@article {bernal_lara_disruption_2023, title = {Disruption Of Non-COVID-19 Health Care In Latin America During The Pandemic: Effects On Health, Lessons For Policy}, journal = {Health Affairs}, volume = {42}, number = {12}, year = {2023}, note = {Publisher: Health Affairs}, month = {dec}, pages = {1657{\textendash}1666}, abstract = {COVID-19 had severe direct and indirect effects on health and well-being in Latin America. To understand the extent to which disruptions among non-COVID-19-related health services affected population health, we used administrative data from the period 2015{\textendash}21 to examine public hospital discharges and mortality for conditions amenable to health care in four Latin American countries: Brazil, Ecuador, Mexico, and Peru. Between March 2020 and December 2021, hospitalization rates for these conditions declined by 28\ percent and mortality rates increased by 15\ percent relative to prepandemic years. Noncommunicable diseases accounted for 89\ percent of this rise in mortality. The poorest states in each country experienced relatively larger increases in mortality. Our results, which focus on the health effects of service disruption, suggest that maintaining health care services in this region during the pandemic could have avoided at least 96,000 deaths. Policies should focus on maintaining essential health care services during emergencies, particularly for patients with noncommunicable diseases, and on minimizing negative consequences by ensuring coordinated and continuous care; leveraging alternative modalities of care, such as telemedicine; broadening the role of nonphysician health care workers; and expanding options for medication delivery.}, issn = {0278-2715}, doi = {10.1377/hlthaff.2023.00720}, url = {https://www.healthaffairs.org/doi/10.1377/hlthaff.2023.00720}, author = {Bernal Lara, Pedro and Savedoff, William D. and Garc{\'\i}a Agudelo, Mar{\'\i}a Fernanda and Bernal, Carolina and Goyeneche, Laura and Sorio, Rita and P{\'e}rez-Cuevas, Ricardo and da Rocha, Marcia Gomes and Shibata, Leonardo Goes and San Roman Vucetich, Cristina and Bauhoff, Sebastian} } @article {choi_impact_2023, title = {Impact of the Influx of Syrian Refugees on Domestic Violence Against Jordanian Women: Evidence from the 2017{\textendash}18 Jordan Population and Family Health Survey}, journal = {PLOS ONE}, volume = {18}, number = {11}, year = {2023}, note = {Publisher: Public Library of Science}, pages = {e0288144}, abstract = {The 2011 Syrian crisis led to a large influx of refugees into neighboring countries, including Jordan. The resulting stress on local host communities could heighten the risk of domestic violence against Jordanian women. We utilized multilevel propensity score weighting and data from the 2017{\textendash}18 Jordan Population and Family Health Survey to empirically test for differences in outcomes related to domestic violence, marital control, and justification of wife-beating between Jordanian communities with varying density levels of Syrian women. We did not find systematic differences in these outcomes across communities. However, we cannot rule out effects that may not be statistically detectable with our sample but could still be substantively meaningful.}, keywords = {Domestic Violence, Emotions, Employment, Health Surveys, Intimate Partner Violence, Medical risk factors, Public and occupational health, Refugees}, issn = {1932-6203}, doi = {10.1371/journal.pone.0288144}, url = {https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0288144}, author = {Choi, Han and Bauhoff, Sebastian} } @article {rubinstein_lives_2023, title = {Lives Versus Livelihoods: The Epidemiological, Social, And Economic Impact Of COVID-19 In Latin America And The Caribbean}, journal = {Health Affairs}, volume = {42}, number = {12}, year = {2023}, note = {Publisher: Health Affairs}, pages = {1647{\textendash}1656}, abstract = {During the COVID-19 pandemic, Latin American and Caribbean countries implemented stringent public health and social measures that disrupted economic and social activities. This study used an integrated model to evaluate the epidemiological, economic, and social trade-offs in Argentina, Brazil, Jamaica, and Mexico throughout 2021. Argentina and Mexico displayed a higher gross domestic product (GDP) loss and lower deaths per million compared with Brazil. The magnitude of the trade-offs differed across countries. Reducing GDP loss at the margin by 1\ percent would have increased daily deaths by 0.5 per million in Argentina but only 0.3 per million in Brazil. We observed an increase in poverty rates related to the stringency of public health and social measures but no significant income-loss differences by sex. Our results indicate that the economic impact of COVID-19 was uneven across countries as a result of different pandemic trajectories, public health and social measures, and vaccination uptake, as well as socioeconomic differences and fiscal responses. Policy makers need to be informed about the trade-offs to make strategic decisions to save lives and livelihoods.}, issn = {0278-2715}, doi = {10.1377/hlthaff.2023.00706}, url = {https://www.healthaffairs.org/doi/10.1377/hlthaff.2023.00706}, author = {Rubinstein, Adolfo and Filippini, Federico and Santoro, Adrian and Lopez Osornio, Alejandro L. and Bardach, Ariel L. and Navarro, Emiliano and Cejas, Cintia and Bauhoff, Sebastian and Augustovski, Federico and Pichon-Riviere, Andr{\'e}s L. and Levy Yeyati, Eduardo L.} } @article {Biswase012836, title = {Performance of Predictive Algorithms in Estimating the Risk of Being a Zero-Dose Child in India, Mali and Nigeria}, journal = {BMJ Global Health}, volume = {8}, year = {2023}, pages = {e012836}, publisher = {BMJ Specialist Journals}, abstract = { Introduction Many children in low-income and middle-income countries fail to receive any routine vaccinations. There is little evidence on how to effectively and efficiently identify and target such {\textquoteleft}zero-dose{\textquoteright} (ZD) children. Methods We examined how well predictive algorithms can characterise a child{\textquoteright}s risk of being ZD based on predictor variables that are available in routine administrative data. We applied supervised learning algorithms with three increasingly rich sets of predictors and multiple years of data from India, Mali and Nigeria. We assessed performance based on specificity, sensitivity and the F1 Score and investigated feature importance. We also examined how performance decays when the model is trained on older data. For data from India in 2015, we further compared the inclusion and exclusion errors of the algorithmic approach with a simple geographical targeting approach based on district full-immunisation coverage. Results Cost-sensitive Ridge classification correctly classifies most ZD children as being at high risk in most country-years (high specificity). Performance did not meaningfully increase when predictors were added beyond an initial sparse set of seven variables. Region and measures of contact with the health system (antenatal care and birth in a facility) had the highest feature importance. Model performance decreased in the time between the data on which the model was trained and the data to which it was applied (test data). The exclusion error of the algorithmic approach was about 9.1\% lower than the exclusion error of the geographical approach. Furthermore, the algorithmic approach was able to detect ZD children across 176 more areas as compared with the geographical rule, for the same number of children targeted. Interpretation Predictive algorithms applied to existing data can effectively identify ZD children and could be deployed at low cost to target interventions to reduce ZD prevalence and inequities in vaccination coverage. }, doi = {10.1136/bmjgh-2023-012836}, url = {https://gh.bmj.com/content/8/10/e012836}, author = {Arpita Biswas and John Tucker and Bauhoff, Sebastian} } @article {Turcotte-Tremblay2023, title = {Tracking Health System Performance in Times of Crisis Using Routine Health Data: Lessons Learned From a Multicountry Consortium}, journal = {Health Research Policy and Systems}, volume = {21}, number = {1}, year = {2023}, month = {Jan}, pages = {14}, abstract = { COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People{\textquoteright}s Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43\% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12\% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72\% of the indicators compiled were related to volume of services delivered, 18\% to health outcomes and only 10\% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and\ employ mixed methods to better understand the underlying causes of service disruptions. }, issn = {1478-4505}, doi = {10.1186/s12961-022-00956-6}, url = {https://doi.org/10.1186/s12961-022-00956-6}, author = {Turcotte-Tremblay, Anne-Marie and Borwornsom Leerapan and Patricia Akweongo and Amponsah, Freddie and Aryal, Amit and Asai, Daisuke and Awoonor-Williams, John Koku and Ayele, Wondimu and Bauhoff, Sebastian and Doubova, Svetlana V. and Gadeka, Dominic Dormenyo and Dulal, Mahesh and Gage, Anna and Gordon-Strachan, Georgiana and Haile-Mariam, Damen and Joseph, Jean Paul and Kaewkamjornchai, Phanuwich and Kapoor, Neena R. and Gelaw, Solomon Kassahun and Kim, Min Kyung and Margaret E. Kruk and Kubota, Shogo and Margozzini, Paula and Mehata, Suresh and Mthethwa, Londiwe and Nega, Adiam and Oh, Juhwan and Park, Sookyung and Passi-Solar, Alvaro and Perez Cuevas, Ricardo Enrique and Reddy, Tarylee and Rittiphairoj, Thanitsara and Sapag, Jaime C. and Thermidor, Roody and Tlou, Boikhutso and Arsenault, Catherine} } @article {Gagee066111, title = {The Role of Teams in Shaping Quality of Obstetrical Care: A Cross-Sectional Study in Dire Dawa, Ethiopia}, journal = {BMJ Open}, volume = {12}, year = {2022}, pages = {e066111}, publisher = {British Medical Journal Publishing Group}, abstract = { Objectives To examine how characteristics of clinical colleagues influence quality of care. Design We conducted a cross-sectional observational study examining the associations between quality of care and a provider{\textquoteright}s coworkers, controlling for individual provider{\textquoteright}s characteristics and contextual factors.Setting Nine health facilities in Dire Dawa Administration, Ethiopia, from December 2020 to February 2021. Participants 824 clients and 95 unique providers were observed across the 9 health facilities.Outcome measures We examine the quality of processes of intrapartum and immediate postpartum care during five phases of the delivery (first examination, first stage of labour, third stage of labour, immediate newborn care and immediate maternal postpartum care). Results For the average client, 50\% of the recommended routine clinical actions were completed during the delivery overall, with immediate maternal postpartum care being the least well performed (17\% of recommended actions). Multiple healthcare providers were involved in 55\% of deliveries. The number of providers contributing to a delivery was unassociated with the quality of care, but a one standard deviation increase in the coworker{\textquoteright}s performance was associated with a 2\% point increase in quality of care (p\<0.01); this association was largest among providers in the middle quartiles of performance. Conclusions A provider{\textquoteright}s typical performance had a modest positive association with quality of delivery care given by their coworker. As delivery care is often provided by multiple healthcare providers, examining the dynamics of how they influence one another can provide important insights for quality improvement. }, issn = {2044-6055}, doi = {10.1136/bmjopen-2022-066111}, url = {http://dx.doi.org/10.1136/bmjopen-2022-066111}, author = {Gage, Anna and Yakob, Bereket and Margaret McConnell and Girma, Tsinuel and Damtachew, Brook and Bauhoff, Sebastian and Kruk, Margaret} } @article {694520, title = {The Quality of Primary Care in Cambodia: An Assessment of Knowledge and Effort of Public Sector Maternal and Child Care Providers}, journal = {Health Systems \& Reform}, volume = {8}, number = {1}, year = {2022}, pages = {e2124903}, abstract = { Improving the quality of primary care is essential for achieving universal health coverage in low- and middle-income countries. This study examined the level and variation in primary care provider knowledge and effort in Cambodia, using cross-sectional data collected in 2014{\textendash}2015 from public sector health centers in nine provinces. The data included clinical vignettes and direct observations of processes of antenatal care, postnatal care, and well-child visits and covered between 290{\textendash}495 health centers and 370{\textendash}847 individual providers for each service and type of data. The results indicate that provider knowledge and observed effort were generally low and varied across health centers and across individual providers. In addition, providers{\textquoteright} effort scores were generally lower than their knowledge scores, indicating the presence of a {\textquotedblleft}know-do gap.