In no other country of the world is that admonition from Louis Pasteur more appropriately applied than India. In a country that has emerged from a net importer of grain products to a net exporter via the Green Revolution, and has moved into the enviable position of having the capacity to feed itself, providing sufficient nutrition for the 2nd largest population on the planet, to its centuries old cultural practices of open defecation, render the new UN’s Sustainable Development Goal #6 (SDG) of ‘sanitation for all’ moot. “India’s 162 million children under age 5 are malnourished, but suffering less a lack of food than poor sanitation. Half of its population defecates outdoors, exposing children to a bacterial brew that often sickens them, leaving them unable to attain a healthy body weight no matter how much food they eat. When this happens during the first two years of life, children become stunted and sustain cognitive loss. Particularly disturbing is that the loss of height and intelligence are permanent. UNICEF and other major charitable organizations said in interviews that they believe that poor sanitation may cause more than half of the world’s stunting problems”.
In terms of adequate nutrition, the UN’s SDG through its ‘Zero Hunger Challenge’ by 2035 will be accomplished. But changing the culturally accepted practice of defecating outdoors, when “just 1% of Chinese and 3% of Bangladeshis relieve themselves outside compared with half of Indians”, presents an insurmountable hurdle on SDG #6.
There is an enormous difference in infant mortality between “Muslim children in India who are 17% more likely to survive infancy than Hindus—even though they are generally poorer and less educated. Muslims are far more likely to use latrines and live next to others using them”.
In an article which carried a New Delhi Date Line, quoting from The Lancet, it was posited that “premature deaths worldwide can be reduced by 40% before 2035. However, at the 2000-2010 rate of progress, deaths in India before age 70 years would fall by 31% before that date, missing the 40% target”. The article made no mention of poor sanitation as the root cause of target failure.
The Population Reference Bureau states that India will soon be the most populous country on earth, with 1.5 billion people by 2030. Its cultural practices on basic sanitation belie its role as the 11th largest economy in the world. India is a nuclear power with intercontinental missile launch capabilities. The Federation of Indian Chambers of Commerce & Industry states its Medical Tourism industry is one of the largest service sector industries, with an estimated value of $78 billion, employing 9 million people. India has been designated as “pharmacy to the developing world” by Doctors Without Borders, providing 80% of antiretroviral products to poor countries. This past September, it became the first Asian nation to place an unmanned spacecraft in the orbit of Mars, achieving a scientific feat at one-tenth the cost incurred by NASA.
When these considerable scientific and economic attributes are combined, one can reasonably ask why India remains an aid-assisted country, and why is it unable to mitigate the self- induced problems of poor sanitation? The magnitude of the task ahead is expressed through its recently inaugurated $10 billion ‘Clean India Campaign.’ If just 50% of these funds were directed to the 620 million Indians who don’t use latrines, then only $8 per capita over an indeterminate period would be focused on an unacceptable portion of its population that will continue to face irreversible stunting and cognitive development—even though they have sufficient nutritional access. If Indian statistics are applied against Goal #6 and included with all other countries, it will be rather improbable to reduce premature deaths globally by 40% in 2035.
India missed “by a significant margin its 2015 MDGs on infant and maternal mortality due to a lack of government expenditure on the health sector which was barely 1% of GDP.” Instead of 8 targets under the MDGs, the UN has doubled-down and instituted 16 through the SDGs. This is eerily similar to the OECD/DAC’s Paris Declaration on Aid Effectiveness, which had 12 targets. At its end in 2010, only one was met, “albeit by a narrow margin.” In November 2011, its proponents reconvened in Seoul, Korea for a High Level Forum to review this dismal record. They concluded their deliberations by proposing 36 targets for the next round of Aid Effectiveness!
When the UN and agencies like the OECD set monumental goals, they immunize themselves from subsequent accountability by stating that they should be measured by their intentions rather than their outcomes. After all these decades of missed targets, they should assume a touch of humility when setting future ones. Rather, their targets are befitting their illusions.
As long one-half the population in a country soon to be the most populous on the planet continues its cultural practices of ineffectual sanitation, the preponderance of its numbers over all other nations will invalidate SDG #6. Through a glass darkly, the global health community can see Louis Pasteur’s centuries old adage spring eternal.
