The Paradox of Happiness: Health and Human Rights in the Kingdom of Bhutan

The Kingdom of Bhutan is seeking to progressively realize the human right to health without addressing the cross-cutting human rights principles essential to a rights-based approach to health. Through a landscape analysis of the Bhutanese health system, documentary review of Bhutanese reporting to the United Nations human rights system, and semi-structured interviews with health policymakers in Bhutan, this study examines the normative foundations of Bhutan’s focus on “a more meaningful purpose for development than just mere material satisfaction.” Under this development paradigm of Gross National Happiness, the Bhutanese health system meets select normative foundations of the right to health, seeking to guarantee the availability, accessibility, acceptability, and quality of health care and underlying determinants of health. However, where Bhutan continues to restrict the rights of minority populations—failing to address the ways in which human rights are indivisible, interdependent, and interrelated—additional reforms will be necessary to realize the right to health. Given the continuing prevalence of minority rights violations in the region, this study raises research questions for comparative studies in other rights-denying national contexts and advocacy approaches to advance principles of non-discrimination, participation, and accountability through health policy

Financial risks of care seeking for malaria by rural households in Jimma Zone, Oromia Region, Southwest Ethiopia: a cross-sectional study

Objectives Despite major progress in the prevention and control of malaria in recent years, the disease remains a major cause of morbidity in Ethiopia. Malaria also imposes substantial socioeconomic costs on households. The aim of this study is to estimate the financial risk of seeking malaria service for rural households across socioeconomic statuses in the Jimma Zone, Oromia Region. Design A facility-based cross-sectional survey. Setting Jimma Zone, Oromia Region, Southwest Ethiopia. Participants A total of 221 patients with malaria from 10 public health facilities were interviewed between September 2018 and December 2019. Primary and secondary outcome measures The main outcome measures capture the financial risks associated with malaria services, specifically catastrophic and impoverishing health expenditures. Catastrophic health expenditure (CHE) occurs when healthcare costs reach 10% of a household’s monthly income, whereas impoverishment occurs when a household’s monthly income falls below the national poverty level after paying for health service. Descriptive statistics were used to summarise the expenditure patterns associated with malaria services. All costs were gathered in Ethiopian birr and reported in 2019 US$. Results The average cost of receiving malaria services was US$4.40 (bootstrap 95% CI: 3.6 to 5.3), with indirect costs accounting for 52% of total costs. Overall, at the 10% threshold, 12% (bootstrap 95% CI: 8.1% to 16.7%) of patients with malaria incurred CHE: 40% (bootstrap 95% CI: 26.7% to 55.6%) of the household in the poorest quintile experienced CHE, but none from the richest quintile did. The proportion of households living in poverty increased by more than 2-3% after spending on malaria-specific health services. Conclusion Healthcare seeking for malaria imposes a substantial financial risk on rural households, particularly for the poorest and most vulnerable. Malaria policies and interventions should therefore seek to alleviate both the direct costs and productivity losses associated with the disease, especially among the poor.publishedVersio

The Broader Economic Value of School Feeding Programs in Low- and Middle-Income Countries: Estimating the Multi-Sectoral Returns to Public Health, Human Capital, Social Protection, and the Local Economy.

Introduction: Globally, there are 370 million children receiving school meals every day. Coverage is least in low-income countries, where the need is greatest and where program costs are viewed as high in comparison with the benefits to public health alone. Here we explore the policy implications of including the returns of school feeding to other sectors in an economic analysis. Methods: We develop an economic evaluation methodology to estimate the costs and benefits of school feeding programs across four sectors: health and nutrition; education; social protection; and the local agricultural economy. We then apply this multi-sectoral benefit-cost analytical framework to school feeding programs in 14 countries (Botswana, Brazil, Cape Verde, Chile, Côte d'Ivoire, Ecuador, Ghana, India, Kenya, Mali, Mexico, Namibia, Nigeria, and South Africa) for which input data are readily available. Results: Across the 14 countries, we estimate that 190 million schoolchildren benefit from school feeding programs, with total program budgets reaching USD11 billion per year. Estimated annual human capital returns are USD180 billion: USD24 billion from health and nutrition gains, and USD156 billion from education. In addition, school feeding programs offer annual social protection benefits of USD7 billion and gains to local agricultural economies worth USD23 billion. Conclusions: This multi-sectoral analysis suggests that the overall benefits of school feeding are several times greater than the returns to public health alone, and that the overall benefit-cost ratio of school feeding programs could vary between 7 and 35, with particular sensitivity to the value of local wages. The scale of the findings suggests that school feeding programs are potentially much more cost-beneficial when viewed from the perspective of their multi-sectoral returns, and that it would be worthwhile following up with more detailed analyses at the national level to enhance the precision of these estimates

Three Essays on Child Wellbeing in Developing Countries

This dissertation explores factors that lead to poor outcomes for children in different developing country contexts—infant mortality in Indonesia, youth physical violence in Zimbabwe and solid fuel-use in southern Africa—and points to ways in which they might be addressed. Chapter 1 probes whether deforestation in Indonesia shapes infant mortality. Given that forest cover losses might lead to a growth in mosquito populations (for example, by causing a reduction in mosquito predators), this paper explores whether there is evidence of malaria being a mediator in the forest cover-infant mortality relationship in the country by testing for a higher detrimental effect of deforestation on the children born to women from their first pregnancies, a time during which women are most vulnerable to malaria infections. Chapter 2 examines whether a national unconditional cash transfer (CT) program in Zimbabwe was able to reduce youth exposure to physical violence by addressing poverty, a structural determinant of child abuse and maltreatment. Finally, Chapter 3 identifies the impacts of CT programs in Malawi and Zambia on household fuel use and evaluates whether the programs allowed recipient households to move away from solid fuels (such as firewood) which impose substantial health and time costs, particularly on sub-groups such as children.Doctor of Philosoph

