What explains the fall in child stunting in Sub-Saharan Africa?

There have been steep falls in rates of child stunting in much of Sub-Saharan Africa (SSA). Using Demographic and Health Survey data, we document significant reductions in stunting in seven SSA countries in the period 2005-2014. For each country, we distinguish potential determinants that move in a direction consistent with having contributed to the reduction in stunting from those that do not.

Impact and spill-over effects of an asset transfer program on child undernutrition: Evidence from a randomized control trial in Bangladesh.

Targeting the Ultra-poor (TUP) is an integrated programme that combines the transfer of income-generating assets and multifaceted training on entrepreneurship, health-nutrition, and social awareness over a two-year period to graduate ultra-poor with mainstream poverty. While positive socioeconomic effects and spill-over effects are well-documented, this is the first paper to evaluate the effects of the programme on nutritional outcomes of under-5 children using data from a randomized control trial over a four-year period. We find notable improvements in nutritional outcomes of children in participating households.

Socioeconomic inequalities in newborn care during facility and home deliveries: a cross sectional analysis of data from demographic surveillance sites in rural Bangladesh, India and Nepal.

Background: In Bangladesh, India and Nepal, neonatal outcomes of poor infants are considerably worse than those of better-off infants. Understanding how these inequalities vary by country and place of delivery (home or facility) will allow targeting of interventions to those who need them most. We describe socio-economic inequalities in newborn care in rural areas of Bangladesh, Nepal and India for all deliveries and by place of delivery.

Voluntary health insurance in Nigeria: Effects on takers and non-takers.

Interventions aiming to simultaneously improve financial protection and quality of care may provide an important avenue towards universal health coverage. We estimate the effects of the introduction of the Kwara State Health Insurance program in Nigeria on not only the insured but also the uninsured. A subsidized voluntary low cost health insurance was offered by a private insurer as well as a quality upgrade in selected health care facilities.

Did contracting effect the use of primary health care units in Pakistan?

For many years, Pakistan has had a wide network of Basic Health Units spread across the country, but their utilization by the population in rural and peri-urban areas has remained low. As of 2004, in an attempt to improve the utilization and performance of these public primary healthcare facilities, the government has gradually started contracting-in intergovernmental organizations to manage these BHUs. Using five nationally representative household surveys conducted between 2001 and 2012, and exploiting the gradual roll-out of this reform to apply a difference-in-difference approach, we evaluate its impact on BHU utilization.

How equitable is the uptake of conditional cash transfers for maternity care in India? Evidence from the Janani Suraksha Yojana scheme in Odisha and Jharkhand.

Background: In 2005, the Indian Government introduced the Janani Suraksha Yojana (JSY) scheme - a conditional cash transfer program that incentivizes women to deliver in a health facility - in order to reduce maternal and neonatal mortality. Our study aimed to measure and explain socioeconomic inequality in the receipt of JSY benefits.

Methods: We used prospectively collected data on 3,682 births (in 2009-2010) from a demographic surveillance system in five districts in Jharkhand and Odisha state, India.

The Effects of Ghana's National Health Insurance Scheme on Maternal and Infant Health Care Utilization.

Increasing equitable access to health care is a main challenge African policy makers are facing. The Ghanaian government implemented the National Health Insurance Scheme in 2004 and the aim of this study is to evaluate its early effects on maternal and infant healthcare use. We exploit data on births before and after the intervention and apply propensity score matching to limit the bias arising from self-selection into the health insurance.

Healthcare seeking behaviour among self-help group households in Rural Bihar and Uttar Pradesh, India.

Background: In recent years, supported by non-governmental organizations (NGOs), a number of community-based health insurance (CBHI) schemes have been operating in rural India. Such schemes design their benefit packages according to local priorities. This paper examines healthcare seeking behaviour among self-help group households with a view to understanding the implications for the benefit packages offered by such schemes.

Impact of Community-based Health Insurance on Access and Financial Protection: Evidence from Three Randomized Control Trials in Rural India.

Since the 1990s, community-based health insurance (CBHI) schemes have been proposed to reduce the financial consequences of illness and enhance access to healthcare in developing countries. Convincing evidence on the ability of such schemes to meet their objectives is scarce. This paper uses randomized control trials conducted in rural Uttar Pradesh and Bihar (India) to evaluate the effects of three CBHI schemes on healthcare utilization and expenditure.

Impact of Performance-Based Financing in a Low-Resource Setting: A Decade of Experience in Cambodia.

This paper exploits the geographic expansion of performance-based financing (PBF) in Cambodia over a decade to estimate its effect on the utilization of maternal and child health services. PBF is estimated to raise the proportion of births occurring in incentivized public health facilities by 7.5 percentage points (25%).

Economic consequences of ill-health for households in northern rural India.

Background: As compared to other countries in South East Asia, India's health care system is characterized by very high out of pocket payments, and consequently low financial protection and access to care. This paper describes the relative importance of ill-health compared to other adverse events, the conduits through which ill-health affects household welfare and the coping strategies used to finance these expenses.

Methods: Cross-sectional data are used from a survey conducted with 5241 households in Uttar Pradesh and Bihar in 2010 that included a household shocks module and detailed information about health care use and spending.

Gastric cancer survival and affiliation to health insurance in a middle-income setting.

Objective: To investigate whether health insurance affiliation and socioeconomic deprivation is associated with overall cause survival from gastric cancer in a middle-income country.

Methods: All patients resident in the Bucaramanga metropolitan area (Colombia) diagnosed with gastric cancer between 2003 and 2009 (n=1039), identified in the population-based cancer registry, were followed for vital status until 31/12/2013. Kaplan-Meier models provided crude survival estimates by health insurance regime (HIR) and social stratum (SS).