{\textquotedblright} Although higher provider knowledge was correlated with higher levels of effort during patient encounters, knowledge only explained a limited fraction of the provider-level variation in effort. Due to low baseline performance and the know-do gap, improving provider adherence to clinical guidelines through training and practice standardization alone may have limited impact. Overall, the findings suggest that raising the low quality of care provided by Cambodia{\textquoteright}s public sector will require multidimensional interventions that involve training, strategies that increase provider motivation, and improved health center management }, url = {https://doi.org/10.1080/23288604.2022.2124903}, author = {Dan Han and Nagpal, Somil and Bauhoff, Sebastian} } @article {690740, title = {Role of User Benefit Awareness in Health Coverage Utilization Among the Poor in Cambodia}, journal = {Health Systems \& Reform}, volume = {8}, number = {1}, year = {2022}, pages = {e2058336}, abstract = { The objective of this study was to understand the steps to health coverage benefit utilization in Cambodia toward improving access to health care and financial risk protection for the poor. We particularly examine the role of user awareness in the pathway to care seeking and benefit utilization with respect to the Health Equity Funds (HEF). Using 2016 survey data that were nationally representative of households with children under two years of age, we used a series of logistic regression models to evaluate associations between respondents{\textquoteright} awareness of benefits, public health care seeking behaviors, coverage benefit claims, and out-of-pocket expenditures. Beneficiaries were generally aware of their entitlements, although their awareness of specific benefits, such as transport reimbursement, was relatively lower. Awareness of free services at public health centers was associated with twice the odds of having ever visited a public provider for outpatient care, while awareness of free services at public hospitals was associated with higher odds of always seeking inpatient care in the public sector. Study findings point to the decision of where to seek care as the critical point in the pathway to HEF utilization. If the decision had already been made to go to a public provider, it was likely that HEF benefits were claimed. Interventions that prompt appropriate care seeking in the public sector may do the most to improve HEF utilization and subsequently improve access to care through sufficient financial risk protection. }, url = {https://doi.org/10.1080/23288604.2022.2058336}, author = {Isabelle Feldhaus and Nagpal, Somil and Bauhoff, Sebastian} } @article {arsenault_covid-19_2022, title = {COVID-19 and Resilience of Healthcare Systems in Ten Countries}, journal = {Nature Medicine}, year = {2022}, note = {Publisher: Nature Publishing Group}, pages = {1{\textendash}11}, abstract = {Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People{\textquoteright}s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26{\textendash}96\% declines). Total outpatient visits declined by 9{\textendash}40\% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5\% to 33\%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.}, keywords = {Developing world, Health Policy, Health Services}, issn = {1546-170X}, doi = {10.1038/s41591-022-01750-1}, url = {https://www.nature.com/articles/s41591-022-01750-1}, author = {Arsenault, Catherine and Gage, Anna and Kim, Min Kyung and Kapoor, Neena R. and Patricia Akweongo and Amponsah, Freddie and Aryal, Amit and Asai, Daisuke and Awoonor-Williams, John Koku and Ayele, Wondimu and Bedregal, Paula and Doubova, Svetlana V. and Dulal, Mahesh and Gadeka, Dominic Dormenyo and Gordon-Strachan, Georgiana and Mariam, Damen Haile and Hensman, Dilipkumar and Joseph, Jean Paul and Kaewkamjornchai, Phanuwich and Eshetu, Munir Kassa and Gelaw, Solomon Kassahun and Kubota, Shogo and Borwornsom Leerapan and Margozzini, Paula and Mebratie, Anagaw Derseh and Mehata, Suresh and Moshabela, Mosa and Mthethwa, Londiwe and Nega, Adiam and Oh, Juhwan and Park, Sookyung and Passi-Solar, {\'A}lvaro and P{\'e}rez-Cuevas, Ricardo and Phengsavanh, Alongkhone and Reddy, Tarylee and Rittiphairoj, Thanitsara and Sapag, Jaime C. and Thermidor, Roody and Tlou, Boikhutso and Valenzuela Gui{\~n}ez, Francisco and Bauhoff, Sebastian and Margaret E. Kruk} } @article {McConnelle007344, title = {How are Health Workers Paid and Does it Matter? Conceptualising the Potential Implications of Digitising Health Worker Payments}, journal = {BMJ Global Health}, volume = {7}, number = {1}, year = {2022}, abstract = { Summary box- Payment digitisation efforts in the health sector in low/middle-income countries have accelerated due to the COVID-19 pandemic. - Research on impacts of worker payment digitisation on health systems is lacking. - Our conceptual model details how payment digitisation could improve health systems. - Wage digitisation has the potential to improve health system performance and provider well-being and consequently, patient outcomes. - Critical gaps in evidence need to be addressed to support implementation and effective innovation. }, doi = {10.1136/bmjgh-2021-007344}, url = {https://gh.bmj.com/content/7/1/e007344}, author = {Margaret McConnell and Mahajan, Mansha and Bauhoff, Sebastian and Kevin Croke and Verguet, St{\'e}phane and Castro, Marcia C and Melo Furtado, Kheya and Mehndiratta, Abha and Farzana, Misha and Faiz Rashid, Sabina and Cash, Richard} } @article {684810, title = {Effect of the Suspension of the J\&J COVID-19 Vaccine on Vaccine Hesitancy in the United States}, journal = {Vaccine}, volume = {40}, number = {3}, year = {2022}, pages = {424-427}, abstract = { On April 13, 2021, U.S. authorities announced an investigation into potential adverse events associated with the Johnson \& Johnson (Janssen, J\&J) COVID-19 vaccine and recommended {\textquotedblleft}a pause in the use of this vaccine out of an abundance of caution.{\textquotedblright} We examined whether public attitudes toward COVID-19 vaccination shifted after this recommended suspension using an interrupted time series with data from the Census Bureau{\textquoteright}s Household Pulse Survey, which was fielded bi-weekly between January 6 and April 26, 2021. We found no significant changes in trends of the proportion of the U.S. adult population hesitant about getting a COVID-19 vaccine, but a significant increase in concerns about safety and efficacy of COVID-19 vaccines among the already hesitant population. }, url = {https://doi.org/10.1016/j.vaccine.2021.11.085}, author = {Hsieh, Yuli and Rak, Summer and SteelFisher, Gillian K and Bauhoff, Sebastian} } @article {681492, title = {Texts Don{\textquoteright}t Nudge: An Adaptive Trial to Prevent the Spread of COVID-19 in India}, journal = {Journal of Development Economics}, volume = {153}, year = {2021}, pages = {102747}, abstract = {We conduct an adaptive randomized controlled trial to evaluate the impact of a SMS-based information campaign on the adoption of social distancing and handwashing in rural Bihar, India, six months into the COVID-19 pandemic. We test 10 arms that vary in delivery timing and message framing, changing content to highlight gains or losses for either one{\textquoteright}s own family or community. We identify the optimal treatment separately for each targeted behavior by adaptively allocating shares across arms over 10 experimental rounds using exploration sampling. Based on phone surveys with nearly 4,000 households and using several elicitation methods, we do not find evidence of impact on knowledge or adoption of preventive health behavior, and our confidence intervals cannot rule out positive effects as large as 5.5 percentage points, or 16\%. Our results suggest that SMS-based information campaigns may have limited efficacy after the initial phase of a pandemic.}, url = {https://doi.org/10.1016/j.jdeveco.2021.102747}, author = {Girija Bahety and Bauhoff, Sebastian and Dev Patel and James Potter} } @article {676645, title = {Evaluating Health Insurance Programmes: An Insurance Cascade Framework}, journal = {Economic \& Political Weekly}, volume = {56}, number = {23}, year = {2021}, pages = {22-28}, abstract = { Abstract (edited by EPW): An array of bottlenecks has ensured that the numerous health insurance schemes introduced over the years have failed to\ make any significant dent on the health sector. This article tries\ to assess these problems by\ using the {\textquotedblleft}insurance cascade,{\textquotedblright}\ a framework that traces the steps from enrolling eligible households to ultimately delivering their benefits. The existing evidence suggests substantial bottlenecks across all cascade steps, with especially large gaps in beneficiaries{\textquoteright} awareness of how to enrol in schemes, what the schemes covers, and how to access scheme benefits. Also available at CGD Working Paper 583. }, url = {https://www.epw.in/journal/2021/23/commentary/evaluating-health-insurance-programmes.html}, author = {Bauhoff, Sebastian and Nikkil Sudharsanan} } @article {666777, title = {The Effects of Performance-Based Financing on Neonatal Health Outcomes in Burundi, Lesotho, Senegal, Zambia and Zimbabwe}, journal = {Health Policy and Planning}, volume = {36}, number = {3}, year = {2021}, pages = {332{\textendash}340}, abstract = { Maternal and newborn care has been a primary focus of performance-based financing (PBF) projects, which have been piloted or implemented in 21 countries in Sub-Saharan Africa since 2007. Several evaluations of PBF have demonstrated improvements to facility delivery or quality of care. However, no studies have measured the impact of PBF programs directly on neonatal health outcomes in Africa, nor compared PBF programs against another. We assess the impact of PBF on early neonatal health outcomes and associated health care utilization and quality in Burundi, Lesotho, Senegal, Zambia and Zimbabwe. We pooled Demographic and Health Surveys and Multiple Indicator Cluster Surveys and apply difference-in-differences analysis to estimate the effect of PBF projects supported by the World Bank on early neonatal mortality and low birthweight. We also assessed the effect of PBF on intermediate outputs that are frequently explicitly incentivized in PBF projects, including facility delivery and antenatal care utilization and quality, and cesarean section. Finally, we examined the impact among births to poor or high-risk women. We found no statistically significant impact of PBF on neonatal health outcomes, health care utilization or quality in a pooled sample. PBF was also not associated with better health outcomes in each country individually, though in some countries PBF improved facility delivery, antenatal care utilization, or antenatal care quality. There was also no improvement on any outcome among poor or high-risk women in the five countries. PBF had no impact on early neonatal health outcomes in the five African countries studied and had limited and variable effects on the utilization and quality of neonatal health care. These findings suggest that there is a need for both a deeper assessment of PBF and for other strategies to make meaningful improvements to neonatal health outcomes. }, url = {https://doi.org/10.1093/heapol/czaa191}, author = {Gage, Anna and Bauhoff, Sebastian} } @article {666775, title = {The Medium-Run and Scale-Up Effects of Performance-Based Financing: An Extension of Rwanda{\textquoteright}s 2006 Trial Using Secondary Data}, journal = {World Development}, year = {2021}, pages = {105264}, abstract = { Performance-based financing (PBF) programs have been introduced in numerous developing countries to increase the provision and quality of health services through financial incentives.