Amidst the tumult of the Ebola crisis, few would know from its response that the World Health Organization (WHO) proclaims itself as “the legitimate inter-governmental authority on global health matters”. In the three affected Ebola countries, the WHO has 100 staff members, while the Region itself has 750 staff. The Regional Office in the Congo has 600 staff, with 2500 contract staff assigned to polio eradication.
Across the ocean, the Centers for Disease Control and Prevention (CDC) is the national public health institute of the United States, headquartered in Georgia. Yet, in the response to the Ebola outbreak in West Africa, the CDC has emerged as the international public face of control, prevention, and treatment of this disease. The WHO’s African office didn’t welcome the CDC’s robust role. Rather, the WHO largely confined itself to the issuance of statistical reports on disease morbidity and mortality, pleading in the process that an insufficiency of funds justified a plodding response that allowed the situation to get out of control. How did this role reversal occur?
The diminution of the WHO brand can be traced to its high water mark in 1977 when it proposed “Health for All by the Year 2000.” This bold initiative was galvanized into operational field programming by the entire global health community. During the period 1977-2000, the OECD/Paris estimates that the community allocated $99 billion in support of its goals, which were largely to build primary care infrastructure in poor countries. At the conclusion of “Health for All in 2000,” the WHO never bothered to issue a report on this extensive global experience which had to have generated a wealth of lessons learned. Despite this vast expenditure of resources, Dr. Paul Farmer has stated that the current Ebola crisis is “a symptom of a weak healthcare system.”
But is due to a lack of donor funds? Dr. Paul Collier, an economist at Oxford University, tracked donor funds released by the Ministry of Finance in Chad. They were designated for rural health clinics. His survey had the modest purpose of finding out how much of the money actually reached the clinics—not whether the clinics spent it well. “Less than 1 percent reached the clinics—99% failed to reach its destination.”
The WHO launched a new effort in 2001, called “Macroeconomics and Health.” The thrust was a formulaic expression: “by expanding coverage to basic health services to the poor through scaling up resources, poverty could be reduced, economic development accelerated, and global security advanced. This could save at least 8 million lives through 2010, and yield a direct economic benefit of $186 billion per year, maybe more.”
When the WHO released the proposal, there wasn’t a single reference to “Health for All” in the main Text, the Notes, the Appendix, or the References. There is no public record of any of the “Macroeconomics and Health” recommendations ever being implemented.
The expansive health programs initiated by the WHO since 1977 can be seen as troublesome reminders of how impermanent values can be when global initiatives of promethean scope can so soon be forgotten and quickly discarded by those who commissioned them.
The WHO is burdened with an antiquated governance structure, constraining its response to Ebola. In 1948, it had 61 Member States supporting WHO through assessed dues. Today, it has 194 Members. The Regular Budget for the current biennium is $944 million, but is effectively reduced to approximately $756 million due to arrears. This is the only budget voted on by Members at the annual assemblies. TheWHO has an Extra Budgetary Account, funded at $3.015 billion by foundations, governments, and corporations. This is its central problem with governance and its difficulties in responding to the Ebola crisis. In order to do so, it needs private contributions to its Extra Budgetary Account.
A former Director General of WHO wrote of his concerns in a 1996 discussion paper on WHO resolutions : “these funds are usually earmarked, the choice of activities is determined by the donor and not by the community of Member States comprising the Organization, and the management of these funds generally escapes the jurisdiction of the Executive Board and Health Assembly.”
The current Director General commented when discussing the Gates Foundation contribution of $300 million to the Extra Budgetary Account: “these dollars come with strings attached, my budget is highly earmarked, it is driven by what I call donor interests.”
Translation: the DGs are referring to a ‘pay to play’ budget.
The WHO’s Regional Directors are elected by Member States in their respective regions. If donors provide funds for Ebola, the money would first go to WHO/Geneva which would apply a fee of at least 13% before allocating it to the African Regional Office. Then, the Regional Director would have more say over their uses than does WHO/Geneva.
The WHO’s sole client in the developing world is ministries of public health. In an official report, WHO described them as: “having the reputation for being among the most bureaucratic and least efficiently managed institutes in the public sector.” Since its Regional Office in Africa is staffed more by ‘friends’ than health professionals, this combination of institutional fragilities foredoomed WHO from an effective response.
