study is on urban agriculture which is a common informal sector activity across most sub-Saharan African cities. Urban agriculture is more common among poor urban households, and acts as a poverty coping mechanism. Poor households often spend more than 60% of their income on food alone. The major thrust of this study was to understand the underlying mechanisms driving farming in cities. A mixed method research approach was adopted and data was collected from 103 households in Glen Norah Township in Harare, Zimbabwe through semi-structured interviews, questionnaires and observations. Arising from analysis of the data, the Urban Livelihoods Coping Model (ULCM) is proposed in order to explain the phenomenon of urban agriculture in African cities. This model acknowledges the fact that the socio-economic conditions and the socio-historical context of Zimbabwe and other African countries today is as a result of the influence of ‘Western leaning’ development policies influenced by modernization and associated theories. These theories combined with cultural factors and the impact of Structural Adjustment Policies resulted in the present situation where urban agriculture plays a critical role in the survival of the urban poor as a coping mechanism against food poverty. The ULCM ascribes the emergence of urban agriculture to necessity, ability and opportunity. The significance of this study is that it will contribute to understanding the socio-economic role of urban agriculture and how it can be factored into the urban planning systems of developing countries.

A primary health care (PHC) strategy was adopted in Ghana in 1978, but the civilian government at the time failed to implement the program designed to achieve health for all Ghanaians. In 1982, the revolutionary military government under Rawlings indicated its commitment to the full implementation of the PHC program. In this article, the author seeks to examine the extent to which the Economic Recovery Program initiated by the Rawlings' regime, its policy of decentralization and mobilization of the masses, and its promise to institute some fundamental organizational and structural changes in the health care delivery system, are contributing to the process of achieving “health for all” Ghanaians.

This paper examined the effect of external factors on economic growth in Tunisia. The economic analysis was carried out using recent quantitative technique of annual time series data from 1976 to 2017. Based on co-integration test with unknown structural breaks and ARDL bound testing we investigated importance of each factor in stimulating economic growth. Our results show that in the long-run FDI does not affect economic growth. Remittances and imports negatively affect economic growth. Exports promote economic growth such that a 1% increase stimulates economic activity by 0.702%. In the short term, our estimates emphasize a structural break in 1988 linked to the structural adjustment program. Likewise, FDI does not have a significant effect on economic growth while remittances and imports slow economic growth significantly at the conventional level. On the other hand, exports form a relevant engine of economic growth. Therefore, our conclusions imply that political decision-makers in Tunisia must guarantee certain level of training and infrastructure to ensure the gain of transfers of new technologies and experiences related to the FDI. Thus, Tunisia must encourage peoples living aboard to create new investment opportunities instead of just supporting their families for consumption. In addition, the state must develop financial system capable of transferring funds for investment in order to better benefit from remittances. Finally, the government must restrict import of consumer goods and allow import of equipment and machinery goods that promote production and economic growth.

After implementing harsh austerity measures during 2008–2011, in the period 2012–2014 the fiscal adjustment programs also involved social equity measures, the quantitative fiscal consolidation being changed into a qualitative one—a reduction of the structural budget deficit accompanied by an improvement of social sustainability indicators. The 2015–2017 period shows mixed evolutions in terms of social progress brought by the recovery of the economic potential lost during the crisis. This research analyzes the sustainability of economic competitiveness dynamics from a social viewpoint during 2012–2014. In this paper, we analyze the way in which the economic and social components of fiscal adjustment programs are dynamically balanced in 24 EU member states. We identify four clusters of countries depending on the relationship between fiscal consolidation/fiscal stimulation and the social dynamics of the sustainability adjusted global competitiveness index. We found that under the pressure of “fiscal adjustment fatigue” caused by tough austerity programs in the period 2008–2011, most of the European countries completed the fiscal adjustment packages with measures to improve the social situation between 2012 and 2017. The fiscal consolidation programs have become more balanced from the perspective of the combination of budgetary austerity—social equity measures. Furthermore, we analyze how some countries on the EU periphery (Central and Eastern Europe, Baltic countries and Portugal, Ireland and Greece, countries that have joined the EU with a lower level of development) are experiencing or not an improvement in the social sustainability generated by the measures aimed at stimulating the economic growth implemented during 2012–2017. To conclude, we proposed a few pillars that could be integrated if an “ideal adjustment program” is to be achieved.

<span>This paper examines the distributional properties of stock returns in the Nigerian stock market. Because emerging stock markets present several institutional, political and economic barriers, we hypothesize that the structural adjustment program begun in 1986 resulted in a sustained increase in the variability of stock returns. Conventional variance homogeneity tests could not reject the hypothesis of changing volatility in the security returns process. However, the Lagrange multiplier test reveals the presence of autoregressive conditional heteroscedasticity (ARCH) effect in the stock returns.</span>

<span>This paper examines the distributional properties of stock returns in the Nigerian stock market. Because emerging stock markets present several institutional, political and economic barriers, we hypothesize that the structural adjustment program begun in 1986 resulted in a sustained increase in the variability of stock returns. Conventional variance homogeneity tests could not reject the hypothesis of changing volatility in the security returns process. However, the Lagrange multiplier test reveals the presence of autoregressive conditional heteroscedasticity (ARCH) effect in the stock returns.</span>

This paper will attempt to critically examine Canada’s Seasonal Agricultural Workers Program (SAWP) with an intent of connecting four themes: the Canadian agricultural industry, indentured servitude, the labour regime in Canada, and the racialization of the SAWP. It has been argued that the workers from the Caribbean who participate in the Temporary Agricultural Workers Program are should consider themselves fortunate to be given such an opportunity. I argue that this assertion is problematic because it overlooks the hardship the workers face in Canada as a result of their non-citizen status. I also examine the fact that many of the workers enlisted in the SAWP are forced to migrate for a living wage due to poor economic conditions in their countries of origin, and that these conditions are a direct consequence of unequal trade policies and structural adjustment programs. Finally, I demonstrate Canada’s complicity in benefiting from these programs.

Abstract This article contributes to the social history of neoliberalism by analyzing the emotions, feelings, and sentiments through which Turkish people experienced the structural adjustment program of the 1980s. I argue that market reforms were experienced through a paradoxical entanglement of desire and disillusionment—an affective politics that Lauren Berlant defines as “cruel optimism.” This concept captures the ways in which neoliberalism generates a series of aspirations, longings, and yearnings that can never be fully achieved or satisfied but nevertheless pulls subjects toward an imagined future. I examine these collective feelings through a visual analysis of Kemalist intellectual Turhan Selçuk’s editorial cartoons that were published in the center-left newspaper Milliyet between 1983 and 1986. These editorial cartoons function in complex ways, providing relief through satire but also narrating the ways in which a sense of optimism encircled sentiments of anxiety, despair, and precarity. I identify three distinctive instances of cruel optimism in his work: first, the will to retain control over economic affairs despite the dominance of international organizations, second, the hope that trade liberalization shall bring prosperity amidst mounting class inequality, and third, the allure of consumption even when most of the population was unable to afford export commodities. Rather than demonstrating a clear temporal gap between the promise and demise of market reforms, the article reveals the coproduction of two oppositional affective registers and suggests that the fluctuation between willingness and reluctance is a constitutive element of neoliberal subjectivity.