\  Despite growing evidence about short-term impacts of PBF, less is known about medium-run impacts and scale-up effects, and about how PBF compares to other financing approaches.\  In this paper, we extend the initial evaluation of Rwanda{\textquoteright}s PBF program to identify medium-run and scale-up effects of incentives and unconditional financing relative to a new {\textquotedblleft}business as usual{\textquotedblright} counterfactual.\  We use data from the Demographic and Health Surveys from Rwanda and several Sub-Saharan African countries from 2001 to 2010, using two control group strategies: all available control regions, and a subset of regions that are similar to Rwanda based on pre-intervention trends in covariates and outcomes.\  We then use difference-in-differences regressions to measure the Rwandan program{\textquoteright}s impacts on four indicators: institutional deliveries, antenatal tetanus prophylaxis, completion of any antenatal visits, and completion of four antenatal visits.\  The results are similar using the various control groups and in additional robustness checks.\  In the short-run and relative to no intervention, both performance-based and unconditional financing raised institutional delivery rates and completion of four antenatal visits.\  In the medium-run, relative to no intervention and in addition to the initial short-run impacts, performance-based incentives resulted in further improvements for institutional deliveries.\  Program scale-up was effective, with few differences between intervention arms after all areas received performance-based incentives.\  There were few effects on antenatal tetanus prophylaxis or on completion of any antenatal visits.\  Together, the results suggest that PBF can have persistent effects for some indicators, but unconditional financing can also be effective.\  Moreover, the analysis demonstrates how observational research methods and secondary data can generate new insights on completed trials.\  Also available at CGD Working Paper 497. }, url = {https://doi.org/10.1016/j.worlddev.2020.105264}, author = {Ngo, Diana and Bauhoff, Sebastian} } @article {666774, title = {Health Equity Funds as the Pathway to Universal Coverage in Cambodia: Care Seeking and Financial Risk Protection}, journal = {Health Policy and Planning}, volume = {36}, number = {1}, year = {2021}, pages = {26{\textendash}34}, abstract = { Cambodia has developed the health equity fund (HEF) system to improve access to health services for the poor, and this strengthens the health system towards the universal health coverage goal. Given rising healthcare costs, Cambodia has introduced several innovations and accomplished considerable progress in improving access to health services and catastrophic health expenditures for the targeted population groups. Though this is improving in recent years, HEF households remain at the higher risk of catastrophic spending as measured by the higher share of HEF households with catastrophic health expenses being at 6.9\% compared to the non-HEF households of 5.5\% in 2017. Poverty targeting poses another challenge for the health system. Nevertheless, HEF appeared to be more significantly associated with decreased out-of-pocket expenditure per illness among those who sought care from public providers. Increasing population and cost coverages of the HEF and effectively attracting beneficiaries to the public sector will further enhance the financial protection and pave the pathway towards universal coverage. Our recommendations focus on leveraging the HEF experience for expanding coverage and increasing equitable access, as well as strengthening the quality of healthcare services. }, url = {https://doi.org/10.1093/heapol/czaa151}, author = {Jithitikulchai, Theepakorn and Isabelle Feldhaus and Bauhoff, Sebastian and Nagpal, Somil} } @article {666773, title = {The Role of Health System Context in the Implementation of Performance-Based Financing: Evidence from Cote d{\textquoteright}Ivoire}, journal = {BMJ Global Health}, volume = {5}, year = {2020}, pages = {e002934}, abstract = { Low quality of care is a significant problem for health systems in low-income and middle-income countries (LMICs). Policymakers are increasingly interested in using performance-based financing (PBF), a system-wide provider payment reform, conditioned on both quantity and quality of performance, to improve quality of care. The health system context influences both the design and the implementation of these programmes and thus their effectiveness. This study analyses how context has influenced the design and implementation of PBF in improving the quality of primary care in one particular setting, Cote d{\textquoteright}Ivoire, a lower-middle income country with some of the poorest health outcomes in the world. Based on literature, an analytical framework was developed identifying five pathways through which financial incentives can influence the quality of primary care: earmarking, conditioning, provider behaviour, community involvement and management. Guided by this framework, semistructured interviews were conducted with policymakers and providers to diagnose the context and to assess the links between financing and quality of care at the primary care level. PBF in Cote d{\textquoteright}Ivoire was found to have increased data availability and quality, facility-wide and disease-specific inputs, provider motivation and management practices in contracted facilities, but had limited success in improving process and outcome measures of quality, as well as community involvement and the provision of non-incentivised services. These limitations were attributable to a centralised health system structure constraining the decision space of health providers; financing and governance challenges across the health sector; and shortcomings with regard to the design of the PBF quality checklist and incentive structures in Cote d{\textquoteright}Ivoire. In order to improve the quality of primary care, health sector reforms such as PBF should incorporate the organisational and service delivery context more broadly into their design and implementation, as is the case in other countries. }, url = {https://gh.bmj.com/content/5/9/e002934.full}, author = {Denizhan Duran and Bauhoff, Sebastian and Berman, Peter and Gaudet, Tania and Konan, Clovis and {\"O}zaltin, Emre and Kruk, Margaret} } @article {653715, title = {The Association between Hospital Occupancy and Mortality Among Medicare Patients}, journal = {The Joint Commission Journal on Quality and Patient Safety}, volume = {46}, number = {9}, year = {2020}, pages = {506-515}, abstract = { Background: Hospital crowding is a major challenge facing US health care systems, but few studies have evaluated the association between inpatient occupancy and patient mortality. Our objective was to determine how increasing hospital occupancy is associated with the likelihood of inpatient and 30-day out-of-hospital mortality using a novel measure of inpatient occupancy. Methods: We conducted a retrospective, observational study using secondary data from the California Office of Statewide Health Planning and Development including non-federal, acute care facilities from 1998-2012. Using measures of relative hospital occupancy, we ran logistic regressions to assess the relationship between increasing hospital occupancy and inpatient mortality and 30-day out-of-hospital mortality among Medicare patients 65 years and older with myocardial infarction, heart failure or pneumonia. Results: Higher admission day occupancy (odds ratio [OR] = 0.96, 95\% confidence interval [CI]: 0.94{\textendash}0.99) and higher discharge day occupancy (OR = 0.62, 95\% CI: 0.60{\textendash}0.64) were associated with decreased inpatient mortality. Thirty-day out-of-hospital mortality increased with higher discharge day occupancy (OR=1.28, 95\% CI: 1.24-1.32), but was unrelated to admission day occupancy. Conclusions: We found a counterintuitive relationship between admission and discharge day occupancy and inpatient mortality. Higher discharge day occupancy appears to displace deaths into the outpatient setting. Understanding why higher inpatient occupancy is associated with lower overall mortality merits investigation to inform best practices for inpatient care in busy hospitals. \  }, url = {https://www.sciencedirect.com/science/article/abs/pii/S1553725020301069}, author = {Abir, Mahshid and Goldstick, Jason and Malsberger, Rosalie and Setodji, Claude M and Bauhoff, Sebastian and Wenger, Neil} } @article {653714, title = {Recalibrating the Anti-Corruption, Transparency, and Accountability Formula to Advance Public Health}, journal = {Global Health Action}, volume = {sup 1}, year = {2020}, pages = {1701327}, abstract = {Policy-makers, implementing organizations, and funders of global health programs aim to improve health care services and health outcomes through specific projects or systemic change. To mitigate the risk of corruption and its harmful effects on those initiatives, health programs often use multiple anti-corruption mechanisms, including codes of conduct, documentation and reporting requirements, and trainings. Unfortunately, the introduction of anti-corruption mechanisms tends to occur without an explicit consideration of how each mechanism will affect health services and health outcomes. This may overlook potentially more effective approaches. In addition, it may result in the introduction of too many controls (thereby stymying service delivery) and a focus on financial or procurement-related issues (at the expense of service delivery objectives). We argue that anti-corruption efforts in health programs can be more effective if they prioritize addressing issues according to their likelihood and level of harm to key program objectives. Recalibrating the anti-corruption formula in this way will require: (i) extending responsibility and ownership over anti-corruption from subject experts to public health and health system specialists, and (ii) enabling those specialists to apply the Fraud Risk Assessment methodology to develop tailored anti-corruption mechanisms. We fill a documented gap in guidance on how to develop anti-corruption mechanisms by walking through the seven analytical steps of the Fraud Risk Assessment methodology as applicable to health programs. We then outline best practices for any anti-corruption mechanism, including a focus on quality health delivery; the alignment of actors{\textquoteright} incentives around the advancement of health objectives; and being minimally corruptible by design.