Fox AM, Choi Y, Lanthorn H, Croke K. Health insurance loss during COVID-19 increases support for universal health coverage. Journal of Health Policy, Politics, and Law. Forthcoming.
Quattrochi JP, Coville A, Mvukiyehe E, Dohou C, Esu F, Cohen B, Lokaya Y, Croke K. Effects of a community-driven water, sanitation, and hygiene intervention on water and sanitation infrastructure, access, behavior, and governance: a cluster-randomized controlled trial in rural Democratic Republic of Congo. BMJ Global Health. 2021;6 :e005030. Publisher's VersionAbstract

Introduction Inadequate water and sanitation is a central challenge in global health. Since 2008, the Democratic Republic of Congo government has implemented a national programme, Healthy Villages and Schools (Villages et Ecoles Assainis (VEA), with support from UNICEF, financed by UK’s Foreign, Commonwealth and Development Office.

Methods A cluster-level randomised controlled trial of VEA was implemented throughout 2019 across 332 rural villages, grouped into 50 treatment and 71 control clusters. Primary outcomes included time spent collecting water; quantity of water collected; prevalence of improved primary source of drinking water; and prevalence of improved primary defecation site. Secondary outcomes included child health, water governance, water satisfaction, handwashing practices, sanitation practices, financial cost of water, school attendance and water storage practices. All outcomes were self-reported. The primary analysis was on an intention-to-treat basis, using linear models. Outcomes were measured October–December 2019, median 5 months post-intervention.

Results The programme increased access to improved water sources by 33 percentage points (pp) (95% CI 22 to 45), to improved sanitation facilities by 26 pp (95% CI 14 to 37), and improved water governance by 1.3 SDs (95% CI 1.1 to 1.5), water satisfaction by 0.6 SD (95% CI 0.4 to 0.9), handwashing practices by 0.5 SD (95% CI 0.3 to 0.7) and sanitation practices by 0.3 SD (95% CI 0.1 to 0.4). There was no significant difference in financial cost of water, school attendance, child health or water storage practices.

Conclusion VEA produced large increases in access to and satisfaction with water and sanitation services, in self-reported hygiene and sanitation behaviour, and in measures of water governance.

Croke K. The Impact of Health Programs on Political Opinion: Evidence from Malaria Control in Tanzania. Journal of Politics. 2021;83 (1) :340-353. Publisher's VersionAbstract
For elections to produce accountable government, citizens must reward politicians who deliver benefits. Yet there is relatively limited causal evidence of changes in public opinion in direct response to specific government programs. This question is examined in Tanzania, which has implemented large health programs targeting diseases such as HIV/AIDS and malaria. Tanzania’s 2010–11 antimalaria campaign took place concurrently with a national household survey. Exploiting discontinuities based on interview dates to estimate the effect of these programs on the popularity of local politicians, this article shows that a bed net distribution campaign resulted in large, statistically significant improvements in approval of political leaders, especially in malaria endemic areas. Effects were largest shortly after program implementation but persisted for up to six months. These findings suggest that citizens update their evaluation of politicians in response to programs, especially those that address important problems, and that the effects decay over time, but not completely.
Virk A, Croke K, Yusoff MM, Mokhtaruddin K, Abdullah Z, Hanafiah ANM, Emira Soleha Ramli, Borhan NF, Almodovar-Diaz Y, Wei-Aun Y, et al. Hybrid Organizations in Health Systems: The Case of Malaysia's National Heart Institute. Health Systems and Reform. 2020;6 (1) :e1833639. Publisher's VersionAbstract
Health system reforms across high- and middle-income countries often involve changes to public hospital governance. Corporatization is one such reform, in which public sector hospitals are granted greater functional independence while remaining publicly owned. In theory, this can improve public hospital efficiency, while retaining a public service ethos. However, the extent to which efficiency gains are realized and public purpose is maintained depends on policy choices about governance and payment systems. We present a case study of Malaysia’s National Heart Institute (IJN), which was created in 1992 by corporatization of one department in a large public hospital. The aim of the paper is to examine whether IJN has achieved the goals for which it was created, and if so, whether it provides a potential model for further reforms in Malaysia and other similar health systems. Using a combination of document analysis and key informant interviews, we examine key governance, health financing and payment, and equity issues. For governance, we highlight the choice to have IJN owned by and answerable to a Ministry of Finance (MOF) holding company and MOF-appointed board, rather than the Ministry of Health (MOH). On financing and payment, we analyze the implications of IJN’s combined role as fee-for-service provider to MOH as well as provider of care to private patients. For equity, we analyze the targeting of IJN care across publicly-referred and private patients. These issues demonstrate unresolved tensions between IJN’s objectives and public service goals. As an institutional innovation that has endured for 28 years and grown dramatically in size and revenue, IJN’s trajectory offers critical insights on the relevance of the hybrid public-private models for hospitals in Malaysia as well as in other middle-income countries. While IJN appears to have achieved its goal of establishing itself as a commercially viable, publicly owned center of clinical excellence in Malaysia, the value for money and equity of the services it provides to the Ministry of Health remain unclear. IJN is accountable to a small Ministry of Finance holding company, which means that detailed information required to evaluate these critical questions is not published. The case of IJN highlights that corporatization cannot achieve its stated goals of efficiency, innovation, and equity in isolation; rather it must be supported by broader reforms, including of health financing, payment, governance, and transparency, in order to ensure that autonomous hospitals improve quality and provide efficient care in an equitable way.
Croke K. The Origins of Ethiopia’s Primary Health Care Expansion: The politics of state building and health system strengthening. Health Policy and Planning. 2020;35 (10) :1318–1327. Publisher's VersionAbstract

