Three Essays on the Economics of Health in Developing Countries

This dissertation consists of three chapters that address health issues in developing countries. The first two chapters study Ghana's social health insurance program, the National Health Insurance Scheme. Many developing countries have recently instituted social health insurance schemes (SHIs) to ease financial barriers to utilization of healthcare services and help mitigate the effects of adverse health shocks. Although these SHIs offer generous terms and benefits, enrollment remains low especially among the poorest households who are the intended primary beneficiaries. The first two chapters are based on randomized field interventions implemented in the Wa West district of the Upper West Region of Ghana to (a) understand the reasons for low enrollment in SHIs; (b) estimate the effects of insurance coverage on utilization of healthcare services, financial protection and health outcomes, and c) learn about how resource-constrained households allocate health resources among its members. The interventions were increased convenience of signing for insurance, an education intervention that provided information about the insurance program, and a subsidy intervention that included varying levels of subsidies for insurance premiums. The first chapter deals with objectives (a) and (b). The results show that inadequate information about the insurance program, and insurance premium and fees affect enrollment. The results also show that the demand for insurance is price elastic in the sense that small subsidies generate substantial enrollment effects. Insurance coverage leads to increased utilization of healthcare services, reduced out-of-pocket payments among individuals with prior positive expenses and ,moderate improvement in health outcomes. The results suggest strong complementarities between providing information and providing subsidies in utilization and health outcomes, an indication of the importance of the combined interventions for achieving changes in health-seeking behavior and outcomes. The second chapter focuses on objective (c): intra-household allocation of health resources among resource-constrained households. The analysis in this chapter is based on households who were assigned to receive subsidies only and the pure control group. Two types of vouchers were issued to households who did not receive full subsidies: one that allowed households to decide how to allocate subsidy among its members and one in which they had no control over the allocation. This chapter compares within household enrollment patterns across these two vouchers. The results suggest that households prioritize children in the presence of resource constraints. Among children, households who were allowed to determine allocation of subsidy amounts enroll 11.7 percentage or 18% more boys than girls. The results suggest that these patterns of allocation cannot be explained by baseline health conditions or expected health. The chater presents supporting evidence that differential labor market participation is a likely explanation for the differential allocation by gender among children: among children aged 7-17 years, labor market participation is 3.6 percentage points higher for boys than girls. The third and final chapter is coauthored with Ayaga A. Bawah and James F. Phillips. The chapter seeks to explore how the quasi-experimental introduction of reproductive and family planning services affects the fertility behavior of different socio-economic groups in a rural African setting. We combine a quasi-experimental introduction of reproductive and family planning services in the Kassena-Nankana districts in the Upper East Region of Ghana with longitudinal data from the Navrongo Health and Demographic Surveillance System to quantify the differential fertility effects of the interventions by socio-economic status (as measured by woman's education status, her husband's education status and wealth). We track the fertility behavior and outcomes of more than 24,000 women in their reproductive age (15-49) over a period of eighteen years. Our results show that before the interventions educated women did not have significantly fewer children, but desired lower family sizes and were more likely to use modern contraceptives. However, husband's education was associated with lower fertility especially when their wives were also educated. Wealth was associated with higher fertility, reflecting a higher child survival rate in wealthy families. Moreover, controlling for wealth does not affect the effect of education on fertility. We find that the reproductive health interventions affected both educated and uneducated women but the effect on educated women was stronger, leading to the emergence of an education-fertility differential 16 years after the introduction of the interventions. Our results suggest that in settings where men dominate reproductive decision-making, their education status may have a stronger effect on fertility than the educational attainment of women

Does the contribution of women to household expenditure explain contraceptive use? An assessment of the relevance of bargaining theory to Africa

This paper draws on the concept of bargaining theory to interpret contraceptive decision-making among women who express a desire to limit or space children. Bargaining theory assumes conflict in decision making within households and posits that such conflict is resolved through bargaining. Women’s bargaining power is said to increase with more control of resources. The underlying assumption is that household decisions are governed by economics. This paper acknowledges that economics may influence reproductive decisions, but posits that African social norms and institutions are more important in defining conjugal roles than spousal relative economic contribution to family expenditure. Findings from seven African countries show that women who contribute more income to household expenditure are no more likely to adopt family planning as predicted by bargaining theory. These results bring into question theoretical perspectives that are sometimes promoted as generic explanatory models without validation in specific cultural settings