}, url = {https://www.tandfonline.com/doi/full/10.1080/16549716.2019.1701327}, author = {Wierzynska, Aneta and Steingr{\"u}ber, Sarah and Oroxom, Roxanne and Bauhoff, Sebastian} } @article {607744, title = {Does Deforestation Increase Malaria Prevalence? Evidence from Satellite Data and Health Surveys}, journal = {World Development}, volume = {127}, year = {2020}, pages = {104734}, abstract = {\ Deforestation can increase malaria risk factors such as mosquito growth rates and biting rates in some settings. But deforestation affects more than mosquitoes{\textemdash}it is associated with socio-economic changes that affect malaria rates in humans. Most previous studies have found that deforestation is associated with increased malaria prevalence, suggesting that in some cases forest conservation might belong in a portfolio of anti-malarial interventions. However, previous peer-reviewed studies of deforestation and malaria were based on a small number of geographically aggregated observations, mostly from the Brazilian Amazon. Here we combine 14 years of high-resolution satellite data on forest loss with individual-level and nationally representative malaria tests for more than 60,000 rural children in 17 countries in Sub-Saharan Africa, where 88\% of malaria cases occur. Adhering to methods that we pre-specified in a pre-analysis plan, we used multiple regression analysis to test ex-ante hypotheses derived from previous literature. Aggregated across countries, we did not find either deforestation or intermediate levels of forest cover to be associated with higher malaria prevalence. In nearly all (n = 78/84) country-year-specific regressions, we also did not find deforestation or intermediate levels of forest cover to be associated with higher malaria prevalence.\ However, we can not rule out associations at the local scale or beyond the geographic scope of our study region. We speculate that our findings may differ from those of previous studies because deforestation in Sub-Saharan Africa is largely driven by the steady expansion of smallholder agriculture for domestic use by long-time residents in stable socio-economic settings where malaria is already endemic and previous exposure is high, while in much of Latin America and Asia deforestation is driven by rapid clearing for market-driven agricultural exports by new frontier migrants without previous exposure. These differences across regions suggest useful hypotheses to test in future research.\ }, url = {https://doi.org/10.1016/j.worlddev.2019.104734}, author = {Bauhoff, Sebastian and Busch, Jonah} } @article {630711, title = {Evaluating the Impact of Emergency Department Crowding on Disposition Patterns and Outcomes of Discharged Patients}, journal = {International Journal of Emergency Medicine}, volume = {12}, number = {4}, year = {2019}, abstract = {Background:\ Crowding is a major challenge faced by EDs and is associated with poor outcomes.Objectives:\ Determine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations.Methods:\ We conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts.Results:\ Disposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95\% CI: [0.89, 0.98]). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95\% CI: [0.87, 1.02]), with-boarders (OR = 0.96, 95\% CI: [0.86, 1.09]), and no-boarders samples (OR = 0.93, 95\% CI: [0.83, 1.04]). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95\% CI: [0.87, 1.24]), the with-boarders (OR = 1.12, 95\% CI: [0.87, 1.44]), and the no-boarders samples (OR = 0.98, 95\% CI: [0.77, 1.24]).Conclusion:\ ED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.}, url = {https://doi.org/10.1186/s12245-019-0223-1}, author = {Abir, Mahshid and Goldstick, Jason and Malsberger, Rosalie and Williams, Andrew and Bauhoff, Sebastian and Parekh, Vikas and Kronick, Steven and Desmond, Jeffrey} } @article {608024, title = {Using Supervised Learning to Select Audit Targets in Performance-Based Financing in Health: An Example from Zambia}, journal = {PLoS ONE}, volume = {14}, number = {1}, year = {2019}, pages = {e0211262}, abstract = {Independent verification is a critical component of performance-based financing (PBF) in health care, in which facilities are offered incentives to increase the volume of specific services but the same incentives may lead them to over-report. We examine alternative strategies for targeted sampling of health clinics for independent verification. Specifically, we empirically compare several methods of random sampling and predictive modeling on data from a Zambian PBF pilot that contains reported and verified performance for quantity indicators of 140 clinics. Our results indicate that machine learning methods, particularly Random Forest, outperform other approaches and can increase the cost-effectiveness of verification activities.}, url = {https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211262}, author = {Grover, Dhruv and Bauhoff, Sebastian and Friedman, Jed} } @article {627293, title = {Measuring and Paying for Quality of Care in Performance-Based Financing: Experience from Seven Low and Middle-Income Countries}, journal = {Journal of Global Health}, volume = {8}, year = {2018}, pages = {021003}, abstract = {Background:\ Performance-based financing (PBF) both measures and determines payments based on the quality of care delivered and is emerging as a potential tool to improve quality.Methods:\ Comparative case study methodology was used to analyze common challenges and lessons learned in quality of care across seven PBF programs (Democratic Republic of Congo, Kyrgyzstan, Malawi, Mozambique, Nigeria, Senegal and Zambia). The eight case studies, across seven PBF programs, compared were commissioned by the USAID-funded Translating Research into Action (TRAction) project (n = 4), USAID{\textquoteright}s Health Finance and Government project (n = 3), and from the Global Delivery Initiative (n = 1).Results:\ The programs show similar design features to assess quality, but significant heterogeneity in their application. The seven programs included 18 unique quality checklists, containing over 1400 quality of care indicators, with an average per checklist of 116 indicators (ranging from 26-228). The quality checklists share a focus on structural components of quality (representing 80\% of indicators on average, ranging from 38\%-91\%). Process indicators constituted an average of 20\% across all checklists (ranging from 8.4\% to 61.5\%), with the majority measuring the correct application of care protocols for MCH services including child immunization. The sample included only one example of an outcome indicator from Kyrgyzstan. Performance data demonstrated a modest upward improvement over time in checklist scores across schemes, however, achievements plateaued at 60\%-70\%, with small or rural clinics reporting difficulty achieving payment thresholds due to limited resources and poor infrastructure. Payment allocations (distribution) and thresholds (for payments), data transparency, and approaches to measuring (verification) of quality differ across schemes.Conclusions:\ Similarities exist in the processes that govern the design of PBF mechanisms, yet substantial heterogeneity in the experiences of implementing quality of care components in PBF programs are evident. This comparison suggests tailoring further the quality component of PBF programs to local and country contexts, and a need to better understand how quality is measured in practice. The growing operational experiences with PBF programs in different settings offer opportunities to learn from best practices, improve ongoing and future programs, and inform research to alleviate current challenges.}, url = {http://www.jogh.org/documents/issue201802/jogh-08-021003.htm}, author = {Gergen, Jessica and Ski, Samantha and Vernon, Christina and Josephson, Erik and Riese, Sara and Bauhoff, Sebastian and Madhavan, Supriya} } @article {626824, title = {Achieving high-quality universal health coverage: a perspective from the National Health Service in England}, journal = {BMJ Global Health}, volume = {3}, year = {2018}, pages = {e000944}, abstract = {Governments across low-income and middle-income countries have pledged to achieve universal health coverage by 2030, which comes at a time where healthcare systems are subjected to multiple and persistent pressures, such as poor access to care services and insufficient medical supplies. While the political willingness to provide universal health coverage is a step into the right direction, the benefits of it will depend on the quality of healthcare services provided. In this\ analysis paper, we ask whether there are any lessons that could be learnt from the English National Health Service, a healthcare system that has been providing comprehensive and high-quality universal health coverage for over 70 years. The key areas identified relate to the development of a coherent strategy to improve quality, to boost public health as a measure to reduce disease burden, to adopt evidence-based priority setting methods that ensure efficient spending of financial resources, to introduce an independent way of inspecting and regulating providers, and to allow for task-shifting, specifically in regions where staff retention is low.}, url = {http://dx.doi.org/10.1136/bmjgh-2018-000944}, author = {Friebel, Rocco and Molloy, Aoife and Leatherman, Sheila and Dixon, Jennifer and Bauhoff, Sebastian and Chalkidou, Kalipso} } @article {624818, title = {Mind the Costs, too: Towards Better Cost-Effectiveness Analyses of PBF Programmes}, journal = {BMJ Global Health}, volume = {3}, year = {2018}, pages = {e000994}, abstract = {Summary boxThe evidence surrounding the cost-effectiveness of performance-based financing (PBF) is weak, and it is not clear how PBF compares with alternative interventions in terms of its value for money.It is important to fill this evidence gap as countries transition from aid and face increasing budget constraints and competing priorities for the use of their domestic resources.In conducting cost-effectiveness analyses of PBF, researchers should be mindful of the identification, measurement and valuation of costs and effects, provide justification for the scope of their studies, and specify appropriate comparators and decision rules.We also recommend the use of a reference case to lay out the principles, preferred methodological choices and reporting standards, as well as a checklist.}, url = {https://gh.bmj.com/content/3/5/e000994}, author = {Chi, Y-Ling and Gad, Mohamad and Bauhoff, Sebastian and Chalkidou, Kalipso and Megiddo, Itamar and Ruiz, Francis and Smith, Peter} } @article {610637, title = {Asylum-Seekers in Germany Differ from Regularly Insured in their Morbidity, Utilizations and Costs of Care}, journal = {PLoS ONE}, volume = {13}, number = {6}, year = {2018}, pages = {e0197881}, abstract = {In the wake of the European refugee crisis, Germany has received over a million new applications for asylum in the last two years. The health care system is struggling to provide asylum-seekers with access to essential medical services and facilitate their longer-term integration. In this article, we report on the morbidity, utilization and costs of care for a sample of asylum-seekers as compared to a matched group of regularly insured. Using administrative data, we found that asylum-seekers had more hospital and emergency department admissions, including more admissions that could be avoided through good outpatient care or prevention. Their average expenditures were 10 percent higher than for the regularly insured, mostly because of higher hospital expenditures, although there was substantial variation in expenditures by country of origin. Facilitating access to the health care system, especially outpatient and mental health care, could improve asylum-seekers health status and integration, possibly at lower costs.