Use of modern medical care for pregnancy and childbirth care : does female schooling matter ?

Controversy exists over whether the estimated effects of schooling on health care use reflect the influence of unobserved factors. Existing estimates may overstate the schooling effect because of the failure to control for unobserved variables or may be downwardly biased due to measurement error. This paper contributes to the resolution of this debate by adopting an instrumental variable approach to estimate the impact of female schooling on maternal health care use. A school construction program in Indonesia in the 1970s is used to construct an instrumental variable for education. The choice between use and non-use of maternal health services is estimated as a function of schooling and other variables. Data from the Indonesia Family Life Survey are used for this paper. Standard regression models estimated in the paper indicate that each additional year of schooling does indeed have a significant, positive effect on maternal health care use. Instrumental variable estimates of the schooling effect are larger. The results suggest that schooling has a positive impact on maternal health care use even after eliminating the effect of unobserved variables and measurement error. This paper moves beyond previous work on the impact of education on health care use by adopting an IV approach to address the problem of endogeneity and measurement error. IV methods have been used widely in the labour economics literature to examine the impact of schooling on wages and other labour market outcomes but rarely to estimate the effect of schooling on health outcomes.Health Monitoring&Evaluation,Population Policies,Health Systems Development&Reform,Gender and Health,Primary Education

Demand-side financing for sexual and reproductive health services in low and middle-income countries : a review of the evidence

Demand-side financing approaches have been introduced in a number of low and middle-income countries, with a particular emphasis on sexual and reproductive health. This paper aims to bring together the global evidence on demand-side financing mechanisms, their impact on the delivery of sexual and reproductive health services, and the conditions under which they have been effective. The paper begins with a discussion of modalities for demand-side financing. It then examines 13 existing schemes, including cash incentives, vouchers, and longer term social protection policies. Based on the available literature, it collates evidence of their impact on utilization of services, access for the poor, financial protection, quality of care, and health outcomes. Evidence on costs and cost-effectiveness are examined, along with analysis of funding and sustainability of policies. Finally, the paper discusses the preconditions for effectiveness of demand-side financing schemes and the strengths and weaknesses of different approaches. It also highlights the extent to which results for sexual and reproductive health services are likely to be generalizable to other types of health care. It is clear that some of these policies can produce impressive results, if the preconditions for effectiveness outlined are met. However, relatively few demand-side financing schemes have benefited from robust evaluation. Investigation of the impact on financial protection, equity, and health outcomes has been limited. Most importantly, cost effectiveness and the relative cost effectiveness of demand-side financing in relation to other strategies for achieving similar goals have not been assessed.sch_iihpub2952pu

Public funding of health at the district level in Indonesia after decentralization – sources, flows and contradictions

<p>Abstract</p> <p>Background</p> <p>During the Suharto era public funding of health in Indonesia was low and the health services were tightly controlled by the central government; district health staff had practically no discretion over expenditure. Following the downfall of President Suharto there was a radical political, administrative and fiscal decentralization with delivery of services becoming the responsibility of district governments. In addition, public funding for health services more than doubled between 2001 and 2006. It was widely expected that services would improve as district governments now had both more adequate funds and the responsibility for services. To date there has been little improvement in services. Understanding why services have not improved requires careful study of what is happening at the district level.</p> <p>Methods</p> <p>We collected information on public expenditure on health services for the fiscal year 2006 in 15 districts in Java, Indonesia from the district health offices and district hospitals. Data obtained in the districts were collected by three teams, one for each province. Information on district government revenues were obtained from district public expenditure databases maintained by the World Bank using data from the Ministry of Finance.</p> <p>Results</p> <p>The public expenditure information collected in 15 districts as part of this study indicates district governments are reliant on the central government for as much as 90% of their revenue; that approximately half public expenditure on health is at the district level; that at least 40% of district level public expenditure on health is for personnel, almost all of them permanent civil servants; and that districts may have discretion over less than one-third of district public expenditure on health; the extent of discretion over spending is much higher in district hospitals than in the district health office and health centers. There is considerable variation between districts.</p> <p>Conclusion</p> <p>In contrast to the promise of decentralization there has been little increase in the potential for discretion at the district level in managing public funds for health – this is likely to be an important reason for the lack of improvement in publicly funded health services. Key decisions about money are still made by the central government, and no one is held accountable for the performance of the sector – the district blames the center and the central ministries (and their ministers) are not accountable to district populations.</p