Routine child immunizations in India during the COVID-19 pandemic

Disruptions in health service delivery and utilization during the COVID-19 pandemic may have caused many children worldwide to not receive vital preventative health services. We investigate the pandemic’s effects on routine childhood vaccinations in India, which has the world’s largest child immunization program. Using data from the Government of India’s health management information system and interrupted time series analyses, we estimate district-level changes in routine child vaccinations during the pandemic relative to typical monthly vaccinations in the pre-pandemic period. Our results indicate there were significant reductions in child vaccinations during the pandemic, with declines being extremely large in April 2020 when a strict national lockdown was in place. For example, district-level administration of the final required dose in the polio series declined by about 60% in April 2020 relative to the typical monthly vaccination levels observed prior to the pandemic. Vaccinations subsequently increased but largely remained below levels observed before the outbreak of COVID-19. Additional declines in vaccinations occurred in 2021 during the second wave of COVID-19 infections in India. Heterogeneity analyses suggest that vaccinations declined the most in districts with the strictest lockdowns and in districts with low health system capacity at baseline. There is a vital need for corrective actions, such as catch-up vaccination campaigns, to limit the deleterious consequences that will arise for the children who missed routine immunizations during the COVID-19 pandemic

The impact of supplementary immunization activities on routine vaccination coverage: An instrumental variable analysis in five low-income countries.

BackgroundCountries deliver vaccines either through routine health services or supplementary immunization activities (SIAs), usually community-based or door-to-door immunization campaigns. While SIAs have been successful at increasing coverage of vaccines in low- and middle-income countries, they may disrupt the delivery of routine health services. We examine the impact of SIAs on routine vaccine coverage in five low-income countries.MethodsData on the number and timing of SIAs conducted in various countries was compiled by WHO and obtained through UNICEF. Information on the coverage of vaccines not targeted by SIAs (e.g., DPT) was extracted from the Demographic and Health Surveys. We focus on SIAs that took place between 1996 and 2013 in Bangladesh, Senegal, Togo, Gambia, and Cote d'Ivoire, and examine outcomes for children aged 12-59 months. To avoid biases resulting from non-random placement and timing of SIAs, we use age of a child at her first SIA as an instrumental variable for total exposure to SIAs.ResultsWe find that SIA exposure reduced the likelihood of receiving routine vaccines in all the countries included in the study; the coefficients of interest are however statistically insignificant for Gambia and Cote d'Ivoire. In countries that witnessed statistically significant SIA-induced declines in the likelihood of obtaining DPT 3, measles as well as BCG, reductions ranged from 1.3 percentage points (Senegal) to 5.5 percentage points (Bangladesh).ConclusionSIA exposure reduced routine vaccination rates in study countries. Efforts should be made to limit the detrimental impact of SIAs on the services provided by routine health systems

Exploring agriculture-child nutrition pathways: evidence from Malawi’s Farm Input Subsidy Program

Child undernutrition is highly prevalent around the world, particularly in low-income countries where economies are largely driven by the agricultural sector. Agricultural policies have the potential to impact total food production as well as food quality and diversity, thereby shaping nutritional status. In this study, we first corroborate evidence that Malawi’s Farm Input Subsidy Program (FISP), which provides subsidized vouchers for farm inputs to targeted rural households, boosts child nutritional status. Our analysis includes recent years during which the program’s nutrition impacts have not been previously examined. We then investigate three broad categories of agriculture-child nutrition linkages in the context of this program: (1) farm production and diversity, (2) crop sales, non-farm enterprises, and food consumption from different sources (purchases and own production), and (3) women’s empowerment and the

Financial risks of care seeking for malaria by rural households in Jimma Zone, Oromia Region, Southwest Ethiopia: a cross-sectional study

Objectives Despite major progress in the prevention and control of malaria in recent years, the disease remains a major cause of morbidity in Ethiopia. Malaria also imposes substantial socioeconomic costs on households. The aim of this study is to estimate the financial risk of seeking malaria service for rural households across socioeconomic statuses in the Jimma Zone, Oromia Region. Design A facility-based cross-sectional survey. Setting Jimma Zone, Oromia Region, Southwest Ethiopia. Participants A total of 221 patients with malaria from 10 public health facilities were interviewed between September 2018 and December 2019. Primary and secondary outcome measures The main outcome measures capture the financial risks associated with malaria services, specifically catastrophic and impoverishing health expenditures. Catastrophic health expenditure (CHE) occurs when healthcare costs reach 10% of a household’s monthly income, whereas impoverishment occurs when a household’s monthly income falls below the national poverty level after paying for health service. Descriptive statistics were used to summarise the expenditure patterns associated with malaria services. All costs were gathered in Ethiopian birr and reported in 2019 US$. Results The average cost of receiving malaria services was US$4.40 (bootstrap 95% CI: 3.6 to 5.3), with indirect costs accounting for 52% of total costs. Overall, at the 10% threshold, 12% (bootstrap 95% CI: 8.1% to 16.7%) of patients with malaria incurred CHE: 40% (bootstrap 95% CI: 26.7% to 55.6%) of the household in the poorest quintile experienced CHE, but none from the richest quintile did. The proportion of households living in poverty increased by more than 2-3% after spending on malaria-specific health services. Conclusion Healthcare seeking for malaria imposes a substantial financial risk on rural households, particularly for the poorest and most vulnerable. Malaria policies and interventions should therefore seek to alleviate both the direct costs and productivity losses associated with the disease, especially among the poor