}, url = {https://doi.org/10.1371/journal.pone.0197881}, author = {Bauhoff, Sebastian and G{\"o}pffarth, Dirk} } @inbook {584796, title = {Gesundheitliche Versorgung von Asylsuchenden - Untersuchungen anhand von Abrechnungsdaten der BARMER [Health Care Services for Asylum-Seekers - Evidence from Claims Data of the BARMER Insurance Plan]}, booktitle = {Barmer GEK Gesundheitswesen aktuell}, year = {2017}, pages = {32-65}, publisher = {Barmer GEK}, organization = {Barmer GEK}, abstract = {Mehr als eine Million Menschen sind in den Jahren 2015 und 2016 vor Krieg, Gewalt und Verfolgung nach Deutschland geflohen. Ihre gesundheitliche Versorgung stellt eine gro{\ss}e Herausforderung f{\"u}r das deutsche Gesundheitssystem dar, zumal eine gute physische und psychische Gesundheit Voraussetzung f{\"u}r eine gelingende Integration darstellt. Allerdings ist wenig {\"u}ber die gesundheitliche Situation, den Versorgungsbedarf und das Inanspruchnahmeverhalten von Asylsuchenden bekannt. In der Analyse werden die Abrechnungsdaten der BARMER der elektronischen Gesundheitskarte f{\"u}r Asylsuchende genutzt, um einen ersten Einblick auf Morbidit{\"a}t, Inanspruchnahme und Gesundheitsausgaben dieser Gruppe zu erhalten.}, url = {https://www.barmer.de/blob/133064/111932f27abc3b54594874d07a668a8a/data/dl-3-gesundheitliche-versorgung-von-asylsuchenden---untersuchungen-anhand-von-abrechnungsdaten-der-barmer.pdf$\#$groupselection}, author = {G{\"o}pffarth, Dirk and Bauhoff, Sebastian}, editor = {Repschl{\"a}ger, Uwe and Schulte, Claudia and Osterkamp, Nicole} } @article {571601, title = {Developing Citizen Report Cards for Primary Health Care in Low and Middle-Income Countries: Results from Cognitive Interviews in Rural Tajikistan}, journal = {PLoS ONE}, volume = {12}, number = {10}, year = {2017}, month = {2017}, pages = {e0186745}, abstract = { Introduction: Citizen report cards on health care providers have been identified as a potential means to increase citizen engagement, provider accountability and health systems performance. \ Research in high-income settings indicates that the wording, presentation and display of performance information are critical to achieve these goals. However, there are limited insights on developing effective report card designs for middle- and low-income settings. \ We conducted cognitive interviews to assess consumers{\textquoteright} understanding, interpretation of and preferences for displaying information for a health care report card in rural Tajikistan. Materials and Methods: We recruited a convenience sample of 40 citizens (20 women and 20 men aged 18-45) from rural areas of two provinces of Tajikistan (Soghd and Khatlon oblasts). \ The interview protocol was adapted from the model of cognitive interviews used in social science research to improve survey questionnaires. \ We used multivariate regression to assess understanding and interpretation of the report card; chi2 tests to assess differences in preferences for displaying information; and tests of proportions to assess the preferred comparison group. Results: Respondents understood the main idea of the report card and are not confused by the indicators or display. \ However, many respondents had difficulties making comparisons, and when asked to identify worst-performing services. \ Respondents preferred detailed rankings using school grades, comparisons of their local clinic with the regional or national average performance, and the use of color in the report card. \ We found some heterogeneity across the two provinces. Conclusions: Overall, our findings are promising regarding the citizens{\textquoteright} comprehension of health care report cards in rural Tajikistan, while underscoring the challenges of effectively providing health care performance information to communities. \ Cognitive interviews and iterative testing can support an effective implementation of reporting initiatives. }, url = {http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0186745}, author = {Bauhoff, Sebastian and Mayer, Lauren and Rabinovich, Lila} } @article {525161, title = {How do Performance-Based Financing Programs Measure Quality of Care? A Descriptive Analysis of 68 Quality Checklists from 28 Low and Middle-Income Countries}, journal = {Health Policy and Planning}, volume = {32}, number = {8}, year = {2017}, pages = {1120-1126}, abstract = { Objective: To systematically describe the length and content of quality checklists used in performance-based financing programs, their similarities and differences, and how checklists have evolved over time. Methods: We compiled a list of supply-side, health facility-based performance-based financing (PBF) programs in low- and lower middle-income countries based on a document review. We then solicited PBF manuals and quality checklists from implementers and donors of these PBF mechanisms. We entered each indicator from each quality checklist into a database verbatim in English, and translated into English from French where appropriate, and categorized each indicator according to the Donabedian framework and an author-derived categorization. Findings: We extracted 8,490 quality indicators from 68 quality checklists across 32 PBF implementations in 28 countries. On average, checklists contained 125 indicators; within the same program, checklists tend to grow as they are updated. Using the Donabedian framework, 80\% of indicators were structure-type, 19\% process-type, and less than 1\% outcome-type. The author-derived categorization showed that 57\% of indicators relate to availability of resources, 24\% to managing the facility and 17\% assess knowledge and effort. There is a high degree of similarity in a narrow set of indicators used in checklists for common service types such as maternal, neonatal and child health. Conclusion:\  Performance-based financing offers an appealing approach to targeting specific quality shortfalls and advancing toward the Sustainable Development Goals of high quality coverage.\  Currently most indicators focus on structural issues and resource availability. There is scope to rationalize and evolve the quality checklists of these programs to help achieve national and global goals to improve quality of care. }, url = {https://doi.org/10.1093/heapol/czx053}, author = {Josephson, Erik and Gergen, Jessica and Coe, Martha and Ski, Samantha and Madhavan, Supriya and Bauhoff, Sebastian} } @article {514906, title = {Plan Responses to Diagnosis-Based Payment: Evidence from Germany{\textquoteright}s Morbidity-Based Risk Adjustment}, journal = {Journal of Health Economics}, volume = {56}, year = {2017}, pages = {397-413}, abstract = { Many competitive health insurance markets adjust payments to participating health plans according to their enrollees{\textquoteright} risk {\textendash} including based on diagnostic information.\  We investigate responses of German health plans to the introduction of morbidity-based risk adjustment in the Statutory Health Insurance in 2009, which triggers payments based on {\textquotedblleft}validated{\textquotedblright} diagnoses by providers.\  Using the regulator{\textquoteright}s data from office-based physicians, we estimate a difference-in-difference analysis of the change in the share and number of validated diagnoses for ICD codes that are inside or outside the risk adjustment but are otherwise similar.\  We find a differential increase in the share of validated diagnoses of 2.6 and 3.6 percentage points (3-4\%) between 2008 and 2013.\  This increase appears to originate from both a shift from not-validated toward validated diagnoses and an increase in the number of such diagnoses. \ Overall, our results indicate that plans were successful in influencing physicians{\textquoteright} coding practices in a way that could lead to higher payments. Also available as CESIfo Working Paper 6507 }, url = {https://www.sciencedirect.com/science/article/abs/pii/S016762961730228X}, author = {Bauhoff, Sebastian and G{\"o}pffarth, Dirk and Fischer, Lisa and Wuppermann, Amelie C.} } @article {gergen_quality_2017, title = {Quality of Care in Performance-Based Financing: How It Is Incorporated in 32 Programs Across 28 Countries}, journal = {Global Health: Science and Practice}, volume = {5}, number = {1}, year = {2017}, pages = {90-107}, abstract = { Objective: To describe how quality of care is incorporated into performance-based financing (PBF) programs, what quality indicators are being used, and how these indicators are measured and verified. Methods: An exploratory scoping methodology was used to characterize the full range of quality components in 32 PBF programs, initiated between 2008 and 2015 in 28 low- and middle-income countries, totaling 68 quality tools and 8,490 quality indicators. The programs were identified through a review of the peer-reviewed and gray literature as well as through expert consultation with key donor representatives. Findings: Most of the PBF programs were implemented in sub-Saharan Africa and most were funded primarily by the World Bank. On average, PBF quality tools contained 125 indicators predominately assessing maternal, newborn, and child health and facility management and infrastructure. Indicators were primarily measured via checklists (78\%, or 6,656 of 8,490 indicators), which largely (over 90\%) measured structural aspects of quality, such as equipment, beds, and infrastructure. Of the most common indicators across checklists, 74\% measured structural aspects and 24\% measured processes of clinical care. The quality portion of the payment formulas were in the form of bonuses (59\%), penalties (27\%), or both (hybrid) (14\%).\ The median percentage (of a performance payment) allocated to health facilities was 60\%, ranging from 10\% to 100\%, while the median percentage allocated to health care providers was 55\%, ranging from 20\% to 80\%. Nearly all of the programs included in the analysis (91\%, n=29) verified quality scores quarterly (every 3 months), typically by regional government teams. Conclusion:\ PBF is a potentially appealing instrument to address shortfalls in quality of care by linking verified performance measurement with strategic incentives and could ultimately help meet policy priorities at the country and global levels, including the ambitious Sustainable Development Goals. The substantial variation and complexity in how PBF programs incorporate quality of care considerations suggests a need to further examine whether differences in design are associated with differential program impacts. \  }, issn = {, 2169-575X}, doi = {10.9745/GHSP-D-16-00239}, url = {https://doi.org/10.9745/GHSP-D-16-00239}, author = {Gergen, Jessica and Josephson, Erik and Coe, Martha and Ski, Samantha and Madhavan, Supriya and Bauhoff, Sebastian} } @article {458536, title = {Knowledge as a Predictor of Insurance Coverage under the Affordable Care Act}, journal = {Medical Care}, volume = {55}, number = {4}, year = {2017}, month = {2017}, pages = {428-435}, abstract = {\ Background: The Affordable Care Act established policy mechanisms to increase health insurance coverage in the United States. While insurance coverage has increased, 10\%-15\% of the US population remains uninsured.Objectives: To assess whether health insurance literacy and financial literacy predict being uninsured, covered by Medicaid, or covered by Marketplace insurance, holding demographic characteristics, attitudes toward risk, and political affiliation constant.Research Design: Analysis of longitudinal data from fall 2013 and spring 2015 including financial and health insurance literacy and key covariates collected in 2013.Subjects: A total of 2742 US residents ages 18-64, 525 uninsured in fall 2013, participating in the RAND American Life Panel, a nationally representative internet panel.Measures: Self-reported health insurance status and type as of spring 2015.Results: Among the uninsured in 2013, higher financial and health insurance literacy were associated with greater probability of being insured in 2015. For a typical uninsured individual in 2013, the probability of being insured in 2015 was 8.3 percentage points higher with high compared with low financial literacy, and 9.2 percentage points higher with high compared with low health insurance literacy. For the general population, those with high financial and health insurance literacy were more likely to obtain insurance through Medicaid or the Marketplaces compared with being uninsured. The magnitude of coefficients for these predictors was similar to that of commonly used demographic covariates.Conclusions: A lack of understanding about health insurance concepts and financial illiteracy predict who remains uninsured. Outreach and consumer-education programs should consider these characteristics.