Publications

2023
Bernal Lara, Pedro, William D. Savedoff, María Fernanda García Agudelo, Carolina Bernal, Laura Goyeneche, Rita Sorio, Ricardo Pérez-Cuevas, et al. 2023. “Disruption Of Non-COVID-19 Health Care In Latin America During The Pandemic: Effects On Health, Lessons For Policy.” Health Affairs 42 (12): 1657–1666. Published paper (open access) 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 2015–21 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.
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 2017–18 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.
Rubinstein, Adolfo, Federico Filippini, Adrian Santoro, Alejandro L. Lopez Osornio, Ariel L. Bardach, Emiliano Navarro, Cintia Cejas, et al. 2023. “Lives Versus Livelihoods: The Epidemiological, Social, And Economic Impact Of COVID-19 In Latin America And The Caribbean.” Health Affairs 42 (12): 1647–1656. Published paper (open access) 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.
Biswas, Arpita, John Tucker, and Sebastian Bauhoff. 2023. “Performance of Predictive Algorithms in Estimating the Risk of Being a Zero-Dose Child in India, Mali and Nigeria.” BMJ Global Health 8. BMJ Specialist Journals: e012836. Published paper (open access) 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 ‘zero-dose’ (ZD) children.

Methods We examined how well predictive algorithms can characterise a child’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.

Turcotte-Tremblay, Anne-Marie, Borwornsom Leerapan, Patricia Akweongo, Freddie Amponsah, Amit Aryal, Daisuke Asai, John Koku Awoonor-Williams, et al. 2023. “Tracking Health System Performance in Times of Crisis Using Routine Health Data: Lessons Learned From a Multicountry Consortium.” Health Research Policy and Systems 21 (1): 14. Published paper (open access) 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’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.

2022
Gage, Anna, Bereket Yakob, Margaret McConnell, Tsinuel Girma, Brook Damtachew, Sebastian Bauhoff, and Margaret Kruk. 2022. “The Role of Teams in Shaping Quality of Obstetrical Care: A Cross-Sectional Study in Dire Dawa, Ethiopia.” BMJ Open 12. British Medical Journal Publishing Group: e066111. Published paper (open access) 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’s coworkers, controlling for individual provider’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’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’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.

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 2014–2015 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 290–495 health centers and 370–847 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’ effort scores were generally lower than their knowledge scores, indicating the presence of a “know-do gap.” 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’s public sector will require multidimensional interventions that involve training, strategies that increase provider motivation, and improved health center management

Feldhaus, Isabelle, Somil Nagpal, and Sebastian Bauhoff. 2022. “Role of User Benefit Awareness in Health Coverage Utilization Among the Poor in Cambodia.” Health Systems & Reform 8 (1): e2058336. Published paper (open access) 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’ 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.

Arsenault, Catherine, Anna Gage, Min Kyung Kim, Neena R. Kapoor, Patricia Akweongo, Freddie Amponsah, Amit Aryal, et al. 2022. “COVID-19 and Resilience of Healthcare Systems in Ten Countries.” Nature Medicine, 1–11. Published paper (open access) 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’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 (26–96% declines). Total outpatient visits declined by 9–40% 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.
McConnell, Margaret, Mansha Mahajan, Sebastian Bauhoff, Kevin Croke, Stéphane Verguet, Marcia C Castro, Kheya Melo Furtado, et al. 2022. “How are Health Workers Paid and Does it Matter? Conceptualising the Potential Implications of Digitising Health Worker Payments.” BMJ Global Health 7 (1). Published paper (open access) 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.

Hsieh, Yuli, Summer Rak, Gillian K SteelFisher, and Sebastian Bauhoff. 2022. “Effect of the Suspension of the J&J COVID-19 Vaccine on Vaccine Hesitancy in the United States.” Vaccine 40 (3): 424-427. Published paper (gated) 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 “a pause in the use of this vaccine out of an abundance of caution.” 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’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.

2021
Bahety, Girija, Sebastian Bauhoff, Dev Patel, and James Potter. 2021. “Texts Don't Nudge: An Adaptive Trial to Prevent the Spread of COVID-19 in India.” Journal of Development Economics 153: 102747. Published paper (gated) 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'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.
Bauhoff, Sebastian, and Nikkil Sudharsanan. 2021. “Evaluating Health Insurance Programmes: An Insurance Cascade Framework.” Economic & Political Weekly 56 (23): 22-28. Published paper (gated) 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 “insurance cascade,” 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’ awareness of how to enrol in schemes, what the schemes covers, and how to access scheme benefits.

Also available at CGD Working Paper 583.

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.

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’s PBF program to identify medium-run and scale-up effects of incentives and unconditional financing relative to a new “business as usual” 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’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.

Jithitikulchai, Theepakorn, Isabelle Feldhaus, Sebastian Bauhoff, and Somil Nagpal. 2021. “Health Equity Funds as the Pathway to Universal Coverage in Cambodia: Care Seeking and Financial Risk Protection.” Health Policy and Planning 36 (1): 26–34. Published paper (open access) 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.

2020
Duran, Denizhan, Sebastian Bauhoff, Peter Berman, Tania Gaudet, Clovis Konan, Emre Özaltin, and Margaret Kruk. 2020. “The Role of Health System Context in the Implementation of Performance-Based Financing: Evidence from Cote d’Ivoire.” BMJ Global Health 5: e002934. Published paper (open access) 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’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’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’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.

Abir, Mahshid, Jason Goldstick, Rosalie Malsberger, Claude M Setodji, Sebastian Bauhoff, and Neil Wenger. 2020. “The Association between Hospital Occupancy and Mortality Among Medicare Patients.” The Joint Commission Journal on Quality and Patient Safety 46 (9): 506-515. Published paper (gated) 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]: 0.94–0.99) and higher discharge day occupancy (OR = 0.62, 95% CI: 0.60–0.64) 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.

 

Wierzynska, Aneta, Sarah Steingrüber, Roxanne Oroxom, and Sebastian Bauhoff. 2020. “Recalibrating the Anti-Corruption, Transparency, and Accountability Formula to Advance Public Health.” Global Health Action sup 1: 1701327. Published paper (open access) 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’ incentives around the advancement of health objectives; and being minimally corruptible by design.

 

Deforestation can increase malaria risk factors such as mosquito growth rates and biting rates in some settings. But deforestation affects more than mosquitoes—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.

     

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