Ethiopia’s expansion of primary health care over the past 15 years has been hailed as a model in sub-Saharan Africa. A leader closely associated with the programme, Tedros Adhanom Gebreyesus, is now Director-General of the World Health Organization, and the global movement for expansion of primary health care often cites Ethiopia as a model. Starting in 2004, over 30 000 Health Extension Workers were trained and deployed in Ethiopia and over 2500 health centres and 15 000 village-level health posts were constructed. Ethiopia’s reforms are widely attributed to strong leadership and ‘political will’, but underlying factors that enabled adoption of these policies and implementation at scale are rarely analysed. This article uses a political economy lens to iden- tify factors that enabled Ethiopia to surmount the challenges that have caused the failure of similar primary health programmes in other developing countries. The decision to focus on primary health care was rooted in the ruling party’s political strategy of prioritizing rural interests, which had enabled them to govern territory successfully as an insurgency. This wartime rural governance strategy included a primary healthcare programme, providing a model for the later national pro- gramme. After taking power, the ruling party created a centralized coalition of regional parties and prioritized extending state and party structures into rural areas. After a party split in 2001, Prime Minister Meles Zenawi consolidated power and implemented a ‘developmental state’ strategy. In the health sector, this included appointment of a series of dynamic Ministers of Health and the mo- bilization of significant resources for primary health care from donors. The ruling party’s ideology also emphasized mass participation in development activities, which became a central feature of health programmes. Attempts to translate this model to different circumstances should consider the distinctive features of the Ethiopian case, including both the benefits and costs of these strategies.

Croke K, Chokotho L, Milusheva S, Bertfelt J, Karpe S, Mohammed M, Mulwafu W. Implementation of a multi-centre digital trauma registry: Experience in district and central hospitals in Malawi. International Journal of Health Planning and Management. 2020;35 (5) :1157-1172. Publisher's VersionAbstract

Background: Trauma is a rapidly growing component of the burden of disease in developing countries; yet systematic data collection about trauma in such contexts is relatively rare.

Methods: This paper describes the implementation of a trauma registry in 10 government-run hospitals in Malawi, with a focus on implementation logistics, stakeholder engagement strategies, and data quality procedures.

Results: 51 337 trauma cases were recorded over the first 14 months of registry operations. The number of cases per month, data accuracy, and the geographic coverage of the registry improved over time as data quality measures were implemented.

Conclusions: Multi-center digital trauma registries are feasible in low-resource settings. Stakeholder engagement, periodic in-person and frequent digital follow up with data teams, and regular channeling of findings back to data collection teams help to improve data quality and complete- ness over a 14month period. Financial and staffing constraints remain challenges for sustainability over time, but this experience demonstrates the feasibility of large-scale registry operations.