As long as the Regular Budget is subordinated to special interest groups funding the Extra Budgetary Account, and Regional Directors are more beholden to their respective Member States rather than to WHO/Geneva, the Organization’s response to global threats such as Ebola will be incomplete. The institutional credentials of the WHO and its governing bodies have tarnished the brand from fulfilling its time-honored role as “the legitimate inter-governmental authority on global health matters.” Without a structural reconstitution of its Mission, that role can be considered one that is gone with the wind.
By Jeremiah Norris
In global health, there is no other percentage that has so captured the public imagination and dominated media coverage than the relationship of national health expenditures to Gross Domestic Product (GDP). In the US, the current figure is 18% of GDP. When published, this percentage ignites a perception that often takes on the value of reality. It is followed by hand-wringing comments in the press and among policy-makers that we spend more than double what other developed countries do and get less in return. This assumes that there is an equivalency within the various components which comprise GDP from developed countries with socialized medicine when compared to a capitalist system. Moreover, the expenditure rate is seen as a resource flow which dissipates into a dark hole in space, notwithstanding the fact that health care itself is a central contributor to the economy, particularly on employment, even in recessionary times.
The US Government’s Bureau of Economic Analysis (BEA) defines GDP as “the output of goods and services produced by labor and property located in the United States. As long as these are supplied by US residents, they may be located either in the US or abroad.”
That is the accepted definition of GDP. But it doesn’t mean that health expenditures within a socialist economy where it is funded through general taxation is measured by the same yardstick as those in the US where it is financed by an equal percentage of public-private sources and delivered almost exclusively through private provision.
These are some items counted towards US GDP but not in socialized medicine countries:
- the cost of mal-practice insurance and awards to plaintiffs;
- the accelerated depreciation on 5-year schedules of plant and equipment;
- health care employer and employee payroll contributions to Social Security, Medicare, 401 (k) retirement plans, and Workmen’s Compensation Insurance;
- and, in most developed countries, capital investments are publicly funded and accounted for through ministries of public works; in the US these same investments are charged against GDP for health.
Canada has a single payer system. When an annual national health budget is passed, it is then divided among the provinces according to population. They can consume the amounts specified in their budget allocations—and then no more. Yet, Canadians spend more on health care than what is accounted for in their national budget. In 2012, more than 40,000 Canadians sought specialty care in U. S. institutions, where their expenditures were charged against US GDP and deducted from Canada’s.
The capital assets in hospitals and medical equipment in the EU are publicly owned, thus there is no need to apply for tax relief on depreciated values. This is a substantial sum in the US as “almost one-third of health care spending pays for hospital services”. EU health care cadres pay one tax into the Treasury for all social services, obviating payroll taxes as in the US for, pension, Social Security, Workmen’s Compensation and Medicare.
Over the past five years, health care jobs in the US have outpaced employment trends overall. They account for one out of every six jobs created by 2012. As jobs disappeared during the Great Recession, health care companies continued hiring. They “added 428,000 jobs throughout the 18-month recession from December 2007 until June 2009 and have continued to grow at a steady rate since the end of the recession.”
The percentage of health care expenditures is lower in “all other developed countries [which] rely on a large degree of direct government intervention and rate-setting to achieve lower-priced medical treatment for all citizens”. For instance, on pharmaceuticals, France and Italy directly regulate prices at launch and subsequent rate of price increases. Germany, the Netherlands, and Denmark operate reference price systems of reimbursement and thereby exert strong pressure on prices charged by manufacturers. The UK operates a system of profit regulation that constrains prices to yield no more than a target overall rate of return on capital. One effect of this regulatory environment is that one of its a major producers maintains a paper registration of corporate ownership on the London stock exchange, but conducts its main manufacturing operations in the US where it can price products on the open market. The Canadian government monitors price levels at launch and rates of increase to assure they are “reasonable”. If US pharmaceutical producers want to be in these markets, then they have to lower their prices and conform to EU regulations, though the same product is available in US markets, often at double the price. Regulated prices in the EU translate into lower health care expenditures relative to GDP; in effect, they also mean that US citizens are subsidizing health care for their counter-parts in the EU.
To change this perception we have to change the reality. Objective-based research is needed on the relationship of GDP and health care spending since policy-makers allocate resources on the basis of comparisons between developed countries. The measurement has to be of like-things to like-things. There can be little doubt that it isn’t equivalent to compare socialist economies with capitalist economies. On one simple indicator, if EU countries permitted market pricing of drug products, then their ratio of health care expenditures to GDP would be far higher than presently reported in the 8-10% range.