\ }, url = {http://journals.lww.com/lww-medicalcare/Abstract/2017/04000/Knowledge_as_a_Predictor_of_Insurance_Coverage.17.aspx}, author = {Hoerl, Maximiliane and Wuppermann, Amelie and Barcellos, Silvia Helena and Bauhoff, Sebastian and Winter, Joachim} } @article {413271, title = {Health System Changes under Pay-For-Performance: the Effects of Rwanda{\textquoteright}s National Programme on Facility Inputs}, journal = {Health Policy and Planning}, volume = {32}, number = {1}, year = {2017}, month = {2017}, pages = {11-20}, abstract = {Pay-for-performance (P4P) programs have been introduced in numerous developing countries with the goal of increasing the provision and quality of health services through financial incentives. Despite the popularity of P4P, there is limited evidence on how providers achieve performance gains and how P4P a ffects health system quality by changing structural inputs. We explore these two questions in the context of Rwanda{\textquoteright}s 2006 national P4P program by examining the program{\textquoteright}s impact on structural quality measures drawn from international and national guidelines. Given the program{\textquoteright}s previously documented success at increasing institutional delivery rates, we focus on a set of delivery-specific and more general structural inputs. Using the program{\textquoteright}s quasi-randomized rollout, we apply multivariate regression analysis to short-run facility data from the 2007 Service Provision Assessment. We find positive program effects on the presence of maternity-related staff, the presence of covered waiting areas, and a management indicator and a negative program effect on delivery statistics monitoring. We find no effects on a set of other delivery-specific physical resources, delivery-specific human resources, delivery-specific operations, general physical resources, and general human resources. Using mediation analysis, we find that the positive input differences explain a small and insignificant fraction of P4P{\textquoteright}s impact on institutional delivery rates. The results suggest that P4P increases provider availability and facility operations but is only weakly linked with short-run structural health system improvements overall.}, url = {https://doi.org/10.1093/heapol/czw091}, author = {Ngo, Diana and Sherry, Tisamarie and Bauhoff, Sebastian} } @article {413266, title = {Perceptions of E-Cigarettes: A Comparison of Adult Smokers and Non-Smokers in a Mechanical Turk Sample}, journal = {American Journal of Drug and Alcohol Abuse}, volume = {43}, number = {3}, year = {2017}, month = {2017}, pages = {311-323}, abstract = {Background: Given plans to extend its regulatory authority to e-cigarettes, the Food and Drug Administration (FDA) urgently needs to understand how e-cigarettes are perceived by the public.Objectives: To examine how smoking status impacts adult perceptions and expectations of e-cigarettes.Methods: We used Mechanical Turk (MTurk), a {\textquotedblleft}crowdsourcing{\textquotedblright} platform, to rapidly survey a large (n=796; female=381; male=415), diverse sample of adult ever (44\%) and never smokers (56\%), with ever (28\%) and never (72\%) users of e-cigarettes. \ Results: Smokers and non-smokers learned about e-cigarettes primarily through the internet and conversations with others. \ Ever smokers were more likely than never smokers, and female current smokers were more likely than female former smokers, to have learned about e-cigarettes from point of sale advertising (p{\textquoteright}s\<0.05) and to believe that e-cigarettes help smokers quit (p{\textquoteright}s\<0.05).\  Among never-users of e-cigarettes, current smokers were more likely than never smokers and former smokers to report that they would try e-cigarettes in the future (p{\textquoteright}s\<0.01). Current smokers{\textquoteright} top reason for wanting to try e-cigarettes was to quit or reduce smoking (56\%), while never and former smokers listed curiosity. In contrast, female current smokers{\textquoteright} top reason for not trying e-cigarettes was health and safety concerns (44\%) while males indicated expense (44\%).Conclusions: Adult smokers and non-smokers have different perceptions and expectations of e-cigarettes.\  Public health messages regarding e-cigarettes may need to be tailored separately for persons with and without a history of using conventional cigarettes. Tailoring messages by gender within smoker groups may also improve their impact.}, url = {http://www.tandfonline.com/doi/full/10.1080/00952990.2016.1207654}, author = {Bauhoff, Sebastian and Montero, Adrian and Scharf, Deborah} } @article {39599, title = {Multitasking and Heterogeneous Treatment Effects in Pay-for-Performance in Health Care: Evidence from Rwanda}, journal = {American Journal of Health Economics}, volume = {3}, number = {2}, year = {2017}, note = { Prepublication draft }, month = {2012}, pages = {192-226}, abstract = { Performance-based contracting is particularly challenging in health care, where multiple agents, information asymmetries and other market failures compound the critical contracting concern of multitasking. As performance-based contracting grows in developing countries, it is critical to better understand not only intended program impacts on rewarded outcomes, but also unintended program impacts such as multitasking and heterogeneous program effects in order to guide program design and scale-up. We use two waves of data from the Rwanda Demographic and Health Surveys collected before and after the quasi-experimental roll- out of Rwanda{\textquoteright}s national pay-for-performance (P4P) program to analyze impacts on utilization of healthcare services, health outcomes and unintended consequences of P4P. We find that P4P improved some rewarded services, as well as some services that were not directly rewarded, but had no statistically significant impact on health outcomes. We do not find evidence that clearly suggests multitasking. We find that program effects vary by baseline levels of facility quality, with most improvements seen in the medium quality tier. }, url = {http://dx.doi.org/10.1162/AJHE_a_00072}, author = {Sherry, Tisamarie and Bauhoff, Sebastian and Mohanan, Manoj} } @article {255466, title = {Opportunities and Considerations for Citizen Report Cards for Primary Care: Qualitative evidence from Rural Tajikistan}, journal = {Health Policy and Planning}, volume = {31}, number = {2}, year = {2016}, pages = {259-266}, abstract = {Transparency interventions, such as public reporting, have emerged as a potential policy approach to improving the performance of health care providers in resource-constrained settings.\  We report on results from focus groups and key informant interviews in rural areas of two Tajik provinces, Soghd and Khatlon, with regards to three important initial considerations for developing a report card initiative for primary health care in this setting: selecting indicators for the report card, collecting data, and working with existing institutions and stakeholders.\  The findings suggest that citizens are able to articulate and prioritize concerns with respect to local health care services.\  Participants indicated a preference for arms-length collection of sensitive feedback on local providers.\  Since citizens and local institutions have close and important relations with their local health care providers, there may be scope for a trusted external actor, such as a non-governmental organization, to facilitate the report card process.}, url = {http://heapol.oxfordjournals.org/content/31/2/259}, author = {Bauhoff, Sebastian and Tkacheva, Olesya and Rabinobich, Lila and Bogdan, Olena} } @inbook {514896, title = {Krankenkassen im Regionalen Vergleich}, booktitle = {Krankenversicherung im Rating: Leistungsbewertungen und Management als Schl{\"u}sselfaktoren}, year = {2016}, pages = {97-121}, publisher = {Springer Gabler}, organization = {Springer Gabler}, edition = {3rd}, address = {Heidelberg}, url = {http://www.springer.com/de/book/9783834947529}, author = {Wuppermann, Amelie C. and Bauhoff, Sebastian and Filser, Andreas and Antoni, Manfred}, editor = {Adolph, Thomas and Everling, Oliver and Metzler, Marco} } @article {458531, title = {India{\textquoteright}s Largest Hospital Insurance Program Faces Challenges in Using Claims Data to Measure Quality}, journal = {Health Affairs}, volume = {35}, number = {10}, year = {2016}, pages = {1792-1799}, abstract = {The routine data generated by India{\textquoteright}s universal coverage programs offer an important opportunity to evaluate and track the quality of health care systematically and on a large scale. We examined the potential and challenges of measuring the quality of hospital care through claims data from India{\textquoteright}s hospital insurance program for the poor, Rashtriya Swasthya Bima Yojana (RSBY). Using data from one district in India, we illustrate how these data already provide useful insights and show that simple efforts to enhance data quality and an effort to expand the data captured could facilitate RSBY{\textquoteright}s ability to track quality of care. The data collected by RSBY has significant potential to characterize and uncover the provision of low-quality care and help inform much-needed efforts to raise the quality of hospital care.}, url = {http://content.healthaffairs.org/content/35/10/1792.abstract}, author = {Morton, Matthew and Nagpal, Somil and Sadanandan, Rajeev and Bauhoff, Sebastian} } @article {413261, title = {The Share Price Effect of CVS Health{\textquoteright}s Announcement to Stop Selling Tobacco: A Comparative Case Study Using Synthetic Controls}, journal = {Forum for Health Economics \& Policy}, volume = {20}, number = {1}, year = {2016}, abstract = { We study how the announcement by CVS Health, a large US-based pharmacy chain, to stop selling tobacco products affected its share price and that of its close competitors, as well as major tobacco companies. Combining event study and synthetic control methodologies we compare measures of CVS{\textquoteright}s stock market valuation with those of a peer group consisting of large publicly listed firms that are part of Standard \& Poor{\textquoteright}s S\&P 500 stock market index. CVS{\textquoteright}s announcement is associated with a short-term decrease in its share price, whereas close competitors have benefitted from CVS{\textquoteright} decision. We also find a negative share price effect for Altria, the largest US domestic tobacco firm. Overall our findings are consistent with markets expecting consumers to shift from CVS to alternative outlets in the short-run, and interpreting CVS{\textquoteright} decision to drop tobacco products as signal that other firms may follow suit. \  }, url = {https://www.degruyter.com/view/j/fhep.ahead-of-print/fhep-2015-0045/fhep-2015-0045.xml}, author = {Andersen,Martin and Bauhoff, Sebastian} } @article {374511, title = {Levels and Variations in the Quality of Facility-Based Antenatal Care in Kenya: Evidence from the 2010 Service Provision Assessment}, journal = {Health Policy and Planning}, volume = {31}, number = {6}, year = {2016}, pages = {777-784}, abstract = {Quality of care is emerging as an important concern for low- and middle-income countries working to expand and improve coverage. However, there is limited systematic, large-scale empirical guidance to inform policy design. Our study operationalized indicators for six dimensions of quality of care that are captured in currently available, standardized Service Provision Assessments. We implemented these measures to assess the levels and heterogeneity of antenatal care in Kenya. Using our indicator mix, we find that performance is low overall and that there is substantial variation across provinces, management authority and facility type. Overall, facilities performed highest in the dimensions of efficiency and acceptability/patient-centeredness, and lowest on effectiveness and accessibility. Public facilities generally performed worse or similarly to private or faith-based facilities. We illustrate how these data and methods can provide readily-available, low-cost decision support for policy.