Health shocks, coping strategies and foregone healthcare among agricultural households in Kenya

Risks are a central part of life for households in low-income countries and health shocks in particular are associated with poverty. Formal mechanisms protecting households against the financial consequences of shocks are largely absent, especially among poor rural households. Our aim is to identify the relative importance of health shocks and to explore factors associated with coping behaviour and foregone care. We use a cross-sectional survey among 1226 randomly selected agricultural households in Kenya. In our sample, illness and injury shocks dominate all other shocks in prevalence. Almost 2% of households incurred catastrophic health expenditure in the last year. Using a probit model we identified the main coping strategies associated with facing a health shock: (1) use savings, (2) sell assets and (3) ask for gifts or loans. One in five households forewent necessary care in the last 12 months. We conclude that health shocks pose a significant risk to households. Implementing pre-payment or saving mechanisms might help protect households against the financial consequences of ill health. Such mechanisms, however, should take into account the competing shocks that agricultural households face, making it almost impossible to reserve a share of their limited resources for the protection against health shocks only

Effects of a smartphone application on maternal health knowledge and dietary diversity among pregnant women in india:A randomized single center pilot study

Background:India contributes to one-fifth of infant and maternal deaths globally. Healthy lifestyles during pregnancy combined with good quality health care can help to avoid many maternal and neonatal deaths. Access to appropriate information is important for developing or maintaining a healthy lifestyle. The increased coverage of smartphones across low- and middle-income countries (LMICs) has given rise to smartphone apps supporting healthy pregnancies. The objective of this study is to evaluate the effects of the smartphone application Together For Her on maternal health knowledge and dietary diversity among pregnant Indian women. Methods:We ran a randomised single-centre pilot study in a private hospital in Maharashtra, India. We randomly selected pregnant women at $20 weeks of gestation who were invited to download the application, in addition to regular antenatal care. The control group only received regular antenatal care. Knowledge about a healthy lifestyle during pregnancy, self-reported dietary diversity and individual characteristics were collected via telephone interviews at baseline (T0), midline (T0 + 4 weeks) and endline (T0 + 12 weeks). Results:Complete data were collected for 179 respondents (intervention:94; control:85). Respondents in the intervention group showed larger increases in their knowledge over the 12-week study period, with an overall knowledge increase of 13.4 percentage points (P&lt;0.001). The largest effects were found in the modules anaemia, breastfeeding and skin-to-skin contact. Self-reported diversity in nutritional intake also improved significantly more in the intervention group than in the control group. Conclusions:Smartphone applications can effectively supplement antenatal care by increasing women’s knowledge about a healthy lifestyle during pregnancy, which is likely to reduce the risk of adverse maternal health outcomes. Future research includes the roll-out of a larger multi-centre RCT to assess the effect of the smartphone application on health outcomes.</p

Effects of performance-based capitation payment on the use of public primary health care services in Indonesia

The Indonesian national health insurance agency BPJS Kesehatan, the largest single-payer system in the world, is among the first to combine capitation-based payments with performance-based financing. The Kapitasi Berbasis Komitmen (KBK) scheme for puskesmas (community health centres) was implemented in province capitals between August 2015 and May 2016. Its main goal was to incentivize the substitution of secondary by primary care use. We evaluate its effect on its three incentivized outcomes: the fraction of insured visiting the puskesmas, the fraction of chronically ill with a puskesmas visit and the hospital referral rate for insured with a non-specialistic condition. We use BPJS Kesehatan claims data from 2015 to 2016 from a stratified one percent sample of its members. Comparable control districts were identified using coarsened exact matching. We adopt a Difference-in-Differences (DID) study design and estimate a two-way fixed effects regression model to compare 27 intervention districts to 300 comparable non-capital control districts. We find that KBK payment increased the monthly percentage of enrolees contacting a puskesmas with 0.578 percentage points. This is a sizeable increase of 48 percent compared to the baseline rate of just 1.2% but it still leaves most puskesmas far below the “sufficient” KBK threshold of 15%. For chronically ill patients, a small increase of 1.15 percentage points was estimated, but it leaves the rate even further below the program's “sufficient” threshold of 50%. We find no statistically significant effect on referral rates to hospitals for conditions not requiring specialist care. While we find positive effects of KBK on two out of three outcomes, all estimated effect sizes leave the actual rates far below the program targets. Our findings suggest that the KBK performance-based capitation reform has not been very successful in substituting secondary care use by greater primary care use.</p

Does health care utilization match needs in Africa? Challenging conventional needs measurement