The five-year term of President Kim Dae Jung ended up deepening political cleavages in the wake of growing social conflicts. We find it ironic that the Kim Dae Jung regime, the first case of horizontal power transfer through election, has seen social conflicts worsening instead of weakening. Since the economic crisis of 1997, the country has undergone a profound societal and political transformation as a result of the International Monetary Fund (IMF)'s program of liberalisation, privatisation and deregulation. We investigate the structural realignment - power shift, social conflicts, and coalition change - in the wake of the economic crisis in Korea. We critically examine the impact of various reform measures on state-society relations. Our starting point is a belief that the stability of a regime depends not only on economic performance but also on social and political performance. The current Korean situation might even suggest that social and political factors are more important than economic performance in evaluating structural adjustment programs. We begin by examining the underlying nature of the Kim Dae Jung regime's reform measures. Then we address the social realignment, coalition change, and social conflicts, and assess their implications for consolidation of democracy. Finally we draw some policy implications.

Historically, health care in Zimbabwe was provided primarily to cater to colonial administrators and the expatriate, with separate care or second-provision made for Africans. There was no need for legislation to guarantee its provision to the settler community. To address the inequities in health that had existed prior to 1980, at independence, Zimbabwe adopted the concept of Equity in Health and Primary Health Care. Initially, this resulted in the narrowing of the gap between health provision in rural areas and urban areas. Over the years, however, there have been clear indications of growing inequities in health provision and health care as a result of mainly Economic Structural Adjustment Policies (ESAP), 1991–1995, and health policy changes. Infant and child mortality have been worsened by the impact of HIV/AIDS and reduced access to affordable essential health care. For example, life expectancy at birth was 56 in the 1980s, increased to 60 in 1990 and is now about 43. Morbidity (diseases) and mortality (death rates) trends in Zimbabwe show that the population is still affected by the traditional preventable diseases and conditions that include nutritional deficiencies, communicable diseases, pregnancy and childbirth conditions and the conditions of the new born. The deterioration of the Zimbabwean health services sector has also partially been due to increasing shortages of qualified personnel. The public sector has been operating with only 19 per cent staff since 2000. Many qualified and competent health workers left the country because of the unfavourable political environment. The health system in Zimbabwe has been operating under a legal and policy framework that in essence does not recognize the right to health. Neither the pre-independence constitution nor the Lancaster House constitution, which is the current Constitution of Zimbabwe, made specific provisions for the right to health. Progress made in the 1980s characterized by adequate financing of the health system and decentralized health management and equity of health services between urban and rural areas, which saw dramatic increases in child survival rates and life expectancy, was, unfortunately, not consolidated. As of 2000 per capita health financing stood at USD 8.55 as compared to USD 23.6, which had been recommended by the Commission of Review into the Health Sector in 1997. At the beginning of 2008 it had been dramatically further eroded and stood at only USD 0.19 leading to the collapse of the health system. Similarly, education in Zimbabwe, in addition to the changes it has undergone during the different periods since attainment of independence, also went through many phases during the colonial period. From 1962 up until 1980, the Rhodesia Front government catered more for the European child. Luckily, some mission schools that had been established earlier kept on expanding taking in African children who could proceed with secondary education (high school education). Inequity in education existed when the ZANU-PF government came into power in 1980. It took aggressive and positive steps to redress the inequalities that existed in the past. Unfortunately, the government did not come up with an education policy or philosophy in spite of massive expansion and investment. The government had cut its expenditure on education because of economic and political instability. This has happened particularly in rural areas, where teachers have left the teaching profession.

The alleviation of poverty is one of the most debated issues among the academicians and policy makers. From 1950s to 1980s the poverty reduction program has been based on increase the participation of poor into the economy by better macroeconomic performance. Though the poor part of population mostly engaged in informal sector1 is identified by researchers but has not become the part of economic models and government policy [Robinson (2001)]. Poverty reduction has been institutionalised in 1944 when World Bank was set up. The World Bank worked through governments and institutions by giving loans to developing countries called structural-adjustment programmes. These programmes were highly unsuccessful, created dependence on aid with little help to poor part of societies [Murduch (1999) and Diop, et al. (2007)].

Abstract:The promotion of the private sector has become an integral part of Ghana's economic development strategy since it embarked on its structural adjustment program (SAP) in 1983. Private sector development, which involves the improvement of the investment climate and the enhancing of basic service delivery, is considered one of the necessary factors for sustaining and expanding businesses, stimulating economic growth, and reducing poverty. This article examines the policies of Ghana's New Patriotic Party (NPP) government and its strategies for making the private sector the bedrock of economic development and for achieving what it calls the “Golden Age of Business.” It argues that while the policies and initiatives being pursued have the potential to help in the development of the private sector in Ghana, the government has to play a more central role in this process, not only by creating the enabling environment for private businesses, but also by providing business with support and protection. While the “Golden Age of Business” is a neoliberal concept, its effective implementation requires a robust statist input.

The conceptual paradigm of the work is that the modernization of the regulatory policy of the state strengthens the relationship and interdependence between the structure of the economy and the institutional basis, the quality of institutions. In these conditions, public investment management becomes a necessary condition and general goal of socio-economic development. That is, structural changes supported by public investment management institutions ensure economic growth, and their implementation is regulated by the criteria for ensuring the economic security of the state. It is proved that the management of public investments is a multifaceted category that reflects socio-economic phenomena and is considered as the motive and goal of the macrosystem functioning; the level of autonomy (independence) of the state of the economy, at which the achievement of the aggregate vector of interests of the structural elements of the macrosystem is ensured; a qualitative characteristic of the economic system, which makes it possible to assess its viability in the face of transformational changes. The study of the structure of the economy, the direction of its progressive changes are still based on sectoral technological and economic aspects without taking into account the strategic prospects and security of the development of the socio-economic macrosystem of the state. The imperfection of the institutional support of structural adjustment makes it impossible to strategically program structural changes as an integral component of structural policy. In general, in the context of radical structural and institutional transformations, the role of the public investment management system is significantly increasing. The applied set of threshold values of public investment management indicators as imperatives for the functioning of the economy at the meso level of the hierarchy should be complemented by a methodology for their determination and substantiation of effective measures and methods for their provision. The study of the problems of public investment management is associated with the development of theoretical foundations and the definition of economic and institutional aspects of public investment management in the context of updating the levers of state regulatory policy, in particular, in the context of participation in the processes of global economic integration.

The article provides a structural and political account of financial intervention in Spain, Portugal and Greece and examines competing explanations for financial liberalization. It focuses on the economic and political objectives underlying financial reform, and the costs and benefits for government, central bank, and the banking sector. It argues that financial liberalization was, to a significant extent a necessary prerequisite for the central banks' programmatic effort to achieve effective disinflation. This challenges the dominant arguments viewing financial liberalization exclusively within the framework of the European financial integration program or as a result of interest group pressure. At a subsequent stage, a stabilization strategy based on monetary austerity entailed the significant political advantage of allowing governments to avoid a more radical pace of fiscal adjustment. Both financial interventionism and liberalization displayed a state-driven policy pattern.