}, url = {https://heapol.oxfordjournals.org/content/early/2016/02/13/heapol.czv132.abstract}, author = {Elizabeth Lee and Madhavan, Supriya and Bauhoff, Sebastian} } @article {374516, title = {Policies Related to Opioid Agonist Therapy for Opioid Use Disorders: The Evolution of State Policies from 2004 to 2013}, journal = {Substance Abuse}, volume = {37}, number = {1}, year = {2016}, pages = {63-69}, abstract = {Background: State Medicaid policies play an important role in Medicaid-enrollees{\textquoteright} access to and use of opioid agonists, such as methadone and buprenorphine, in the treatment of opioid use disorders. Little information is available, however, regarding the evolution of state policies facilitating or hindering access to opioid agonists among Medicaid-enrollees. Methods: During 2013{\textendash}14, we surveyed state Medicaid officials and other designated state substance abuse treatment specialists about their state{\textquoteright}s recent history of Medicaid coverage and policies pertaining to methadone and buprenorphine. We describe the evolution of such coverage and policies and present an overview of the Medicaid policy environment with respect to opioid agonist therapy from 2004 to 2013. Results: Among our sample of 45 states with information on buprenorphine and methadone coverage, we found a gradual trend toward adoption of coverage for opioid agonist therapies in state Medicaid agencies. In 2013, only 11\% of states in our sample (n = 5) had Medicaid policies that excluded coverage for methadone and buprenorphine, while 71\% (n = 32) had adopted or maintained policies to cover both buprenorphine and methadone among Medicaid-enrollees. We also noted an increase in policies over the time period that may have hindered access to buprenorphine and/or methadone. Conclusions: There appears to be a trend for states to enact policies increasing Medicaid coverage of opioid agonist therapies, while in recent years also enacting policies, such as prior authorization requirements, that potentially serve as barriers to opioid agonist therapy utilization. Greater empirical information about the potential benefits and potential unintended consequences of such policies can provide policymakers and others with a more informed understanding of their policy decisions.}, url = {http://www.tandfonline.com/doi/full/10.1080/08897077.2015.1080208}, author = {Burns, Rachel M and Pacula, Rosalie and Bauhoff, Sebastian and Gordon, Adam J and Hendrikson, Hollie and Leslie, Douglas L and Stein, Bradley D} } @report {514901, title = {Aligning Incentives, Accelerating Impact: Next Generation Financing Models for Global Health. A Report for the Center for Global Development Working Group on Next Generation Financing Models in Global Health.}, year = {2015}, institution = {Center for Global Development}, address = {Washington DC}, url = {https://www.cgdev.org/publication/aligning-incentive-accelerating-impact-next-generation-financing-models-global-health}, author = {Rachel Silverman and Over, Mead and Bauhoff, Sebastian} } @article {323976, title = {Where Is Buprenorphine Dispensed to Treat Opioid Use Disorders? The Role of Private Offices, Opioid Treatment Programs, and Substance Abuse Treatment Facilities in Urban and Rural Counties}, journal = {Milbank Quarterly}, volume = {93}, number = {3}, year = {2015}, pages = {561{\textendash}583}, abstract = {Context: Opioid use disorders are a significant public health problem. In 2002, the FDA approved buprenorphine as an opioid use disorder treatment when prescribed by waivered physicians who were limited to treating 30 patients at a time. In 2006, federal legislation raised this number to 100 patients. Although federal legislators are considering increasing these limits further and expanding prescribing privileges to nonphysicians, little information is available regarding the impact of such changes on buprenorphine use. We therefore examined the impact of the 2006 legislation{\textemdash}as well as the association between urban and rural waivered physicians, opioid treatment programs, and substance abuse treatment facilities{\textemdash}on buprenorphine distributed per capita over the past decade. Methods: Using 2004-2011 state-level data on buprenorphine dispensed and county-level data on the number of buprenorphine-waivered physicians and substance abuse treatment facilities using buprenorphine, we estimated a multivariate ordinary least squares regression model with state fixed effects of a state{\textquoteright}s annual total buprenorphine dispensed per capita as a function of the state{\textquoteright}s number of buprenorphine providers. Findings: The amount of buprenorphine dispensed has been increasing at a greater rate than the number of buprenorphine providers. The number of physicians waivered to treat 100 patients with buprenorphine in both rural and urban settings was significantly associated with increased amounts of buprenorphine dispensed per capita. There was no significant association in the growth of buprenorphine distributed and the number of physicians with 30-patient waivers. Conclusions: The greater amounts of buprenorphine dispensed are consistent with the potentially greater use of opioid agonists for opioid use disorder treatment, though they also make their misuse more likely. The changes after the 2006 legislation suggest that policies focused on increasing the number of patients that a single waivered physician could safely and effectively treat could be more effective in increasing buprenorphine use than would alternatives such as opening new substance abuse treatment facilities or raising the overall number of waivered physicians.}, url = {http://onlinelibrary.wiley.com/doi/10.1111/1468-0009.12137/abstract}, author = {Stein, Bradley D and Pacula, Rosalie and Gordon, Adam J and Burns, Rachel M and Leslie, Douglas L and Sorbero, Mark J and Bauhoff, Sebastian and Mandell, Todd W and Dick, Andrew W} } @article {228656, title = {More Choice in Health Insurance Marketplaces May Reduce the Value of Subsidies Available to Low-Income Enrollees}, journal = {Health Affairs}, volume = {34}, number = {1}, year = {2015}, pages = {104-110}, abstract = { Federal subsidies available to enrollees in health insurance Marketplaces are pegged to the premium of the second-lowest-cost silver plan available in each rating area (as defined by each state). People who qualify for the subsidy contribute a percentage of their income to purchase coverage, and the federal government covers the remaining cost up to the price of that premium. Because the number of plans offered and plan premiums vary substantially across rating areas, the effective value of the subsidy may vary geographically. We found that the availability of more plans in a rating area was associated with lower premiums but higher deductibles for enrollees in the second-lowest-cost silver plan. In rating areas with more than twenty plans, the average deductible in the second-lowest-cost silver plan was nearly $1,000 higher than it was in rating areas with fewer than thirteen plans. Because premium costs for second-lowest-cost silver plans are capped, deductibles may be a more salient measure of plan value for enrollees than premiums are. Greater standardization of plans or an alternative approach to calculating the subsidy could provide a more consistent benefit to enrollees across various rating areas. }, url = {http://content.healthaffairs.org/content/34/1/104.abstract }, author = {Taylor, Erin and Saltzman, Evan and Bauhoff, Sebastian and Pacula, Rosalie and Eibner, Christine} } @inbook {514936, title = {Self-Report Bias in Estimating Cross-Sectional and Treatment Effects.}, booktitle = {Encyclopedia of Quality of Life Research }, year = {2014}, pages = {5798-5801}, publisher = {Springer}, organization = {Springer}, address = {Berlin}, url = {https://link.springer.com/referencework/10.1007/978-94-007-0753-5}, author = {Bauhoff, Sebastian}, editor = {Michalos, Alex C.} } @article {Barcellos24032014, title = {Preparedness of Americans for the Affordable Care Act}, journal = {Proceedings of the National Academy of Sciences}, volume = {111}, number = {15}, year = {2014}, pages = {5497{\textendash}5502}, abstract = {This paper investigates whether individuals are sufficiently informed to make reasonable choices in the health insurance exchanges established by the Affordable Care Act (ACA). We document knowledge of health reform, health insurance literacy, and expected changes in healthcare using a nationally representative survey of the US population in the 5 wk before the introduction of the exchanges, with special attention to subgroups most likely to be affected by the ACA. Results suggest that a substantial share of the population is unprepared to navigate the new exchanges. One-half of the respondents did not know about the exchanges, and 42\% could not correctly describe a deductible. Those earning 100{\textendash}250\% of federal poverty level (FPL) correctly answered, on average, 4 out of 11 questions about health reform and 4.6 out of 7 questions about health insurance. This compares with 6.1 and 5.9 correct answers, respectively, for those in the top income category (400\% of FPL or more). Even after controlling for potential confounders, a low-income person is 31\% less likely to score above the median on ACA knowledge questions, and 54\% less likely to score above the median on health insurance knowledge than a person in the top income category. Uninsured respondents scored lower on health insurance knowledge, but their knowledge of ACA is similar to the overall population. We propose that simplified options, decision aids, and health insurance product design to address the limited understanding of health insurance contracts will be crucial for ACA{\textquoteright}s success.}, doi = {10.1073/pnas.1320488111}, url = {http://www.pnas.org/content/111/15/5497}, author = {Barcellos, Silvia and Wuppermann, Amelie and Carman, Katherine and Bauhoff, Sebastian and McFadden, Daniel and Kapteyn, Arie and Winter, Joachim and Dana Goldman} } @article {134881, title = {Effect of Chiranjeevi Yojana on Institutional Deliveries and Neonatal and Maternal Outcomes in Gujarat, India: A Difference-in-Differences Analysis}, journal = {Bulletin of the World Health Organization}, volume = {92}, number = {3}, year = {2014}, pages = {187-194}, abstract = {Objective: To evaluate the effect of the Chiranjeevi Yojana programme, a public{\textendash}private partnership to improve maternal and neonatal health in Gujarat, India. Methods: A household survey (n = 5597 households) was conducted in Gujarat to collect retrospective data on births within the preceding 5 years. In an observational study using a difference-in-differences design, the relationship between the Chiranjeevi Yojana programme and the probability of delivery in health-care institutions, the probability of obstetric complications and mean household expenditure for deliveries was subsequently examined. In multivariate regressions, individual and household characteristics as well as district and year fixed effects were controlled for. Data from the most recent District Level Household and Facility Survey (DLHS-3) wave conducted in Gujarat (n = 6484 households) were used in parallel analyses. Findings: Between 2005 and 2010, the Chiranjeevi Yojana programme was not associated with a statistically significant change in the probability of institutional delivery (2.42 percentage points; 95\% confidence interval, CI: -5.90 to 10.74) or of birth-related complications (6.16 percentage points; 95\% CI: -2.63 to 14.95). Estimates using DLHS-3 data were similar. Analyses of household expenditures indicated that mean household expenditure for private-sector deliveries had either not fallen or had fallen very little under the Chiranjeevi Yojana programme. Conclusion: The Chiranjeevi Yojana programme appears to have had no significant impact on institutional delivery rates or maternal health outcomes. The absence of estimated reductions in household spending for private-sector deliveries deserves further study.