Politics, Child Mortality, and Health System Development in Tanzania and Uganda, 1995-2009.

Sub-Saharan African countries have diverged sharply in health status in recent years: Some have reduced premature mortality rapidly while others have made little progress, despite significant health-oriented foreign aid. This article identifies political economy and institutional factors that help explain dramatic differences in the pace of child mortality reduction between Tanzania and Uganda from 1995-96 to 2006-07. The existing literature largely explains divergence in basic health outcomes like child mortality with reference to economic variables such as GDP per capita, or in terms of inputs such as the level of public sector health spending. However, these factors cannot explain recent divergence across African countries with similar levels of GDP per capita, rates of economic growth, and levels of health funding. I argue that in addition to economic factors, governance-related variables can play a large role in determining health outcomes. I argue that institutional and governance divergences between Tanzania and Uganda can be linked directly to differing levels of coverage of key child health interventions (especially related to malaria control), and thus to differing child health outcomes. These governance-related divergences are found in the institutional dynamics of malaria control, in the degree of meritocracy and bureaucratic autonomy found at the Ministry of Health, in the political economy of health sector decentralization, and in corruption levels in the pharmaceutical supply chain. These institutional differences can be explained in part by historical factors, but the more relevant causes can be found in recent years. In Tanzania, there was an unusually effective project of institution-building in the health sector, centered on malaria policy and research institutions, and on district-level reforms driven by use of demographic surveillance systems. In Uganda, by contrast, there was a negative political shock to the health system, driven by the repatrimonialization of the Ugandan state after President Yoweri Museveni’s decision to eliminate term limits in the 2001-2006 period and embark on the “president-for-life project.” This repatrimonialization process reversed previous health sector institutional gains and had particularly negative effects on child health service delivery in Uganda

\ud Foreign Aid, Child Health, and Health System Development in Tanzania and Uganda, 1995-2009 \ud

As donors have scaled up efforts to improve health in sub-Saharan African, African countries have diverged sharply in their health performance: Some countries have made rapid progress while others have stagnated. Yet the reasons for these divergences are often not well understood. In this dissertation I present in-depth case studies of two such divergent countries, Tanzania and Uganda, over the 1995-2007 period. Over this period, Tanzania reduced its under-5 mortality rate by 35%, while Uganda’s mortality rate decline was less than half as rapid; between 12% and 15% over virtually the same period. This occurred despite the fact that both countries received similar amounts of foreign aid for health, implemented virtually identical health sector reforms, and saw comparable rates of growth in GDP per capita and similar trends in other socioeconomic indicators. Explanations for such differences often vary by academic discipline. Public health scholars often focus on coverage levels of critical child health interventions, while political scientists emphasize variation in the quality of governance institutions. I show that coverage of child survival interventions did indeed differ between Tanzania and Uganda, particularly in the area of malaria control, but that the ultimate determinant of these differences can be traced to political economy factors. Specifically, regime maintenance dynamics and the differing composition of political patronage coalitions in the two countries determined the relative success of health sector programming in Tanzania and Uganda. In addition to outcomes such as under-5 mortality, I also analyze the results of broader health system strengthening efforts in Tanzania and Uganda over the 1995-2009 period. To structure this comparison, a new theoretical framework for health system performance is developed and tested, based on previous theory developed by Pritchett and Woolcock (2002) and Fukuyama (2004). The same political economy dynamics that contributed to Tanzania’s stronger performance on child mortality reduction also enabled its greater progress on health system strengthening. Furthermore, Tanzania’s experience demonstrates the potential for “second best” strategies for health system strengthening that can be implemented in conditions of relatively low state capacity.\u

Mass deworming programmes in middle childhood and adolescence

Soil-transmitted helminthes (STH) deworming programs remain among the largest public health programs in low- and lower-middle-income countries as measured by coverage. The actual scale of these programs remains unknown but substantial, with more than 1 billion donated doses of medicines effective against STHs delivered by formal programs and supplemented by widespread self-treatment and unprogrammed activities. STH infection declines worldwide likely reflect the influence of improved hygiene and sanitation associated with global declines in poverty, but it also reflects control efforts during the twentieth century that have largely eliminated STHs as a public health problem in previously endemic areas of North America (Mexico and the United States), Japan, Korea, and upper- middle-income countries throughout southern and eastern Asia. Much of the treatment targets delivery through schools and targets school-age children. STH infection associates with clinical and developmental outcomes that prove largely reversible by treatment. Both historical and contemporary trials of targeted treatment of infected individuals have also demonstrated benefit from treatment