Abstract Since 1994, people in Ghana have eagerly registered for the United States Diversity Visa lottery, an annual program that makes immigrant visas available to residents of countries that historically sent few immigrants to the United States. Although the green card lottery was not created to facilitate immigration from Africa, Ghanaians embraced the lottery enthusiastically. The program dovetailed with the growing popularity of international migration—framed as seeking “greener pastures”—since the country’s adoption of neoliberal economic reforms beginning in the 1980s. In particular, the lottery in Ghana was amplified by urban visa entrepreneurs whose self-interested efforts marketing the program drove demand for diversity visas and related migration services. Examining how and why visa entrepreneurs disseminated information about the lottery and found paying customers eager for assistance, this article historicizes how Ghanaians thought about citizenship, mobility, and their place in the world, illuminating how people navigated structural adjustment and neoliberal logic in Ghana in the 1990s and 2000s. The United States became a prime destination for contingent reasons related to transformations of Ghana’s economy and politics that made permanent emigration more desirable and spurred urban residents to set up and expand small-scale enterprises. In a context of heightened global migration restrictions in the 1990s and 2000s, the visa lottery, a migration program that operated as a game of chance, took root in Ghanaians’ imaginations.

Development' is a political project which is based on a principle of reducing inequalities and poverty. It is a centuries-old concept that is deeply rooted in the history of economic thoughts. From the age of mercantilism to the liberal and neoliberal context, the nature of development has changed drastically. From 1945 to the 1970s, there was a popular liberal model of development under the slogans of 'right to development. The liberal nature of development tuned into conservatively camouflaged neoliberal development in the 1980s protected by the world bank structural adjustment program. In neoliberal development facade, the development process is emptied from welfarist. Development without welfare and development for underdevelopment are the main characteristics of neoliberal development. This paper is an exploration of the political economy of development, which means development to whom? Through a qualitative approach, it is found that neoliberal forces benefited from CPEC developmental project. The political economy of CPEC is a complex phenomenon that is linked with development, investment, technology, and human resources.

Global Financial Crisis has revealed major weakness in the design and implementation of the existing economic governance framework of the European Union. In addition, the first temporary fiscal backstop is EFSF (The European Financial Stability Facility) as a temporary crisis resolution mechanism by the Euro area Member States. In this case, The EFSF does not provide any further financial assistance, so the task of EFSF being replace by the new mechanism that includes the establishment of a permanent crisis management mechanism as the safeguard against imbalances in individual countries that is ESM (European Stability Mechanism). Spain as one of the Eurozone Member States that fall on financial crisis caused by disproportionate growth in the real estate sector, along with the expansion of credit, on 25 June 2012 made an official request for financial assistance through ESM for its banking system. In accordance with MoU, Spain must conduct a structural adjustment program through identifying individual bank capital needs, recapitalising and restructuring.

Abstract Failures of neo-liberalism in Africa through Structural Adjustment Program in the 1980s and 1990s compelled many post-colonial African states to seek alternative growth models to transform and grow their economies. Inspired by the economic success of Asian region, South Africa seeks to replicate the Asian developmental model to transform and industrialise its economy. Reviewing only the literature, the paper found that despite displaying so many similarities with East and South Asian developmental states, the rhetoric for the replication of the Asian developmental state model in South Africa works like a pendulum thus adopting a topsy-turvy approach. The notion of a developmental state is elevated through policy pronouncement and government commitments through the medium term and long-term strategic frameworks for the country. Despite displaying so many similarities with Asian developmental states, affixing the label of a developmental state onto the country by South Africans themselves is not going to make it one.

On February 19, 1990 a national conference opened in Benin at the Hotel PLM-Aledjo in Cotonou. Participants included representatives of the ruling People's Revolutionary Party, trade unionists, civil servants, students, religious leaders, a few agricultural producers, elements of the military, former heads of state, as well as Beninese living and working abroad. Members of the diplomatic corps and officials from the international financial institutions (IFIs) were also in attendance. The conferees claimed to represent the nation in its entirey—toutes les forces vives de la nation, quoi quoi que soient leurs affinitées. In reality, they were drawn from the political class and the educated elites of civil society. President Mathieu Kérékou opened the conference with a call for political renewal and a pledge to implement the IMF's structural adjustment program. He focused on the country's severe economic crisis and called on the delegates to draw up a list of the problems to be addressed.

<abstract> <p>This study examined the nexus between foreign direct investment (FDI), financial development, and sustainable economic growth in Sudan during the period of the structural adjustment program and the full Islamization of the banking and financial system that took place in the 1980s. The research provides a comprehensive analysis using the most recent time series secondary data from 1990 to 2020 and the study employed co-integration, Granger causality, and VAR error correction technique to estimate the models, to clarify the claimed relationship between FDI and its effect on the financial sector and subsequently attending a sustainable economic development in Sudan. In this research, Augmented Dickey-Fuller (ADF) unit root tests are applied to test the stationarity of data and the data was found stationary at first difference. The results of the ARDL bounds showed the existence of a long-term relationship between the FDI and other independent variables but the short-term showed otherwise. The Granger causality test implies that the past values of FDI don't significantly contribute to the prediction of sustainable economic growth. Also, results show that there's evidence of observed causality running from the country's trade openness and the financial sector's development. The implication of these results shows there is a complementary relationship between sustainable economic growth and both financial development and trade openness in the short run. Interestingly, the findings of the study show that the effect of financial development on economic growth is further enhanced by the inflows of FDI.</p> </abstract>

In spite of the growing importance of oil, Nigeria has remained essentially an agrarian economy, with agriculture still significantly contributing to its Gross Domestic Product. However, the potentials of the agricultural sector to contribute to economic development in Nigeria have varied widely in the last two decades. This variation appears to be correlated to the nature of the political and economic regimes that exists. There were indications of some moderate output increase following the introduction of SAP. But, it is not yet certain whether the extent of deregulation policy currently being pursued by the Government and the preliminary outcome has elicited the desired response. One of the indications of the adverse development is the diversion of scarce foreign exchange from financing capital and intermediate imports to paying for food imports. Successive governments have experimented with various options in the promotion of agro-based industries, import substitution, promotion of specific sectors and specific areas. The outcome is an imbalance growth of various sub-sectors in the sector, poor capacity utilization, eroded competitiveness of local manufacturers and uneven playing field within the country. This paper basically reviews and analyzes the components of Nigeria’s agricultural sector, its contributions to economic development, and strategies adopted within the sector before and during the Structural Adjustment Program. It recommends that providing the right policy framework/enabling environment and incentives for private sector investment in the sector enshrined in the new economic blue print‘Transformation Agenda’ could be a viable option for revitalizing the sector.

Maize is one of the most important cereal crops produced and consumed in West Africa, but yields are far under their potential and the production gap leads to growing import bills. After the structural adjustment program, fertilizer subsidies again became a popular intervention to increase yields in most African countries. Ghana introduced fertilizer subsidies in 2008, with high government expenses. This study assesses the competitiveness of Ghanaian maize production and the significance of socio-economic and management variables in determining high yields in northern Ghana. Household survey data and secondary data were applied in a Policy Analysis Matrix (PAM) to test private and social profitability of the fertilizer subsidy policy. Additionally, a probit model is used to determine the characteristics that contribute to higher yields. The results suggest that production systems with Ghana’s above-average yields of 1.5 Mt/ha are profitable at household level and contribute to its economic growth, whereas production systems below this threshold report negative social profits and depend on government intervention. However, fertilizers did not increase the likelihood of a household to fall in the category of high-output production system, whereas the use of improved seeds and herbicides does. In conclusion, the analysis highlights the importance of additional measures, especially the use of supporting inputs as well as management practices, to increased maize productivity.