Abstract. An equitable distribution of health care 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 eighteen SSA countries and find that (a) considerable inequalities in health care use exist and vary across countries, but that (b) identifying the extent to which these inequalities are unfair, i.e. do not correspond to inequalities in need, is not straightforward to ascertain with the conventional tools. These tools include rank-based measures such as the concentration index and the index of inequity. The two main concerns when using conventional tools to measure equity are (i) the reporting heterogeneity in self-reported health variables across socio-economic groups and (ii) the weak relationship between need and use. We show that the use of subjective self-reports of health leads to much lower measured degrees of socio-economic inequalities than those obtained using more objective indicators. This leads to an underestimation of the degree of inequity when using self-reported health measures. The observed weak relationship between indicators of ill-health and use of health care does not appear to provide an estimate of the adequate response to needs, which further puts a downward bias on equity measures. In all countries, apart from the more developed Mauritius, health care use is distributed according to wealth rather than to need. A better match of needs and use is realized in those countries with better governance and more physicians but, perhaps surprisingly, not those with greater urbanization. Given the importance of equity in many health policies worldwide, it is vital to develop more robust equity measures relevant to low income settings

Empirical Essays on Inventors, Workers and Firms

My research seeks to understand the behaviour of workers and firms and how their decisions affect labour market outcomes. My PhD dissertation consists of three separate Chapters that use detailed historical, census and administrative data to gain insights into the mechanisms at play when incentives for production and location decisions change. Chapter 1 asks whether financial incentives can induce inventors to innovate more. I exploit a large reduction in the patent fee in the United Kingdom in 1884 to distinguish between its effect on increased efforts to invent, and a decrease in patent quality due to a lower quality threshold. For this analysis I create a detailed new dataset of 54,000 British inventors with renewal information for each patent. In the longer run high-quality patenting increases by over 100 percent, and the share of new patents due to greater effort accounts for three quarters of the pre-reform share of high-quality patents. To test for the presence of credit constraints I generate two wealth proxies from inventor names and addresses, and find a larger innovation response for inventors with lower wealth. These results indicate efficiency gains from decreasing the cost of inventing and in addition, from relaxing credit constraints. In Chapter 2 we assess the effects of changes in ethnic neighbourhood composition in England and Wales. A change in social housing allocations in the 1990s serves as instrument for changes in the local ethnic composition. For the analysis we create a dataset of highly disaggregated census geographies for 1991-2011. The results imply that an exogenous increase in social housing minority share by 10 percentage points raises the minority share in private housing by 1.2 percentage points initially. This sorting effect is larger for privately rented than for privately owned housing. We further show that an increase in the minority share leads to higher local population growth and a small decrease in house prices in the longer run. Chapter 3 proposes a new approach for analysing responses to comprehensive labour market reforms. Using detailed micro data we evaluate the German Hartz reforms that aimed at reducing unemployment. The timing of the reforms affects the model parameters, which are estimated using matched data on 430,000 workers in 340,000 firms. Contrary to previous findings, our analysis shows that the reforms marginally reduced unemployment at the cost of a pronounced decline in wages. Low-skilled workers suffered the largest wage losses. Furthermore, we decompose the contribution of each reform wave on employment and wages, and document a structural shift in the factors that govern overall wage dispersion

Hypertension in Sub-Saharan Africa: Cross-Sectional Surveys in Four Rural and Urban Communities

Background: Cardiovascular disease (CVD) is the leading cause of adult mortality in low-income countries but data on the prevalence of cardiovascular risk factors such as hypertension are scarce, especially in sub-Saharan Africa (SSA). This study aims to assess the prevalence of hypertension and determinants of blood pressure in four SSA populations in rural Nigeria and Kenya, and urban Namibia and Tanzania. Methods and Findings: We performed four cross-sectional household surveys in Kwara State, Nigeria; Nandi district, Kenya; Dar es Salaam, Tanzania and Greater Windhoek, Namibia, between 2009-2011. Representative population-based samples were drawn in Nigeria and Namibia. The Kenya and Tanzania study populations consisted of specific target groups. Within a final sample size of 5,500 households, 9,857 non-pregnant adults were eligible for analysis on hypertension. Of those, 7,568 respondents ≥18 years were included. The primary outcome measure was the prevalence of hypertension in each of the populations under study. The age-standardized prevalence of hypertension was 19.3% (95%CI:17.3-21.3) in rural Nigeria, 21.4% (19.8-23.0) in rural Kenya, 23.7% (21.3-26.2) in urban Tanzania, and 38.0% (35.9-40.1) in urban Namibia. In individuals with hypertension, the proportion of grade 2 (≥160/100 mmHg) or grade 3 hypertension (≥180/110 mmHg) ranged from 29.2% (Namibia) to 43.3% (Nigeria). Control of hypertension ranged from 2.6% in Kenya to 17.8% in Namibia. Obesity prevalence (BMI ≥30) ranged from 6.1% (Nigeria) to 17.4% (Tanzania) and together with age and gender, BMI independently predicted blood pressure level in all study populations. Diabetes prevalence ranged from 2.1% (Namibia) to 3.7% (Tanzania). Conclusion: Hypertension was the most frequently observed risk factor for CVD in both urban and rural communities in SSA and will contribute to the growing burden of CVD in SSA. Low levels of control of hypertension are alarming. Strengthening of health care systems in SSA to contain the emerging epidemic of CVD is urgently needed