New tunnel diode for zero-bias direct detection for millimeter-wave imagers

High-resolution passive millimeter wave imaging cameras require per pixel detector circuitry that is simple, has high sensitivity, low noise, and low power. Detector diodes that do not require bias or local oscillator input, and have high cutoff frequencies are strongly preferred. In addition, they must be manufacturable in large quantities with reasonable uniformity and reproducibility. Such diodes have not been obtainable for W-band and above. We are developing zero-bias square-law detector diodes based on InAs/Alsb/GaAlSb heterostructures which for the first time offer a cost-effective solution for large array formats. The diodes have a high frequency response and are relatively insensitive to growth and process variables. The large zero- bias non-linearity in current floor necessary for detection arises from interband tunneling between the InAs and the GaAlSb layers. Video resistance can be controlled by varying an Alsb tunnel barrier layer thickness. Our analysis shows that capacitance can be further decreased and sensitivity increased by shrinking the diode area, as the diode can have very high current density. DC and RF characterization of these devices and an estimate of their ultimate frequency performance in comparison with commercially available diodes are presented

Mass Deworming Programs in Middle Childhood and Adolescence

The current debate on deworming presents an interesting public health paradox. Self-treatment for intestinal worm infection is among the most common self-administered public health interventions, and the delivery of donated drugs through mass drug administration (MDA) programs for soil-transmitted helminths (STHs) exceeds 1 billion doses annually. The clinical literature, especially the older historical work, shows significant impacts of intense STH infection on health; a burgeoning economics literature shows the long-run consequences for development (see, for example, chapter 29 in this volume, Ahuja and others 2017; Fitzpatrick and others 2017). Yet, the literature on clinical trials shows conflicting results, and the resulting controversy has been characterized as the worm wars. The two previous editions of Disease Control Priorities contain chapters on STH and deworming programs (Hotez and others 2006; Warren and others 1993). Much of the biological and clinical understanding reflected in those chapters remains largely unchanged. This chapter presents current estimates of the numbers infected and the disease burden attributable to STH infections to illuminate current program efforts, advances in the understanding of epidemiology and program design, and the controversy regarding the measurement of impact. Definitions of age groupings and age-specific terminology used in this volume can be found in chapter 1 (Bundy, de Silva, and others 2017)

New tunnel diode for zero-bias direct detection for millimeter-wave imagers

High-resolution passive millimeter wave imaging cameras require per pixel detector circuitry that is simple, has high sensitivity, low noise, and low power. Detector diodes that do not require bias or local oscillator input, and have high cutoff frequencies are strongly preferred. In addition, they must be manufacturable in large quantities with reasonable uniformity and reproducibility. Such diodes have not been obtainable for W-band and above. We are developing zero-bias square-law detector diodes based on InAs/Alsb/GaAlSb heterostructures which for the first time offer a cost-effective solution for large array formats. The diodes have a high frequency response and are relatively insensitive to growth and process variables. The large zero- bias non-linearity in current floor necessary for detection arises from interband tunneling between the InAs and the GaAlSb layers. Video resistance can be controlled by varying an Alsb tunnel barrier layer thickness. Our analysis shows that capacitance can be further decreased and sensitivity increased by shrinking the diode area, as the diode can have very high current density. DC and RF characterization of these devices and an estimate of their ultimate frequency performance in comparison with commercially available diodes are presented

Relationships between sickle cell trait, malaria, and educational outcomes in Tanzania