Multisectoral Approaches to Addressing Malnutrition in Bangladesh: The Role of Agriculture and Microcredit

The objective of this study is to demonstrate how the interaction between sectors can be improved to increase the effectiveness of sectoral interventions, and how the interventions in the agricultural sector and microfinance can be used to improve nutritional outcomes. The study will examine what has been done to improve nutrition through interventions in the agriculture sector and microcredit programmes in Bangladesh and around the world, how they were implemented and to the extent possible, what the impact of those interventions was. The populations of primary concern for this study are infants, children and women of childbearing age, the group that is the target of many of the millennium development goals. The study will also pay special attention to the extent to which programmes and policies are successful at reaching poor and vulnerable groups in society and thus, reduce inequalities in nutrition. The introduction provides the background and rationale for this work. Chapter two assesses the status of malnutrition in Bangladesh, provides a brief history of policies and programmes to address malnutrition in the country and lays out the case for a multi-sectoral response to malnutrition. Chapter three reviews the potential role of interventions in the agriculture sector, including existing evidence on the impact of such interventions and institutional and other challenges to enhancing the impact. Chapter four provides a similar review of the role of microcredit programmes in improving nutrition outcomes. Recommendations on using multi-sectoral approaches to improve nutrition in Bangladesh are the subject of chapter five

Vietnam's universal health coverage

노트 : Title) Frontiers in Development Policy: Workshop on Innovative Development Case StudiesDate) November 21-22, 2013Venue) Hotel Shilla Seoul, Seoul, Republic of Korea (http://www.shilla.net/) 행사명 : Workshop on Innovative Development Case Studie

Malnutrition in Sri Lanka: Scale, Scope, Causes, and Potential Response

The Millennium Development Goals (MDGs) are a set of eight goals which United Nations member countries are committed to reach by 2015. The first MDG is to eradicate poverty and hunger. This report focuses on the attainment of human development-related MDG by sub-national units in Sri Lanka relating to poor and integrating nutrition with other sectoral activities, including health, agriculture, education, economic reform, and rural development. It primarily focuses on developing a programmatic framework for the health sector. Malnutrition includes both under nutrition and overweight. Overweight predisposes the population to higher risks of cardiovascular diseases, diabetes, and other noncommunicable diseases (NCDs). Even with relatively optimistic assumptions about economic growth, it alone is insufficient to meet the MDGs. The Government of Sri Lanka's (GOSL'S) current policy response to malnutrition consists of three broad strategies: direct food assistance programs, poverty reduction programs and the provision of an integrated package of maternal and child health and nutrition services through the Ministry of Healthcare and Nutrition. Complementary strategies to reduce poverty or to improve access to safe water and sanitation must be specifically designed to reduce inequalities. GOSL and the World Bank both recognize the need to address malnutrition. Sri Lanka needs to focus on three key changes to appropriately address malnutrition: (a) Finance a technically correct set of strategies and interventions in an economically justifiable formulation to maximize cost-effectiveness; (b) Ensure a high level of political commitment to sustain these actions; and (c) Identify the appropirate instiutional arrangements and develop necessary capacities in these instiutions

Mobilising financial resources for maternal health.

Coverage of cost-effective maternal health services remains poor due to insufficient supply and inadequate demand for these services among the poorest groups. Households pay too great a share of the costs of maternal health services, or do not seek care because they cannot afford the costs. Available evidence creates a strong case for removal of user fees and provision of universal coverage for pregnant women, particularly for delivery care. To be successful, governments must also replenish the income lost through the abolition of user fees. Where insurance schemes exist, maternal health care needs to be included in the benefits package, and careful design is needed to ensure uptake by the poorest people. Voucher schemes should be tested in low-income settings, and their costs and relative cost-effectiveness assessed. Further research is needed on methods to target financial assistance for transport and time costs. Current investment in maternal health is insufficient to meet the fifth Millennium Development Goal (MDG), and much greater resources are needed to scale up coverage of maternal health services and create demand. Existing global estimates are too crude to be of use for domestic planning, since resource requirements will vary; budgets need first to be developed at country-level. Donors need to increase financial contributions for maternal health in low-income countries to help fill the resource gap. Resource tracking at country and donor levels will help hold countries and donors to account for their commitments to achieving the maternal health MDG