Cost of implementing a community-based primary health care strengthening program: The case of the Ghana Essential Health Interventions Program in northern Ghana

Background The absence of implementation cost data constrains deliberations on consigning resources to community-based health programs. This paper analyses the cost of implementing strategies for accelerating the expansion of a community-based primary health care program in northern Ghana. Known as the Ghana Essential Health Intervention Program (GEHIP), the project was an embedded implementation science program implemented to provide practical guidance for accelerating the expansion of community-based primary health care and introducing improvements in the range of services community workers can provide. Methods Cost data were systematically collected from intervention and non-intervention districts throughout the implementation period (2012–2014) from a provider perspective. The step-down allocation approach to costing was used while WHO health system blocks were adopted as cost centers. We computed cost without annualizing capital cost to represent financial cost and cost with annualizing capital cost to represent economic cost. Results The per capita financial cost and economic cost of implementing GEHIP over a three-year period was $1.79, and$1.07 respectively. GEHIP comprised only 3.1% of total primary health care cost. Health service delivery comprised the largest component of cost (37.6%), human resources was 28.6%, medicines was 13.6%, leadership/governance was 12.8%, while health information comprised 7.5% of the economic cost of implementing GEHIP. Conclusion The per capita cost of implementing the GEHIP program was low. GEHIP project investments had a catalytic effect that improved community-based health planning and services (CHPS) coverage and enhanced the efficient use of routine health system resources rather than expanding overall primary health care costs

The child survival impact of the Ghana Essential Health Interventions Program: A health systems strengthening plausibility trial in Northern Ghana

Background: The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods: Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results: The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion: GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up

Cost-benefit analysis of water source improvements through borehole drilling or rehabilitation: an empirical study based on a cluster randomized controlled trial in the Volta Region, Ghana.

BACKGROUND: Despite remarkable progress in water coverage improvements, diseases associated with poor water remain a considerable public health problem in many developing countries. OBJECTIVE: We aimed to estimate the costs and benefits of drilling or rehabilitating boreholes with handpumps in resource-poor settings and hard-to-reach areas. METHODS: Diarrheal reduction in the population was predicted on the basis of the empirical findings from a cluster randomized controlled trial. The full investment and estimated annual running costs were used to calculate the intervention costs. Direct economic benefits of avoiding child diarrheal disease, indirect economic benefits related to health improvements, and non-health benefits related to water improvement were estimated. One-way and multi-way sensitivity analyses were performed to determine the robustness of the findings. RESULTS: Our analysis found that the return on a US$1 investment was US$ 9.4 for borehole drilling and US$ 14.1 for borehole rehabilitation. Time savings were the main contributor, accounting for 68% of the benefits, followed by the economic benefits of averted child deaths, which contributed to 15% of the benefits. The sensitivity analyses suggested that improving water sources yields high returns under all circumstances, and that borehole rehabilitation is more efficient than borehole drilling. CONCLUSION: This study explicitly justifies increased investment in water improvement in rural areas and demonstrates the high returns of rehabilitating boreholes. We hope that this study will be used as evidence for informing the policy decisions of governments or international agencies regarding further investments in improved water coverage in rural areas and the selection of appropriately designed interventions

Contraceptive use intentions and unmet need for family planning among reproductive-aged women in the Upper East Region of Ghana

Background Motivations for use of contraceptives vary across populations. While some women use contraceptives for birth spacing, others adopt contraception for stopping childbearing. As part of efforts to guide the policy framework to promote contraceptive utilization among women in Ghana, this paper examines the intentions for contraceptive use among reproductive-aged women in one of the most impoverished regions of Ghana. Methods This paper utilizes data collected in 2011 from seven districts in the Upper East Region of northern Ghana to examine whether women who reported the use of contraceptives did so for the purposes of stopping or spacing childbirth. A total of 5511 women were interviewed on various health and reproductive health related issues, including fertility and family planning behavior. Women were asked if they would like to have any more children (for those who already had children or those who were pregnant at the time of the survey). Results The prevalence of contraceptive use was low at 13%, while unmet need is highly pervasive and demand for family planning is predominantly for spacing future childbearing rather than for the purpose of stopping. Overall, about 31.7%of women not using contraceptives reported a need for spacing while 17.6% expressed a need for limiting. Thus, the latent demand for family planning is dominated by preferences for space rather than limiting childbearing. Conclusion Results show that there is latent demand for family planning and therefore if family planning programs are appropriately implemented they can yield the desired impact