Background: Sickle Cell Trait (SCT) has been shown to be protective against malaria. A growing literature suggests that malaria exposure can reduce educational attainment. This study assessed the relationship and interactions between malaria, SCT and educational attainment in north-eastern Tanzania. Methods: Seven hundred sixty seven children were selected from a list of individuals screened for SCT. Febrile illness and malaria incidence were monitored from January 2006 to December 2013 by community health workers. Education outcomes were extracted from the Korogwe Health and Demographic Surveillance system in 2015. The primary independent variables were malaria and SCT. The association between SCT and the number of fever and malaria episodes from 2006 to 2013 was analyzed. Main outcomes of interest were school enrolment and educational attainment in 2015. Results: SCT was not associated with school enrolment (adjusted OR 1.42, 95% CI [0.593,3.412]) or highest grade attained (adjusted grade difference 0.0597, 95% CI [−0.567, 0.686]). SCT was associated with a 29% reduction in malaria incidence (adjusted IRR 0.71, 95% CI [0.526, 0.959]) but not with fever incidence (adjusted IRR 0.905, 95% CI [0.709-1.154]). In subgroup analysis of individuals with SCT, malaria exposure was associated with reduced school enrollment (adjusted OR 0.431, 95% CI [0.212, 0.877]). Conclusions: SCT appears to reduce incidence of malaria. Overall, children with SCT do not appear to attend more years of school; however children who get malaria despite SCT appear to have lower levels of enrolment in education than their peers

Population confidence in the health system in 15 countries: results from the first round of the People's Voice Survey

Population confidence is essential to a well functioning health system. Using data from the People's Voice Survey—a novel population survey conducted in 15 low-income, middle-income, and high-income countries—we report health system confidence among the general population and analyse its associated factors. Across the 15 countries, fewer than half of respondents were health secure and reported being somewhat or very confident that they could get and afford good-quality care if very sick. Only a quarter of respondents endorsed their current health system, deeming it to work well with no need for major reform. The lowest support was in Peru, the UK, and Greece—countries experiencing substantial health system challenges. Wealthy, more educated, young, and female respondents were less likely to endorse the health system in many countries, portending future challenges for maintaining social solidarity for publicly financed health systems. In pooled analyses, the perceived quality of the public health system and government responsiveness to public input were strongly associated with all confidence measures. These results provide a post-COVID-19 pandemic baseline of public confidence in the health system. The survey should be repeated regularly to inform policy and improve health system accountability

Measuring people's views on health system performance: design and development of the People's Voice Survey

Todd Lewis and co-authors discuss development and use of the People's Voice Survey for health system assessment

Re-Imagining School Feeding : A High-Return Investment in Human Capital and Local Economies

Analysis shows that a quality education, combined with a guaranteed package of health and nutrition interventions at school, such as school feeding, can contribute to child and adolescent development and build human capital. School feeding programs can help get children into school and help them stay there, increasing enrollment and reducing absenteeism. Once children are in the classroom, these programs can contribute to their learning by avoiding hunger and enhancing cognitive abilities. The benefits are especially great for the poorest and most disadvantaged children. As highlighted in the World Bank’s 2018 World Development Report (World Bank 2018), countries need to prioritize learning, not just schooling. Children must be healthy, not hungry, if they are to match learning opportunities with the ability to learn. In the most vulnerable communities, nutrition-sensitive school meals can offer children a regular source of nutrients that are essential for their mental and physical development. And for the growing number of countries with a “double burden” of undernutrition and emerging obesity problems, well-designed school meals can help set children on the path toward more healthy diets. In Latin America, for example, where there is a growing burden of noncommunicable diseases (NCDs), school feeding programs are a key intervention in reducing undernutrition and promoting healthy diet choices. Mexico’s experience reducing sugary beverages in school cafeterias, for example, was found to be beneficial in advancing a healthy lifestyle. A large trial of school-based interventions in China also found that nutritional or physical activity interventions alone are not as effective as a joint program that combines nutritional and educational interventions. In poor communities, economic benefits from school feeding programs are also evident—reducing poverty by boosting income for households and communities as a whole. For families, the value of meals in school is equivalent to about 10 percent of a household’s income. For families with several children, that can mean substantial savings. As a result, school feeding programs are often part of social safety nets in poor countries, and they can be a stable way to reliably target pro-poor investments into communities, as well as a system that can be scaled up rapidly to respond to crises. There are also direct economic benefits for smallholder farmers in the community. Buying local food creates stable markets, boosting local agriculture, impacting rural transformation, and strengthening local food systems. In Brazil, for example, 30 percent of all purchases for school feeding come from smallholder agriculture (Drake and others 2016). These farmers are oftentimes parents with schoolchildren, helping them break intergenerational cycles of hunger and poverty. Notably, benefits to households and communities offer important synergies. The economic growth in poor communities helps provide stability and better-quality education and health systems that promote human capital. At the same time, children and adolescents grow up to enjoy better employment and social opportunities as their communities grow