Purpose: Empirical investigations into the interest rate effects on domestic savings have provided mixed results. Hence, this study examined the interest rate effects on domestic savings in line with the financial liberalization hypothesis since the period of structural adjustment program (SAP) in Nigeria. Approach/Methodology/Design: Data on gross domestic savings, interest rate, gross capital formation, and rate of inflation from 1986 to 2018 were obtained and analyzed using the autoregressive distributed lag (ARDL) technique. Findings: The results revealed that interest rate and gross domestic savings are co-integrated in the long-run. The study showed that while capital formation positively affects domestic savings, the interest rate affects domestic savings negatively since the economic reforms of 1986 in Nigeria. Practical Implications: The results of the study are important for the Nigerian government to promote home-grown investments through domestic savings and capital formation. This will be made possible in the face of interest rate liberalization in which a higher interest rate serves as incentives for the household to save more thereby increasing domestic savings of the economy. Originality/value: The study further revealed that the long-run relationship exists between domestic private investments and interest rates.

This paper examined the activities/policies of privatization and commercialization of public enterprises in Nigeria and how they have affected the development of the Nation. Although, some of the problems facing public- owned enterprise were examined as well. It looked at the pressure on the International Monetary Fund (IMF) to fully implement the structural adjustment program that leads to massive deregulation, privatization, and commercialization of public owned enterprises. In addition, it looked at the merits if any, of privatization and commercialization through extensive theoretical review of the performance of the private enterprise in Nigeria. Theories, rationale, and challenges of privatization and commercialization were addressed. The conclusion was that privatization is a good policy measure, which must be pursued with vigor, truth, sincerity, and transparencies even though the government is using such policies to foster a new division of labor between the public and private sectors in a bid to order, increase the efficiency and contribution to the development of both sectors. Privatization and commercialization in Nigeria will be a mirage unless institutional reforms take place. The government should create an environment favorable for private economic activity. This can be done by showing zero tolerance for corruption, nepotism, and misuse of public funds and property by both government and non-government officials.

The continued evolution of mixed farming systems will depend on the development of technology which addresses the basic biophysical constraints of the agro ecological zone within which these systems have developed. However, the application of these technologies will increasingly depend on the extent to which they address all dimensions of the social–economic–environmental system within which mixed farmers operate. The Grain & Graze program has accelerated the adoption of several technologies that can provide a basis for continuing evolution of mixed farming systems (e.g. grazing of cereals, drought containment of livestock, perennial pastures) while initiating the development and exploration of others whose potential will be realised in the longer term (e.g. pasture cropping, integrated pest management in mixed farming systems, cover cropping and alley farming with old man saltbush). Some technologies capable of supporting continued evolution were not addressed comprehensively by the program but remain opportunities for future development, particularly technologies for feed demand management and inter-seasonal feed transfer. The program made considerable progress in fostering the explicit consideration of the ‘triple bottom line’ consequences of new technology. It has confirmed that no universal solution to the question of profitability and sustainability is to be expected but has also demonstrated that methodology is available to make the formal consideration of this question much more robust. Clearer definition of the institutional requirements for support of change in complex systems, and for effective management of large national projects, will provide key underpinnings to ensure that subsequent programs achieve the benefits of scale in RD&E that Grain & Graze has convincingly demonstrated. In addition, we argue that ongoing evolution of mixed farming systems that will deliver triple bottom line outcomes will require policies that achieve appropriate cost sharing for delivery of environmental benefits and increased capacity for structural adjustment within the industry itself, to account for changes in demography, infrastructure and farm management arrangements.

Upon the attainment of independence many African countries emerged with a new spirit of entrepreneurial governance and domestic industrialization. However with time, most of the state owned enterprises (SOEs) set up have been privatized largely because of mismanagement, huge deficits and operational inefficiencies created by many factors. In all material moments, the objective of divesture of SOEs was to stimulate efficiency, productivity and relieve the state of the huge financial burden they bring. Our study examines the methods of privatization of healthcare technology and equipment SOEs in Africa and their impact on post-divestiture productivity based on cases from Ghana, Nigeria, Tanzania and Kenya.We simultaneously collect and model privatization data from International Monetary Fund (IMF) and the World Bank relating to Ghana, Nigeria, Tanzania and Kenya. These were data submitted to the IMF and World Bank as part of the measures to implement the different forms of economic recovery and structural adjustment programs in the respective countries. Our empirical strategy follows the broader literature in estimating reduced form equations for firm performance as a function of ownership, while trying to account for potential problems of heterogeneity (observed and unobserved) and simultaneity bias. We note the insider/employee shareholding accounted for only 23.6 percent of privatization of healthcare equipments and technology manufacturing enterprises on average while mass privatization program accounts for 18.2 percent of the privatization mode. We note that each of these methods yield positive post divestiture labour productivity. However privatization of healthcare equipment and technology manufacturing enterprises by block sale to outside investors generated the highest form of labour productivity.

While the imposition of neoliberal policies by Western development institutions has been widely criticized, the ways in which such policies have found allies in the Third World have not received the same attention. This article focuses on India's cooperative dairying program in order to trace its transformation from an organization seeking to protect small-scale dairy producers against foreign dairy interests to current shifts in favor of the privatization of the dairy sector. The story of how India averted neocolonial dependence in its (dairy) White Revolution merits consideration now, when the global percentage of people in food poverty is again increasing. For decades, the International Monetary Fund and the World Bank enforced the Washington consensus demanding that developing countries adopt structural adjustment programs including privatization of state services, subsidy cuts to indigenous farmers and consumers, and the opening of markets to (often subsidized) food imports from rich countries. Neoliberal policies are implicated in rural poverty, hunger, and migration to sprawling megacities. Given this, it is important to focus on struggles against the possible loss of cooperative institutions and thus build a broader understanding of the ways in which neoliberal policies spawn rural conflicts. This article is divided into three main sections. In the first section, the growth of dairy productivity in India under the cooperative dairying program is traced from the 1970s onwards, beginning with its ability to utilize EEC food aid for the growth of the national dairy sector in a program called Operation Flood. A large part of the credit for this creative use of monetized food aid is usually attributed to Verghese Kurien, who has been associated with cooperative dairying from its beginnings in the small town of Anand, Gujarat, and whose pro-cooperative philosophy guided national dairy development organizations till recently. The second section of the article focuses on the institutional politics of dairy development, taking as its point of entry the replacement of Kurien by officials who are less likely to be oppositional to the privatization of the dairy sector. The departure of Kurien thus marks a key moment in the neoliberalisation of the cooperative dairying sector. The third section focuses on the wider politics of the state of Gujarat within which the ‘Anand pattern’ of cooperative dairying was established. Here, the pro-business policies of Chief Minister Narendra Modi have been focused on attracting foreign investment to the state, leading to accelerated, but not equitable, economic growth. The ways in which agrarian interests have both clashed and intersected with Modi's vision of development provides an understanding of the transformed political economy within which cooperative dairying now has to function. Overall, the politics of cooperative dairying in India provides an insight into the place-based nature of neoliberal experiences, and can serve as an illustration of impending rural struggles across the world.