Supplementary polio immunization activities and prior use of routine immunization services in non-polio-endemic sub-Saharan Africa

OBJECTIVE: To determine participation in polio supplementary immunization activities (SIAs) in sub-Saharan Africa among users and non-users of routine immunization services and among users who were compliant or non-compliant with the routine oral poliovirus vaccine (OPV) immunization schedule. METHODS: Data were obtained from household-based surveys in non-polio-endemic sub-Saharan African countries. Routine immunization service users were children (aged < 5 years) who had ever had a health card containing their vaccination history; non-users were children who had never had a health card. Users were considered compliant with the OPV routine immunization schedule if, by the SIA date, their health card reflected receipt of required OPV doses. Logistic regression measured associations between SIA participation and use of both routine immunization services and compliance with routine OPV among users. FINDINGS: Data from 21 SIAs conducted between 1999 and 2010 in 15 different countries met inclusion criteria. Overall SIA participation ranged from 70.2% to 96.1%. It was consistently lower among infants than among children aged 1–4 years. In adjusted analyses, participation among routine immunization services users was > 85% in 12 SIAs but non-user participation was > 85% in only 5 SIAs. In 18 SIAs, participation was greater among users (P < 0.01 in 16, 0.05 in 1 and < 0.10 in 1) than non-users. In 14 SIAs, adjusted analyses revealed lower participation among non-compliant users than among compliant users (P < 0.01 in 10, < 0.05 in 2 and < 0.10 in 2). CONCLUSION: Large percentages of children participated in SIAs. Prior use of routine immunization services and compliance with the routine OPV schedule showed a strong positive association with SIA participation

Research capacity building integrated into PHIT projects: leveraging research and research funding to build national capacity

Background: Inadequate research capacity impedes the development of evidence-based health programming in sub-Saharan Africa. However, funding for research capacity building (RCB) is often insufficient and restricted, limiting institutions’ ability to address current RCB needs. The Doris Duke Charitable Foundation’s African Health Initiative (AHI) funded Population Health Implementation and Training (PHIT) partnership projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia) to implement health systems strengthening initiatives inclusive of RCB. Methods: Using Cooke’s framework for RCB, RCB activity leaders from each country reported on RCB priorities, activities, program metrics, ongoing challenges and solutions. These were synthesized by the authorship team, identifying common challenges and lessons learned. Results: For most countries, each of the RCB domains from Cooke’s framework was a high priority. In about half of the countries, domain specific activities happened prior to PHIT. During PHIT, specific RCB activities varied across countries. However, all five countries used AHI funding to improve research administrative support and infrastructure, implement research trainings and support mentorship activities and research dissemination. While outcomes data were not systematically collected, countries reported holding 54 research trainings, forming 56 mentor-mentee relationships, training 201 individuals and awarding 22 PhD and Masters-level scholarships. Over the 5 years, 116 manuscripts were developed. Of the 59 manuscripts published in peer-reviewed journals, 29 had national first authors and 18 had national senior authors. Trainees participated in 99 conferences and projects held 37 forums with policy makers to facilitate research translation into policy. Conclusion: All five PHIT projects strongly reported an increase in RCB activities and commended the Doris Duke Charitable Foundation for prioritizing RCB, funding RCB at adequate levels and time frames and for allowing flexibility in funding so that each project could implement activities according to their trainees’ needs. As a result, many common challenges for RCB, such as adequate resources and local and international institutional support, were not identified as major challenges for these projects. Overall recommendations are for funders to provide adequate and flexible funding for RCB activities and for institutions to offer a spectrum of RCB activities to enable continued growth, provide adequate mentorship for trainees and systematically monitor RCB activities. Electronic supplementary material The online version of this article (10.1186/s12913-017-2657-6) contains supplementary material, which is available to authorized users

Data-driven quality improvement in low-and middle-income country health systems: lessons from seven years of implementation experience across Mozambique, Rwanda, and Zambia

Well-functioning health systems need to utilize data at all levels, from the provider, to local and national-level decision makers, in order to make evidence-based and needed adjustments to improve the quality of care provided. Over the last 7 years, the Doris Duke Charitable Foundation’s African Health Initiative funded health systems strengthening projects at the facility, district, and/or provincial level to improve population health. Increasing data-driven decision making was a common strategy in Mozambique, Rwanda and Zambia. This paper describes the similar and divergent approaches to increase data-driven quality of care improvements (QI) and implementation challenge and opportunities encountered in these three countries