By Jeremiah Norris
The upward thrust of events that have shaped healthcare in America since 1900 when national health expenditures were unknown to 18% of GDP in 2013 constitutes a study often lost in the mist of time, and one that is illustrative of the long road to the Affordable Care Act of 2010 (ACA). The 18% is seen as expenditure within a seamless, integrated ‘system’, rather than the amorphous components which comprise a public-private cottage industry. At the advent of the 20th Century, population was 76m with a life expectancy of 47 years. Health insurance wasn’t available, nor published reports on health expenditures until the mid 1950s. Now, we have 317m with a life expectancy of 78.2 years, and 84% is covered by health insurance.
The beginnings of organized medicine weren’t in place until the Flexner Report of 1910, funded by Carnegie Foundation. The Report served as the catalyst for establishing a standard curriculum in medical schools, their accreditation, and the licensing and certification of practitioners. Up until that point, there were proprietary medical schools, mainly operated as private businesses. Approximately one-third of them closed in the decade following publication of this Report. From 1910 – 1928, the Rockefeller Foundation funded a momentum for change through the reorganization of medical education within twenty-four universities.
Since then, the major drivers on the upward expenditure curve have been government initiatives. During the Great Depression of the 1930s, patients had difficulty paying hospitals for services. The government stepped in, offered community hospitals non-profit status in return for a fixed percentage of their income over expenses to cover uncompensated care. This was the birth of Blue Cross-Blue Shield Association.
In the late 1950s, the government established wage and price controls in private businesses. It then permitted employers to substitute health insurance as a covered benefit in lieu of wage increases.
In 1965, the Congress passed Medicare, which provided healthcare for those aged 65+. In 1972, legislation authorized the End Stage Renal Disease Program under Medicare. It now covers 90% of all US citizens with severe chronic kidney disease, regardless of age. In 1997, the Congress added a new component, the Program of All-Inclusive Care for the Elderly. It provides comprehensive care for individuals age 55 and older who are sufficiently frail to be categorized as “nursing home eligible” by their state’s Medicaid program. Disability insurance was added in the 1970s for those under age 65, some as infants. In 2006, the Prescription Drug Benefits Program was added.
In 1966, the Congress enacted Medicaid, a program for the provision of health services to the poor. States provide up to one half of the funding. Those with disabilities who do not have a work record and receive Supplemental Security Income (SSI), are enrolled into Medicaid as a mechanism to provide them with health insurance. Medicaid payments currently assist nearly 60% of all nursing home residents and about 37% of all childbirths in the US. The federal government pays on average 57% of Medicaid expenses.
In 1997, the Children’s Health Insurance Program (CHIP) was enacted by the Congress as a partnership between federal and state governments. It is administered by HHS and provides matching funds to states for health insurance to families with incomes that are modest but too high to qualify for Medicaid.
In 1960, Congress enacted the Federal Employees Health Benefit Program (FEHB). The government contributes 72% of the premium of all plans offered to active and retired federal employees. FEHB is administered by the US Office of Personnel Management.
The Military Health System is under the US Department of Defense, while the Veterans Administration is a separate Cabinet post. They provide healthcare to active duty, retired military personnel, dependents, and veterans from all service branches.
The Indian Health Services was established in 1955, and is operated through HHS. In 2011, its budget was $4.3 billion, covering 2,700 nurses, 900 physicians, 400 engineers, 500 pharmacists and 300 dentists. Other health professionals bring total staffing to more than 15,000. Indians are also eligible to apply for health care provided by Medicaid.
For the period 2013-2022, these health spending differences per enrollee can be seen in 2013 and 2022:
Medicare spending per enrollee $11,829 $16,914
Medicaid spending per enrollee $7,784 $10,777
CHIP $2,187 $3,115
Employer-sponsored Private Health Ins. $5,435 $8,204
Other Private Health Insurance $2,434 $5,587
A central premise of ACA is that it will bend the cost curve downward on national health expenditures. Excepting Medicaid, the other programs mentioned will be outside of ACA’s specific domain, though they cover some 100m people. For those enrolled into Medicaid, the Federal government will pay States its full costs for the first three years, and 95% thereafter. There will be no deductibles. This will accelerate the present differential between government and private spending, assuring that the HHS’s actuary prediction of health expenditures rising to 20% of GDP by 2022 will be realized.
by Jeremiah Norris
Advocates of Universal Health Coverage (UHC) believe that the key to success can be seen in the World Bank’s new vision as stated by its President in his address to the World Health Assembly in May 2013. He said: “We must be the generation that delivers universal health coverage … warning that UHC could become a toothless slogan”.