The subject of the study is the effectiveness of providing the regional economy (on the example of a typical subject for Central Russia – the Voronezh Region) with personnel, taking into account demographic development trends. The purpose of the study is to conduct a comprehensive analysis of the impact of demographic processes (which should become the basis for a significant adjustment of the dynamics of the values of the calculated indicators of the main parameters of the labor market and employment, including the forecast of the economy’s staffing) on the staffing of enterprises at the level of the Russian regions. The scientific novelty consists in substantiating the need to increase labor productivity as the most effective tool for countering negative demographic trends that cause a reduction in the number and complexity of the structure of labor resources. The authors use methods of analysis, argumentation, logical constructions and modeling, systematization and classification, analogy, abstraction, induction and deduction, description. In the course of the study, the authors come to the following results and conclusions: regional strategies related to human resources management should be developed on the basis of population size and structure forecasts; at the regional level, it is necessary to develop a long-term demographic policy concept that is scientifically sound and approved by the expert community; in modern socio-demographic conditions, a significant part of the region’s enterprises are experiencing an unmet need for personnel, which is not fully compensated by the introduction of new technologies and robotics; labor productivity growth as an integral part of digitalization and intensification of the economy in the face of significant demographic losses is the most effective way to solve the problem of staffing enterprises and organizations; the policy aimed at overcoming the imbalances of the regional labor market and ensuring structural compliance of the demand for labor and its supply should be comprehensive, including changes in the structure and quality of vocational education; effective regulation of regional labor markets is impossible without the use of a socio-demographic approach based on design and program mechanisms, taking into account the regional specifics of the reproduction of labor resources; in the current conditions of increased demographic risks, the possibilities of solving the most complex socio-economic and socio-political tasks facing Russia without ensuring labor productivity growth and intensification of the economy as a whole are limited.

The article is devoted to the development of methodological tools for budget financing of the agricultural sector of the economy of Ukraine. It is substantiated that the agricultural sector is a basic component of sustainable development of the national economy, a multiplier of general economic growth. The low quality of budget planning was diagnosed, which negatively affected the formation of the system of budget financing of the agricultural sector of the Ukrainian economy. Systemic shortcomings of the financial support of the agricultural sector of the economy from the State Budget of Ukraine identified: repeated adjustment of planned expenditures for the general and especially for the special fund, due to non-fulfillment of planned volumes and untimely budget allocations for the needs of the agricultural sector, lack of continuity the amount of funding for government programs, etc. It is established that agriculture of Ukraine is financed by 2/3 from the general fund of the State budget, from the special - by a third; the main source of funding for other sectors of the agricultural sector is the general fund. The types of models of state regulation of the agricultural sector of the economy in terms of basic features are identified - the type of financial policy, the level of state intervention, targeting, consequences for the market environment, and countries that apply the relevant models. According to this set of features, American and European types of models are distinguished. The type of capital reproduction model in the agrarian sector of Ukraine's economy is diagnosed as an intermediate type (between American and European) with a specific mechanism of financial regulation, in which direct methods of state regulation with appropriate levers and tools are preferred. It is emphasized that the target vector of state support should be positive dynamics in creating added value in the agricultural sector of the economy and stabilizing the financial stability of agricultural enterprises, which will form the basis of expanded capital reproduction and encourage accelerated sustainable development of the agricultural sector. The main directions of budget financing of the agrarian sector of the economy of Ukraine are formed: increase of absolute volume and specific weight in the general expenses of the Consolidated budget of Ukraine at the level of the contribution of the branch to the GDP of the country; improving the quality of budget planning of expenditures, limiting the possibility of adjusting their volumes for the general and special fund; expenditures to support food security and export potential of the agricultural sector of the economy under protected items; ensuring structural changes in favor of the development budget and its formation on a medium-term basis; prohibition of discretion in the financing of state and regional target programs in accordance with the approved passports, specification of these expenditures in accordance with the departmental and program classification, to ensure the transparency of the budget process.

Zimbabwe has witnessed a rapid expansion of informal cross border trading (ICBT) with neighbouring countries over the past two and a half decades. That expansion has largely been due to a persistent decline in the economy since the introduction of the Economic Structural Adjustment Programme (ESAP) in the 1990s, which led to the closure of many industries, increased unemployment and forced many people into the informal sector. This 2014 study sought to provide a current picture of ICBT in Zimbabwe by interviewing 514 informal entrepreneurs involved in ICBT between Harare (Zimbabwe) and Johannesburg (South Africa). The sample profile revealed that ICBT in Zimbabwe is dominated by females and young adults and that traders are fairly educated. The study results demonstrate the important role played by ICBT in the survival of households in the country.

This study empirically examined the relationship between human capital development and economic growth in Zimbabwe for the period 1980 to 2015, using time series analysis techniques of co-integration, error correction model, and Granger causality tests. The study was motivated by changes which have characterised the financing of human capital since the country attained independence. A decade after independence, the government was able to adequately finance the social sectors; however, thereafter government financing has been declining since the adoption of the structural adjustment programme. The findings of this study indicate the existence of a short-run and long-run relationship between human capital development and economic growth in Zimbabwe. On the direction and significance of the relationship, the result is mixed. Human capital development, proxied by government expenditure on health, had a significant positive impact on economic growth—both in the short run and the long run—reaffirming that a healthy labour force will be more productive and efficient. Human capital development, proxied by government expenditure on education, was found to negatively impact economic growth in the long run. In conclusion, a positive relationship between human capital development and economic growth in Zimbabwe was found, although the relationship is weak.

A Fund-supported program is a package of envisaged policies which, combined with approved financing, is expected to achieve certain economic objectives such as fostering macroeconomic stability and orderly external adjustment, promoting growth and poverty reduction, and reducing vulnerability to future balance of payments problems or financial crises. This paper reviews experience with specific macroeconomic and structural policies intended to achieve these objectives.

The article focuses on economic structures that crush the poor, especially global economic structures that trap and keep people in poverty. The concept of poverty occupies centre stage in South Africa and many other developing countries. There is no longer a middle class. One is either rich or poor. Globalisation has created a system or program that continues to crush the poor, while also breeding greed and selfishness. The rich always accumulate resources while the poor struggle to make ends meet. These problems are created by the World Bank, the International Monetary Fund, and Structural Adjustment Programs, to name a few. These structures have introduced a system of inequality that widens the gap between the rich and the poor because of self-interest, which continues to crush the latter. The end result is that the concept of Ubuntu or Botho among African communities is destroyed. Injustice becomes the order of the day.