Introduction of performance-based financing in burundi was associated with improvements in care and quality.

Several governments in low- and middle-income countries have adopted performance-based financing to increase health care use and improve the quality of health services. We evaluated the effects of performance-based financing in the central African nation of Burundi by exploiting the staggered rollout of this financing across provinces during 2006-10. We found that performance-based financing increased the share of women delivering their babies in an institution by 22 percentage points, which reflects a relative increase of 36 percent, and the share of women using modern family planning services by 5 percentage points, a relative change of 55 percent.

The effects of performance incentives on the utilization and quality of maternal and child care in Burundi.

Africa's progress towards the health related Millennium Development Goals remains limited. This can be partly explained by inadequate performance of health care providers. It is therefore critical to incentivize this performance.

Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia.

Objective: To evaluate the effect of vouchers for maternity care in public health-care facilities on the utilization of maternal health-care services in Cambodia.

Methods: The study involved data from the 2010 Cambodian Demographic and Health Survey, which covered births between 2005 and 2010. The effect of voucher schemes, first implemented in 2007, on the utilization of maternal health-care services was quantified using a difference-in-differences method that compared changes in utilization in districts with voucher schemes with changes in districts without them.

Persistent inequalities in child undernutrition: evidence from 80 countries, from 1990 to today.

Background: Global progress in reducing the burden of undernutrition tends to be measured at the population level. It has been hypothesized that population-level improvements may mask widening socioeconomic inequalities, but little attempt has been made to assess whether this is true.

Methods: Original data from 131 demographic health surveys and 48 multiple indicator cluster surveys from 1990 to 2011 were used to examine trends in socioeconomic inequalities in stunting and underweight, as well as the relationship between changes in prevalence and changes in inequality, in 80 countries.

Healthcare-seeking behaviour in rural Ethiopia: evidence from clinical vignettes.

Objectives: To investigate the determinants of healthcare-seeking behaviour using five context-relevant clinical vignettes. The analysis deals with three issues: whether and where to seek modern care and when to seek care.

Setting: This study is set in 96 villages located in four main regions of Ethiopia.

Does the distribution of healthcare utilization match needs in Africa?

An equitable distribution of healthcare use, distributed according to people's needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa (SSA). We examine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries.

Effects of NCMS on access to care and financial protection in China.

The introduction of the New Cooperative Medical Scheme (NCMS) in rural China has been the most rapid and dramatic extension of health insurance coverage in the developing world in this millennium. The literature to date has mainly used the uneven rollout of NCMS across counties as a way of identifying its effects on access to care and financial protection. This study exploits the cross-county variation in NCMS generosity in 2006 and 2008 in the Ningxia and Shandong provinces to estimate the effect of coverage generosity on utilization and financial protection.

Coping with the economic consequences of ill health in Indonesia.

We assess the economic risk of ill health for households in Indonesia and the role of informal coping strategies. Using household panel data from the Indonesian socio-economic household survey (Susenas) for 2003 and 2004, and applying fixed effects Poisson models, we find evidence of economic risk from illness through medical expenses. For the poor and the informal sector, ill health events impact negatively on income from wage labour, whereas for the non-poor and formal sector, it is income from self-employed business activities which is negatively affected.

Measurement of inequity in health care with heterogeneous response of use to need.

We propose a method of measuring and decomposing inequity in health care utilisation that allows for heterogeneity in the use-need relationship. This makes explicit inequity that derives from unequal treatment response to variation in need, as well as that due to differential effects of non-need determinants. Under plausible conditions concerning heterogeneity in the use-need relationship and the distribution of need, existing methods that impose homogeneity will underestimate pro-rich inequity.

Reconciling research and implementation in micro health insurance experiments in India: study protocol for a randomized controlled trial.

Background: Microinsurance or Community-Based Health Insurance is a promising healthcare financing mechanism, which is increasingly applied to aid rural poor persons in low-income countries. Robust empirical evidence on the causal relations between Community-Based Health Insurance and healthcare utilisation, financial protection and other areas is scarce and necessary. This paper contains a discussion of the research design of three Cluster Randomised Controlled Trials in India to measure the impact of Community-Based Health Insurance on several outcomes.

Quantifying the impoverishing effects of purchasing medicines: a cross-country comparison of the affordability of medicines in the developing world.

Background: Increasing attention is being paid to the affordability of medicines in low- and middle-income countries (LICs and MICs) where medicines are often highly priced in relation to income levels. The impoverishing effect of medicine purchases can be estimated by determining pre- and postpayment incomes, which are then compared to a poverty line. Here we estimate the impoverishing effects of four medicines in 16 LICs and MICs using the impoverishment method as a metric of affordability.

What explains the rural-urban gap in infant mortality: household or community characteristics?

The rural-urban gap in infant mortality rates is explained by using a new decomposition method that permits identification of the contribution of unobserved heterogeneity at the household and the community level. Using Demographic and Health Survey data for six Francophone countries in Central and West sub-Saharan Africa, we find that differences in the distributions of factors that determine mortality--not differences in their effects--explain almost the entire gap. Higher infant mortality rates in rural areas mainly derive from the rural disadvantage in household characteristics, both observed and unobserved, which explain two-thirds of the gap.

Urbanization and the spread of diseases of affluence in China.

We quantify, track and explain the distribution of overweight and of hypertension across Chinese provinces differentiated by their degree of urbanicity over the period 1991-2004. We construct an index of urbanicity from longitudinal data on community characteristics from the China Health and Nutrition Survey and compute, for the first time, a rank-based measure of inequality in disease risk factors by degree of urbanicity. Prevalence rates of overweight and hypertension almost doubled between 1991 and 2004 and these disease risk factors became less concentrated in more urbanized areas.