Senior policy-makers at the Bank, and its sister organization, the IMF, should take this warning seriously. In 1999, the Bank conducted an audit of 107 of its health projects, finding: 1) “the Bank does not adequately assess borrower capacity to implement planned project activities; 2) notably lacking is an adequate assessment on demand for health services; 3) we know little about what the Bank has ‘bought’ with its investments”.
In 2009, it conducted another internal audit based on corrective measures it had set in place, finding: one-third of World Bank health, nutrition and population program loans met with unsatisfactory outcomes. The Bank spent $17 billion on these initiatives.
Subsequently, the Guardian Weekly drilled deeper into the Bank’s audit, determining that: “despite the Bank’s raison d’être to end poverty, that was the specific objective of only 6% of projects and a secondary objective of 7%. Even when this was a stated objective, there was little monitoring of outcomes. Where it was done, few projects had achieved that goal … and much of the spending aids [the] richest 20% of people”.
The Bank conducts annual reviews through its Independent Evaluation Group (IEG). In a 2006 evaluation of a subsample of 25 Bank-assisted countries for which outcomes had been assessed, “only 11 reduced the incidence of poverty between 1990s and the early 2000s, while poverty either stagnated or increased in the remaining 14 countries”.
In 2007, the IMF published a report on health aid and infant mortality. It found that “despite the vast empirical literature considering the effect of foreign aid on growth, there is little systematic empirical evidence on how overall aid affects health, and none (to our knowledge) on how health aid affects health”.
The Bank’s funding is directed mainly to the public health sector of developing countries. Here, it is burdened by high transaction costs, lack of ownership, and interest payments. It competes with private resource flows, often without these operational liabilities. Official Development Assistance (ODA was once the dominate form of assistance to developing countries. But today, according to Hudson’s Index of Global Philanthropy and Remittances, “Nearly 80% of all DAC donors’ total economic engagement with the developing world is through private financial flows.”
An October report by the Bank on global remittances has estimated that they are “expected to reach $414 billion in 2013, and $540 billion by 2015”. These flows often are used to purchase health and educational benefits. Sooner or later, every remitted hard currency ends up in a country’s central bank where it is used to purchase goods and services which can only be procured through the use of scarce foreign exchange.
In the post-colonial world of the early 1960s, most countries emerging into independence had virtually no private health sectors. In that environment, it was perfectly logical for the World Bank to lend into their public sectors. That world has changed dramatically. For instance, in the largest countries, private expenditures on health as a percent of total expenditures on health show that it is 69% in Bangladesh; 81% in Cambodia; 64% in China; 76% in India; 65% in Indonesia; 55% in Mexico; 75% in Nigeria; 73% in Pakistan; 62% in South Africa; 70% in Uganda; and 73% in Viet Nam.
The successful implementation of UHC is dependent upon: “1) removal of direct out-of-pocket payments); 2) [a migration from] employment-based and contributory insurance models … to the public health sector; and 3) financial support through general government revenues”. Given the choice between low cost private resources for healthcare and heavily burdened ODA for UHC, it shouldn’t be surprising that ministries of finance would choose a resource flow which would provide them with increased levels of foreign exchange at least cost to their societies, while at the same time improving their international credit ratings for borrowing.
The Bank’s president is prescient in his caution that UHC could end up as a slogan. Yet, when used in his new vision To End Extreme Poverty by 2035 during the Bank’s Annual Meeting in October, it indemnifies donors from performance accountability. Who could be against such a laudable goal! When cast against an ocean of inconsequential Bank and IMF audits and their leadership in debt forgiveness of $93 billion for 40 poor countries through the Jubilee Program—the same countries which would be the main subjects of UHC, an embrace of these concepts by the Bank can be seen as a continuous tight grip on slogans in a retracing search for yesterday’s icebergs.