Abstract Background The link between health and the economy is well known. However, economic growth as measured in SDG8, continues to leave people behind and the funding gap for realizing SDG3 for good health and well-being remains vast. International financial institutions, i.e. the IMF, influence national policies in ways that may undermine the SDGs. We examine incoherencies between economic growth and health goals in Malawi, Uganda, and Tanzania. Methods We conducted qualitative research based on policy analysis. To analyse IMF policy advice in the three countries we reviewed relevant program documents, article IV consultation reports (2016-18) and literature on structural adjustment. We accessed health information from WHO and World Bank databases, and national policies. Results In all three countries, some indicators, e.g. infant and child mortality, improved, but others lag behind. Underfunding is a major cause for poor health and inequities. GDP increases (as a measure of economic growth) do not automatically translate to increases in health spending. Health expenditure from domestic public resources remains much lower than international thresholds. To achieve this level of spending domestically, GDP in these countries would require an unrealistic manifold increase. IMF policy advice and loan conditionality that focus on GDP growth and tight monetary and fiscal targets impair social spending, while suggested taxation measures are generally regressive. Conclusions The GDP-focused SDG8 can delay efforts towards the SDG3 if governments opt to focus on GDP growth without measures to equally distribute wealth and invest in social sectors, often under IMF's influence. Although the IMF has acknowledged the importance of social development, its policy advice still adheres to austerity, harming population health. To realize the SDGs everywhere, governments should abandon GDP growth as a policy objective, strive for equitable economic development and emphasise global co-operation. Key messages GDP increases do not automatically translate to an increase of health spending, partly a result of IMF structural adjustment programs and policy advice. To realize the SDGs everywhere, governments should abandon GDP growth as a policy objective and place more emphasis on SDG17 on global co-operation.

Based on the theory of “Non-Economic Promotion Championship,” this paper takes Appraisal-And-Commendation (AAC) policy of National Civilised City (NCC) program in China as the research object, and analyses the influence and mechanism of the NCC on carbon emissions from the perspective of energy demand. We find that NCC reduces carbon emissions significantly, and this reduction effect continues to expand over time. Furthermore, the NCC reduces carbon emissions through two mechanisms: First, the NCC reduces carbon emissions by slowing urbanisation. This mechanism mainly functions in big cities, megacities, and super cities, and does not function in small and medium cities. Second, the NCC reduces carbon emissions by promoting industrial restructuring from secondary industry to tertiary industry. This carbon reduction effect is a pure structural adjustment effect, regardless of any effects on technological level and productivity. Moreover, there are regional differences in the reduction of carbon emissions by NCC through industrial restructuring in two dimensions: In the first dimension, compared with the western region and the northeast region, the eastern and central regions are more able and willing to reduce carbon emissions through industrial restructuring. In the second dimension, compared with the northern region, the southern region is more likely to reduce carbon emissions through industrial restructuring.

The Managing Director’s Global Policy Agenda (GPA) presented to the IMFC in April identified a range of actions needed to bolster today’s actual and tomorrow’s potential output, diminish risks, and confront emerging global challenges. These actions included calibrating fiscal adjustment to economic conditions while establishing credible long-term fiscal frameworks and implementing growth-friendly fiscal policies, improving monetary policy effectiveness while containing excessive financial risk-taking, and accelerating structural reforms to raise growth potential and ensure inclusiveness. The GPA also outlined how the Fund would support the membership through assessments and policy advice provided in the context of multilateral and bilateral surveillance, financial support, and capacity building. This document translates the policy priorities laid out in the GPA and the IMFC communiqué into a work agenda for the Executive Board over the next 12 months. In particular, the Board will be engaged on several issues of multilateral scope, including quota reform and resources, the SDR basket review, challenges facing the international monetary system, and the post-2015 global development agenda. The work program also includes several items from the action plan of the 2014 Triennial Surveillance Review (TSR).

Background: As a transportation infrastructure that connects one area to another, roads have an essential role in economic and social growth, together with establishing a location that may improve the quality of life in the surrounding community. For this reason, it is necessary to perform road maintenance when the structural or functional capacity of the road is inadequate, one of which is by overlaying the road. Objective: The main objective of this research is to determine the thickness of the flexible pavement overlay and subsequently examine the damage model produced by the 2015 MEPDG method with Arizona calibration. This study also proposes recommendations for implementing the 2015 MEPDG procedures in Indonesian settings. Methods: The thickness of the road overlay can be designed through a mechanistic-empirical approach, which is commonly referred to as the Mechanistic-Empirical Pavement Design Guide (MEPDG). The back calculation on the BAKFAA program was utilized to examine the existing situation. At the same time, a stress-strain analysis was performed using the KENPAVE software to calculate the response of the pavement structure. Results: The 2015 MEPDG with Arizona calibration by controlling fatigue cracking has resulted in an overlay thickness of 180 mm. In addition, the damage model was obtained for each type of road failure and can be beneficial in estimating the future IRI value. Conclusion: The damage model generated from the 2015 MEPDG procedure is specific to the types of road damage, which can eventually be utilized to predict the future IRI value. It also encompasses local and global calibration variables, such as adjustment factors for its implementation in road pavement conditions in Indonesia. The MEPDG application can be simplified by shortening the mechanistic analysis process, along with reducing traffic variations and the level of detail in the daily climate analysis.

The article analyses the construction of the health care system of Ukraine, the historical preconditions of its current state. The reasons that hinder the development of the industry, one of which is the urgent need for effective management, the development of which is complicated by a number of subjective and objective factors, including gaps in the legal field, insufficient competence of management, and their undesirable development and implementation of new management technologies. Positive changes in government regulations, promising areas of training have been identified. The educational and scientific program “Management in health care” (specialty 073 “Management”) and the requirements for the competence of specialists are also analyzed. The issue of the need to build and develop a new model of health care, which should correspond to the modern market economy, comprehensive and intensive reform of the health care system, related to the methods of management, financing, reorganization of medical institutions. In Ukraine, the heads of health care institutions are staffed mainly by doctors who, undoubtedly, have significant experience and high qualification in medical specialization, no longer have special training in management and economics of health care. It becomes obvious that the presence of special education is NOT a priority sign during the appointment to the position of head of a medical institution. Health care reforms in Ukraine began much later than in other post-Soviet countries, almost two decades after independence. Transformations in this area, first of all, the acquisition of autonomy by institutions in administrative activities, the ability to raise funds from various sources, etc., necessitate effective management of medical organizations. The international experience of countries with developed health care systems shows that it is expedient to lead organizations and institutions with specialists in the field of management, economics and health care. The inconsistency of the training of specialists with the needs of practical health care and the tasks of structural adjustment of this type of economic activity is the main thing that hinders the effective management of health care organizations, as a result of which the quality of medical care deteriorates. Improving the management of health care organizations in Ukraine will allow you to effectively manage human resources and financial flows, which will result in both economic and social results of the individual, team, organization and the country as a whole.