}, url = {http://www.who.int/bulletin/volumes/92/3/13-124644.pdf}, author = {Mohanan, Manoj and Bauhoff, Sebastian and La Forgia, Gerald and Singer Babiarz, Kimberly and Singh, Kultar and Grant Miller} } @article {86226, title = {The Effect of School Nutrition Policies in California on Dietary Intake and Obesity: A Synthetic Control Approach}, journal = {Economics \& Human Biology}, volume = {12}, year = {2014}, pages = {45{\textendash}55}, abstract = {School nutrition policies aim to eliminate ubiquitous unhealthy foods and beverages from schools to improve adolescent dietary behavior and reduce childhood obesity. This paper evaluates the impact of an early nutrition policy, Los Angeles Unified School District{\textquoteright}s food-and-beverage standards of 2004, using two large datasets on food intake and physical measures. I implement cohort and cross-section estimators using {\textquoteleft}{\textquoteleft}synthetic{\textquoteright}{\textquoteright} control groups, combinations of unaffected districts that are reweighted to closely resemble the treatment unit in the pre-intervention period. The results indicate that the policy was mostly ineffective at reducing the prevalence of overweight or obesity 8-15 months after the intervention but significantly decreased consumption of two key targets, soda and fried foods. The policy{\textquoteright}s impact on physical outcomes appears to be mitigated by substitution toward foods that are still (or newly) available in the schools.}, url = {http://dx.doi.org/10.1016/j.ehb.2013.06.001}, author = {Bauhoff, Sebastian} } @report {514941, title = {Toolkit for the Evaluation of Financial Capability Programs in Low and Middle-Income Countries}, year = {2013}, institution = {World Bank}, address = {Washington DC}, url = {http://documents.worldbank.org/curated/en/677231468107071094/A-toolkit-for-the-evaluation-of-financial-capability-programs-in-low-and-middle-income-countries}, author = {Yoong, Joanne and Mihaly, Kata and Bauhoff, Sebastian and Rabinovich, Lila and Hung, Angela} } @article {105971, title = {Financial Literacy and Consumer Choice of Health Insurance: Evidence from Low-Income Populations in the United States}, journal = {RAND Working Paper Series}, volume = {WR-1013}, year = {2013}, abstract = {Under the U.S. Affordable Care Act (ACA), many low income consumers will become eligible for government support to buy health insurance. Whether these consumers are able to take advantage of the support and to make sound decisions about purchasing health insurance will likely depend on their knowledge and skills in navigating complex financial products. This ability is frequently referred to as {\textquotedblleft}financial literacy.{\textquotedblright} This paper examined the level and distribution of consumers{\textquoteright} financial literacy across income groups, using 2012 data collected in the RAND American Life Panel, an internet panel representative of the U.S. population. Financial illiteracy was particularly prevalent among individuals with incomes between 100-400\% of the Federal Poverty Line, many of whom will be eligible for subsidies. In this group, the young, less educated, females, and those with less income were more likely to have low financial literacy. The findings suggest the need for targeted policies to support vulnerable consumers in making good choices for themselves, possibly above and beyond the support measures already planned for in the ACA.}, url = {http://ssrn.com/abstract=2326756}, author = {Bauhoff, Sebastian and Carman, Katherine and Wuppermann, Amelie} } @article {7758, title = {Do Health Plans Risk-Select? An Audit Study on Germany{\textquoteright}s Social Health Insurance}, journal = {Journal of Public Economics}, volume = {96}, number = {9-10}, year = {2012}, pages = {750{\textendash}759}, type = {Revise and resubmit at the Journal of Public Economics}, abstract = {This paper evaluates whether health plans in Germany{\textquoteright}s Social Health Insurance select on an easily observable predictor of risk: geography. To identify plan behavior separately from concurrent demand-side adverse selection, I implement a double-blind audit study in which plans are contacted by fictitious applicants from different locations. I find that plans are less likely to respond and follow-up with applicants from higher-cost regions, such as West Germany. The results suggest that supply-side selection may emerge even in heavily regulated insurance markets. The prospect of risk selection by firms has implications for studies of demand-side selection and regulatory policy in these settings. }, url = {http://www.sciencedirect.com/science/article/pii/S004727271200059X}, author = {Bauhoff, Sebastian} } @article {13169, title = {Responsiveness and Satisfaction with Providers and Carriers in a Safety Net Insurance Program: Evidence from Georgia{\textquoteright}s Medical Insurance for the Poor}, journal = {Health Policy}, volume = {102}, number = {2-3}, year = {2011}, pages = {286-294}, abstract = {Objective. To evaluate provider responsiveness and beneficiary satisfaction with insurance carriers participating in the Republic of Georgia{\textquoteright}s Medical Insurance for the Poor. Study setting. A dedicated survey of approximately 3,500 households in two types of regions {\textendash} with different eligibility thresholds {\textendash} in November and December 2008. Study design. Regression-based estimation of responsiveness ratings by beneficiaries and non-beneficiaries of the insurance program and estimation of mean satisfaction scores for beneficiaries. Principal findings. In the high-threshold regions, provider responsiveness toward beneficiaries and non-beneficiaries is comparable. In the low-threshold regions, beneficiary status is associated with lower responsiveness of outpatient providers. Inpatient providers may have become less responsive toward beneficiaries during the program{\textquoteright}s transition from public to private administration. While satisfaction of beneficiaries with carriers is above average, there are reports of difficulties obtaining reimbursement and information about benefits. Conclusions. The results suggest that relying on private insurance companies to deliver public programs in middle-income settings may impact provider responsiveness and indicates the need for continuous monitoring and regulation. }, url = {http://www.sciencedirect.com/science/article/pii/S0168851011001357}, author = {Bauhoff, Sebastian and Hotchkiss, David R. and Smith, Owen} } @inbook {13158, title = {Adoption of a Cost-Saving Innovation: Germany, UK and Simvastatin}, booktitle = {England and Germany in Europe {\textendash} What Lessons Can We Learn from Each Other?}, year = {2011}, pages = {11-26}, publisher = {Nomos Verlag}, organization = {Nomos Verlag}, address = {Baden-Baden, Germany}, abstract = {We examine how the UK and German health care systems responded to a major cost-saving innovation: the availability of generic simvastatin, a cho{\textlnot}lesterol-lowering drug. In the German Social Health Insurance, the generic{\textquoteright}s entry reduced sales volumes for both branded simvastatin (Zocor) and a close substitute, branded atorvastatin (Lipitor/Sortis). In UK, only the sales of branded simvastatin fell whereas the sales of atorvastatin were mostly unaf{\textlnot}fected. We trace these experiences to institutional differences in the two health care systems and to the structure of patient cost-sharing in particular. }, author = {McGuire, Thomas and Bauhoff, Sebastian}, editor = {Klusen, N., and Verheyen, F. and Wagner, C.} } @article {7757, title = {Systematic Self-Report Bias in Health Data: Impact on Estimating Cross-Sectional and Treatment Effects}, journal = {Health Services and Outcomes Research Methodology}, volume = {11}, number = {1-2}, year = {2011}, pages = {44-53}, abstract = {This paper examines the effect of systematic self-report bias, the non-random deviation between the self-reported and true values of the same measure. This bias may be constant or variable, and can mislead empirical analyses based on descriptive statistics, program evaluation and instrumental variables estimation. I illustrate these issues with data on self-reported and measured overweight/obesity status, and BMI, height and weight z-scores of public school students in California from 2004 to 2006. I find that the prevalence of overweight/obesity is 2.4{\textendash}7.6 percentage points lower in self-reported data relative to measured data in the cross-section. A school nutrition policy changed the bias differentially in the treatment and control groups so that program evaluations could find spurious positive or null impacts of the intervention. Potential channels for this effect include improved information and stigma. }, url = {http://www.springerlink.com/content/7150v712n8r7138n/}, author = {Bauhoff, Sebastian} } @article {7756, title = {The Impact of Medical Insurance for the Poor in Georgia: A Regression Discontinuity Approach}, journal = {Health Economics}, volume = {20}, number = {11}, year = {2011}, pages = {1362{\textendash}1378}, abstract = {Improving access to health care and financial protection of the poor is a key concern for policymakers in low- and middle-income countries, but there have been few rigorous program evaluations. The Medical Insurance Program for the Poor in the republic of Georgia provides a free and extensive benefit package and operates through a publicly funded voucher program, enabling beneficiaries to choose their own private insurance company. Eligibility is determined by a proxy means test administered to applicant households. The objective of this study is to evaluate the program{\textquoteright}s impact on key outcomes including utilization, financial risk protection, and health behavior and management. A dedicated survey of approximately 3500 households around the thresholds was designed to minimize unobserved heterogeneity by sampling clusters with both beneficiary and non-beneficiary households. The research design exploits the sharp discontinuities at two regional eligibility thresholds to estimate local average treatment effects. Results suggest that the program did not affect utilization of health services but decreased mean out-of-pocket expenditures for some groups and reduced the risk of high inpatient expenditures. There are no systematic impacts on health behavior, management of chronic illnesses, and patient satisfaction. }, url = {http://onlinelibrary.wiley.com/doi/10.1002/hec.1673/abstract}, author = {Bauhoff, Sebastian and Hotchkiss, David R. and Smith, Owen} } @inbook {13171, title = {A Decade of Choice: Tracking the German National Experience with Consumer Choice of Sickness Fund}, booktitle = {Auf der Suche Nach der Besseren L{\"o}sung}, year = {2007}, pages = {145-159}, publisher = {Nomos Verlag}, organization = {Nomos Verlag}, address = {Baden-Baden, Germany}, author = {McGuire, Thomas and Bauhoff, Sebastian}, editor = {Oberender, P. and Straub, C.} }