By Jeremiah Norris
At Alma Ata, Kazakhstan, in 1977, WHO was charged with a new program initiative, “Health for All by the Year 2000” (HFA). Broadly, its aims were to “bring health within reach of everyone in a given country. By ‘health’, it is meant a personal state of well being, not just the availability of health services. [it implies] A state of health that enables a person to lead a socially and economically productive life.”
Subsequently, bilateral and multilateral agencies, as well as numerous non-governmental organizations, supported its goals and funded them extensively from that date through 2000 with billions of donor dollars. In 2001, WHO published “Macroeconomics and Health: Investing in Health for Economic Development” (MH). It was written by an impressive list of Commissioners, headed by Prof. Jeffery Sachs, then with HarvardUniversity, and funded at $2.5 million by WHO. The basic thrust of this new initiative is a formulaic expression: “expanding coverage for essential health services to the world’s poor through scaling up resources, poverty would be reduced, economic development accelerated, and global security advanced. This could save at least 8 million lives each year by the end of the decade, and assuming that each DALY saved “gives an economic benefit of 1 year’s per capita income of a projected $535 in 2015, the direct economic benefit … would be $186 billion per year, and plausibly several times more”.
A critical component of HFA was Multisectoral Planning, in which WHO would engage all line ministries in its global effort. It re-emerged in MH as a recommendation for the formation of National Macroeconomic Commissions, co-chaired by ministries of finance and health. There isn’t any public record of these Commissions having been formed. MH is completely absent of any references to HFA in the main text, in Appendix I listing the Commissioners; their Biographical Sketches; or Reports and Working Papers; or Appendix 2; or References; or even in the Glossary!
It calculated an economic benefit for the 8 million lives saved annually by essential health interventions. The Commissioners walked away from the downstream implications by making an assumption that those saved would go on to a life of suspended animation, free of noncommunicable diseases (NCD) and the costs associated with them. Once a child makes it beyond age 5, the unerring arrow of a costly NCD morbidity will strike somewhere along life’s path. Not much else in healthcare is certain. This is.
WHO never published a final report on HFA. This would have generated a wealth of ‘lessons learned’. Applied to the Commissioners 2001 work, this valuable resource could have substantially grounded its proposal in a legitimacy otherwise difficult to obtain.
Notwithstanding the lack of progress on these two initiatives, the 2005 World Health Assembly resolution and the 2012 UN General Assembly resolution supported the concept of Universal Health Coverage (UHC). Proponents of this concept believe that universal health coverage means “that people should have access to all the services they need, of good quality, without suffering financial hardship when paying for them”.
A key financial barrier to this coverage is co-payments by patients. At the 66th World Health Assembly in May 2013, the President of the World Bank said: “anyone who has provided health care to poor people knows that even tiny out-of-pocket charges can drastically reduce their use of needed services. This is both unjust and unnecessary”.
His statement was in contravention to the Bank’s report of 20 years ago, titled: “Investing in Health”. It proposed the implementation of user fees, a policy which was adopted by many Member States. It is also contrary to WHO’s ranking of Members on healthcare. In every category, “Singapore is either the very best in the world or near the very top. Its out-of-pocket healthcare costs are the highest in the world”.
The predominant form of health financing in most developing countries is in their private sectors. Out-of-pocket payments include co-payments for those covered by health insurance plans, government retirees under medical care through social security-type systems (it is 65% of total public health expenditures in Bolivia), and private health plans. Their removal under UHC would require approval from ministries of finance, causing them to impose additional sources of funding for public health via new taxes.
Alongside these two global initiatives, other programs were launched independent of direct WHO management. Two of the largest are PEPFAR (the President’s Emergency Plan for HIV/AIDS, TB and Malaria) launched in 2003 with a $15 billion grant from the U. S. It was renewed in 2008 with an additional grant of $53 billion. It works closely with the Global Fund to Fight HIV, TB and Malaria, “which in its recent replenishment was able to obtain $18.9 billion in new pledges”. Together, these two organizations expect to have 10 million AIDS patients under ARV treatment by the end of 2013. For the first time in the global fight against AIDS, the number of new infections has declined.
Rather than leading the way forward on global health, the two WHO initiatives followed past remedies: pour in money and stir. Money was used as a product for consumption when experience informed PEPFAR and the Global Fund that it needed to be used as a medium with a command power to create something of value between partners.