Photo by Marek Studzinski on Unsplash ABSTRACT Payment models directly impact the way patients experience care. Historically, payment model innovations have been examined mostly from economic, organizational, and public health lenses. Financial incentives exist in all healthcare systems, whether a socialized, private or public insurance, or single payer system. This article examines the alignment of current predominant payment models of fee-for-service, capitation, and value-based payments with patient care ethics. The volume-based incentive of fee-for-service is misaligned with patient care, while capitation is a relatively neutral and highly modifiable model. Value-based payments offer a unique benefit in improving patient agency and have a larger benefit of cost control. However, no model adequately addresses health disparities, and a larger consideration for justice is needed by payment model designers when considering incentives. In consideration of related values, bioethics must expand the discourse around patient care ethics to cover patient interactions with the health system and market forces outside the clinical context. INTRODUCTION Healthcare payment models have always been controversial. Discussions about healthcare payment models broadly include economic, ethical, and medical realms. The “simple” act of one party paying for health care creates interactions between the payer, the provider, and the patient. Payments are based on an agreed-upon price between the paying party and the provider. While in most industries, at the level of retail delivery, the direct customer pays for the item received, in healthcare, the system is more complex. Deciding what metrics to base healthcare prices on has become arduous. Whether organizations should charge a patient for healthcare in nations where it is considered a human right is a subject of debate. This ethical debate over providing care is combined with the theoretical framework of how to price and pay for healthcare. This paper examines the ethics of various approaches to paying for care. Outside of the controversial notion of patients financing their care, existing payment models always involve some entity other than the patient paying for the bulk of the care – whether in a socialized system, single payer, or public or private insurance system. In these systems, an implicit financial incentive to provide care based on payment criteria arises.[1] Depending on the nature of the payment, the financial incentive may align with, be neutral toward, or misalign with a patient’s best interest and goals of care. These payments create market forces in capitalistic or single payer healthcare models and drive organizational behavior in nationalized models.[2] We can see the organizational and marketplace adaptations to predominant volume-based payment models in the United States in the form of shorter visits, unnecessary care or increased volume of care, and medical determination of which care is provided based on coverage. Fee-for-service has incentivized higher patient volume over quality time with patients, leading to 10- to 25-minute patient visits.[3] Payments based on any metric implicitly direct patient care by moving provider action toward the metric the payment is based on, regardless of intent or conscious effort.[4] For example, when the paying body financially rewards hospitals for shorter inpatient stays, then the average length of stay will decrease.[5] Payment for care has numerous, widespread effects on how patients experience care and even the quality of care they receive, creating ethical and economic issues. Oddly, from a strictly financial perspective, patients are secondary consumers of their care in most healthcare systems. With this, providers have a financial responsibility to the paying body to act within the bounds of payment incentives (specifically, the paying body, such as an insurance company, is assured that the patient gets the care that is paid for based usually on pre-agreed terms) and an ethical and duty-based responsibility to the patient for patient care. As an example of misaligned interests, there is a clear financial incentive to deny prior authorization for a medication that is an expensive yet otherwise appropriate alternative for a patient’s condition. This could result in equal treatment, perhaps a generic version even, or an alternative that the provider and patient would not have chosen otherwise. It could result in the patient being deprived of a choice. l. Patient Care Ethics and Payment Using the four principles of bioethics, the tenets of ethics for patient care, the payment systems have clear effects on patient autonomy and agency, and may conflict with beneficence, non-maleficence, and justice.[6]The tension that providers experience in navigating payers while fulfilling their patient responsibility causes ethical dilemmas. Volume-based reimbursement schemes prioritize efficiency, regardless of these major bioethical principles. To truly evaluate a payment model, we need not vaguely consider the supposed moral intentions of a model – we need to evaluate the theoretical incentive design as it pertains to the tenets of bioethics. I propose a novel model for viewing incentives with a bioethical framework. The motivation for viewing how the system design for payment models use incentives under a bioethical lens is summarized below. a. Payments, by nature, create active and passive organizational incentives. b. Incentives affect organizational and provider behavior, regardless of intent. c. Changed behavior in response to a financial incentive directly and implicitly impacts the tenets of bioethics. d. For payment models to be considered ethical, they must align organizational incentives with patient care goals and ethics. The argument that incentives should not exist in healthcare because they foster competition and, therefore, cause disparities is acknowledged.[7] However, the argument against incentives ignores the reality of healthcare, especially in the United States, where the most progressive recommendations still retain a paying agency. Therefore, the focus in this paper concerns the existing payment models. The alignment of predominant payment models—including fee-for-service, capitation or mixed models, and value-based payments —with patient care ethics is difficult. This paper argues that the value-based payment model is the most appropriately aligned model when considering health disparities, the Rawlsian difference principle, and distributive justice. ll. Payment Models and Patient Care Ethics Alignment Payment models are highly varied. As it currently stands, the most widely used model globally is fee-for-service, a volume-based model in which insurance companies pay physicians and organizations for performed actions based on evaluations such as relative value units. Relative value units consider physician work, practice expense, service rendered, and professional liability.[8] Later models, like capitation, were enacted to control costs. Simply put, purely capitated payments consist of flat-term payments for patient care that do not change based on services rendered.[9] Within the past decade, value-based payments, which pay physicians based on patient value, as defined by outcomes divided by costs, became popular.[10] There are other approaches to paying for patient care, such as health savings accounts or direct primary care (patients directly pay physicians without insurance).[11] While these are assuredly interesting areas of study, the financial incentives mimic fee-for-service, in which physicians and organizations receive payments based on direct services rendered and will not be discussed further in this article. lll. Fee-For-Service Fee-for-service is the main payment model worldwide.[12] It has played a large role in shaping the structural nature of healthcare, particularly in the United States.[13] Fee-for-service, although declining, is still pervasive in the US health system and has created market forces that indirectly affect the geographic distribution of care, with an obvious volume-based market force.[14] Even with the advent of alternative payment models, fee-for-service remains the primary mode of physician compensation by percentage in primary care in the US.[15] Fee-for-service’s financial and organizational incentives are based on the number of patients seen and services rendered. The World Health Organization stated in its 2010 Health System Financing report that this model likely leads to care overprovision, inefficiency, and upwardly spiraling costs.[16] The pervasive volume-based incentive in fee-for-service misaligns with patient care goals as patient care is not its primary goal. This rudimentary payment system attempts to finance health care as if it were any other good or industry. But more care is not necessarily better care, and fee-for-service leads to higher patient bills, higher system costs, and largely inefficient and unnecessary treatment schemes.[17] Tummalapalli, et al. found that capitated models had lower visit frequency and fewer interventional actions with no difference in outcomes compared to fee-for-service models. Care overprovision—in services rendered—and upwardly spiraling costs are not in the best interest of patients, violating beneficence at the population level. The misalignment of incentives is at the root of the problem. As a rudimentary payment system, fee-for-service does not have patient care in mind, nor has beneficence as its goal. To evaluate fee-for-service from its own goals, the question here should not center around whether this model is in the best interest of patients. Instead, it should focus on the principle of non-maleficence. Can we truly say that upwardly spiraling healthcare costs do not harm patients? In the US, fee-for-service has largely negative social effects on burdens in minority populations, enhancing disparity.[18] The system is arguably unjust, violating the principle of justice. Disadvantaged groups bear a disproportionally large brunt of the deleterious effects of fee-for-service.[19] With the wastefulness, the inefficiency, the failure to align with patient goals, and the injustice, it becomes clear that fee-for-service does not align with patient care ethics because of organizational and financial incentives. lV. Capitation and Mixed Payment Models Pure capitation is a less common model than fee-for-service. The maximum effectiveness of this model is generally achieved with some combination of fee-for-service or value-based payment modifiers.[20] Both in principle and practice, capping payments for a term or service period inherently controls costs by setting a payment “cap.” From a theoretical perspective, the issue here is clear – there are minimal incentives in pure capitation to provide more care. In some cases, this can lead to care underprovision.[21] This neglect is a problem: whether intended, there are generally fewer visits and interventional approaches to care in pure capitation models.[22] Some view the care under-provision as a disservice to patients. However, the true practice of capitation is rarely without some combined incentive model for organizations or physician salary.[23] Adding fee-for-service incentives to capitation balances these issues while maintaining a discordant theoretical incentive compared to patient care. Value-based modifiers add a more aligned incentive for reasons described in the following section. The overall nature of capitation is not inherently aligned or misaligned with patient care, given that it is a highly moldable model, and therefore is neutral regarding its alignment with patient care ethics. V. Value-Based Payments Since their inception, value-based payments have become a widespread and popular payment model internationally.[24] The payment revolves around value, defined as patient outcomes divided by costs. The assumption in adopting such a model is that outcomes and costs can be readily measured, which is a challenge in implementing this model. However, aligning payments with patient value has spurred the adoption of more accurate cost accounting systems and the innovation of patient-reported outcome measures. While the full details of cost accounting are beyond the scope of this paper, Robert Kaplan is a proponent of using time-driven activity-based costing, an essential component in calculating value and an empirically more accurate accounting method than the other predominant forms in healthcare and fee-for-service payments.[25] While this is an accomplishment, perhaps the more ethically interesting innovation in value-based payments comes from measuring patient outcomes. These generally take form in two ways: objective measures and patient-reported measures. The objective measures include ideally controllable disease factors, such as hospital admissions or disease exacerbations in patients living with chronic obstructive pulmonary disease.[26] Such measures align payment incentives with quality and results, an important aspect of patient care but not an absolute placeholder for ethical measures. One of the largest critiques of value-based payments has always been that value cannot simply be measured with empirical data but must account for patient values.[27] The solution to such a critique is patient-reported outcome measures (PROMs), which factor patient values and lifestyle into the empirical payment calculation.[28] A study by Groeneveld et al. showed that PROMs were useful in evaluating the progression of stroke patients at several different time intervals.[29] Bernstein showed that PROMs give insight into the sociodemographic factors a patient may be experiencing, which can guide targeted interventions.[30] To providers, these may not sound like innovative clinical tools, but they resemble the everyday scoring systems and social work consultations seen in patient care. PROMs are an attempt to formally incorporate such items directly to payment. Value-based payments directly incentivize innovation, use of accurate costs and the consideration of patient values. However, there are valid critiques. This payment model has the potential to prioritize care for those who are healthy and more likely to achieve favorable outcomes. Adjustment for important social factors could worsen outcomes and undermine the model’s propensity to drive value for all patients.[31] Comparatively, value-based payments still incentivize a market force that is more in line with patient care ethics when contrasted with the other predominant forms of payment. This payment model has the theoretical advantage of spurring competitive forces to work toward a goal-like value while outcomes consider patient priorities and costs to be more accurate. From an ethical standpoint, the ideal value-based payment model addresses beneficence toward patients with some (but comparatively less) potential for harm and worsening of disparities. Safeguards can protect patients in this realm. Another main ethical advantage of value-based payments is that they add more patient marketplace agency by allowing patient desires and priorities to play a direct role in the payment process. This is a unique benefit that value-based payments have over fee-for-service and pure capitation, where the latter models are simply modicums for payment, not modicums for patient agency. Based on these comparative ethics, the value-based payment models are the most aligned payment model with patient care ethics but require safeguards. Vl. Limitations of Payment Models in Addressing Disparities and Distributive Justice The aforementioned payment models continually miss opportunities to explicitly incentivize care for underserved and at-risk populations. Studies have explicitly shown how fee-for-service can worsen care for minority groups. The greatest difference in care is seen in the chronically ill, the poor, and those with high burdens based on the social determinants of health.[32] While value-based payments have been touted as a potential route to incentivize care for these populations, comparative studies show that those of lower socioeconomic status experienced no benefit when using a value-based modifier.[33] Other scholars have pointed out that these payment models are both slower to roll out in low-resource areas and are more likely to have the unintended consequence of leading to lower funding in these areas.[34] Therefore, the disparity may be a lack of access to the model rather than a reflection of its capabilities. These valid critiques of worsening health disparities under all existing payment models show that such models are not a silver bullet for the health system and that they do not address other crucial issues in medicine, like equity. However, this is not to say that payment models cannot address social disadvantages and disparities. Value-based payments more ethically align payment-related incentives and spur more innovation. To this end, innovation must take place with consideration for distributive justice. The Rawlsian difference principle, or the notion that any systemic approach must maximize the improvement of the least advantaged groups, is essential when discussing payment models.[35] As it currently stands, value-based payments may incentivize procedural justice or a more just and equitable process once patients are in the healthcare system. Yet, none of them ensure a just distribution of care to those of low socioeconomic status. Future models must work towards incentivizing principles of distributive justice. While there have been many attempts to modify payments, those who design payment models clearly tend not to leverage financial benefits to help patients of low socioeconomic status. By leaving those least well-off in society out of the consideration, payment model designers contribute to systemic disparities, regardless of intent. All future designers of payment models must do more to improve incentive designs to work for these patients, not against them. Vll. How Should We Ethically View Incentive Design? The public and those in charge of medical policy must realize the importance of market forces beyond efficiency. Payment incentives should align with patient well-being, autonomy, access to care for underserved populations, and market efficiency. While some of these factors will be more pertinent than others depending on which health system is under discussion, we need ethical principles for patients on a system level that prioritize the patient's interaction with the health system outside of purely clinical scenarios. CONCLUSION Payment models remain a powerful tool for any health system that pays providers or organizations. The simple act of payment creates both direct and indirect financial incentives. These incentives create market forces that affect how patients experience their care, directly impacting autonomy, beneficence, non-maleficence, and justice. As it currently stands, the predominant payment model of fee-for-service does not align with patient care ethics. While follow-up models to fee-for-service, such as capitation, aimed to simply control costs, neither explicitly intended to give patients marketplace agency or improve patient care ethics. The overall alignment of capitation and patient care ethics remained relatively neutral. Newer innovations such as value-based payments have a much stronger stated purpose of aligning payment with positive outcomes and lower costs, where outcomes have patient-defined criteria and costs are more accurate. Value-based payments create a comparatively more aligned model than fee-for-service or capitation. Yet no payment model fully addresses the tenet of justice, and the Rawlsian difference principle must be employed here to ensure that those of lowest socioeconomic status or the most disadvantaged are not worse off than before the implementation of a new payment model. As a system, healthcare should strive for the best possible outcomes for all patients, necessitating an integrated approach to social factors. - [1] Porter M. What is Value in Healthcare? N Engl J Med. 2010;363(26):2477-2482. [2] Kontopantelis E, Reeves D, Valderas JM, Campbell S, Doran T. Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: A longitudinal observational study. BMJ Qual Saf. 2013;22(1):53-64. doi:10.1136/bmjqs-2012-001033 [3] Linzer M, Bitton A, Tu SP, Plews-Ogan M, Horowitz KR, Schwartz MD. The End of the 15–20 Minute Primary Care Visit. 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