Croke K, Mengistu AT, O'Connell S, Tafere K. The impact of a health facility construction campaign on health service utilization and outcomes: Analysis of spatially-linked survey and facility location data in Ethiopia. BMJ Global Health. 2020;5 (8) :e002430. Publisher's Version ethiopia_bmj_final.pdf
Croke K, Yusoff MM, Abdullah Z, Hanafiah ANM, Mokhtaruddin K, Emira Soleha Ramli, Borhan NF, Almodovar-Diaz Y, Atun R, Virk AK. The political economy of health financing reform in Malaysia. Health Policy and Planning. 2019;34 (10) :732-739. Publisher's VersionAbstract
There is growing evidence that political economy factors are central to whether or not proposed health financing reforms are adopted, but there is little consensus about which political and institutional factors determine the fate of reform proposals. One set of scholars see the relative strength of interest groups in favour of and opposed to reform as the determining factor. An alternative literature identifies aspects of a country’s political institutions–specifically the number and strength of formal ‘veto gates’ in the political decision-making process—as a key predictor of reform’s prospects. A third group of scholars highlight path dependence and ‘policy feedback’ effects, stressing that the sequence in which health policies are implemented determines the set of feasible reform paths, since successive policy regimes bring into existence patterns of public opinion and interest group mobilization which can lock in the status quo. We examine these theories in the context of Malaysia, a successful health system which has experienced several instances of proposed, but ultimately blocked, health financing reforms. We argue that policy feedback effects on public opinion were the most important factor inhibiting changes to Malaysia’s health financing system. Interest group opposition was a closely related factor; this opposition was particularly powerful because political leaders perceived that it had strong public support. Institutional veto gates, by contrast, played a minimal role in preventing health financing reform in Malaysia. Malaysia’s dramatic early success at achieving near-universal access to public sector healthcare at low cost created public opinion resistant to any change which could threaten the status quo. We conclude by analysing the implications of these dynamics for future attempts at health financing reform in Malaysia.
Chukwuma A, Bossert TJ, Croke K. Health service delivery and political trust in Nigeria. Social Science and Medicine - Population Health. 2019;7. Publisher's VersionAbstract
Do improvements in health service delivery affect trust in political leaders in Africa? Citizens expect their government to provide social services. Intuitively, improvements in service delivery should lead to higher levels of trust in and support for political leaders. However, in contexts where inadequate services are the norm, and where political support is linked to ethnic or religious affiliation, there may be weak linkages between improvements in service delivery and changes in trust in political leaders. To examine this question empirically, we take advantage of a national intervention that improved health service delivery in 500 primary health care facilities in Nigeria, to estimate the impact of residence within 10 km of one or more of the intervention facilities on trust in the president, local councils, the ruling party, and opposition parties. Using difference-in-difference models, we show that proximity to the intervention led to increases in trust in the president and the ruling party. By contrast, we find no evidence of increased trust in the local council or opposition parties. Our study also examines the role of ethnicity and religious affiliation in mediating the observed increases in trust in the president. While there is a large literature suggesting that both the targeting of interventions, and the response of citizens to interventions is often mediated by ethnic, geographic or religious identity, by contrast, we find no evidence that the intervention was targeted at the president's ethnic group, zone, or state of origin. Moreover, there is suggestive evidence that the intervention increased trust in the president more among those who did not share these markers of identity with the president. This highlights the possibility that broad-based efforts to improve health services can increase trust in political leaders even in settings where political attitudes are often thought to be mediated by group identity.
Croke K, Atun R. The Long Run Impact of Early Childhood Deworming on Numeracy and Literacy: Evidence from Uganda. PLOS Neglected Tropical Diseases. 2019;13 (1) :e0007085. Publisher's Version croke_atun_deworming.pdf
Bundy DAP, de Silva N, Horton S, Patton GC, Schultz L, Jamison DT, and Group DCP-3 CAHDA. Investment in child and adolescent health and development: key messages from Disease Control Priorities, 3rd Edition. The Lancet. 2018;391 (10121) :687-699. Publisher's Version
de Neve J-W, Andriantavison RL, Croke K, Krisam J, Rajoela VH, Rakotoarivony RA, Rambeloson V, Schultz LB, Qamruddin J, Verguet S. Health, financial, and education gains of investing in preventive chemotherapy for schistosomiasis, soil-transmitted helminthiases, and lymphatic filariasis in Madagascar: a modeling study. PLOS Neglected Tropical Diseases. 2018;12 (12) :e0007002. Publisher's Version
Bundy DAP, Appleby LJ, Bradley M, Croke K, Hollingsworth TD, Pullan R, Turner HC, de Silva N. 100 Years of Mass Deworming Programmes: A Policy Perspective From the World Bank's Disease Control Priorities Analyses. Advances in Parasitology. 2018;100 :127-154. Publisher's Version
Bundy D, Appleby L, Bradley M, Croke K, Hollingsworth TD, Pullan R, Turner HC, de Silva N. Deworming Programs in Middle Childhood and Adolescence. In: Disease Control Priorities: Child and Adolescent Health and Development, Chapter 13. Vol. 8. 3rd ed. Washington DC: World Bank ; 2017. pp. 165-182. Publisher's Version dcp3_cahd_ch_13.pdf
Croke K, Ishengoma DS, Francis F, Makani J, Kamugisha ML, Lusingu J, Lemnge M, Larreguy H, Fink G, Mmbando BP. Relationships between sickle cell trait, malaria, and educational outcomes in Tanzania. BMC Infectious Diseases . 2017;17 :568. Publisher's VersionAbstract


Sickle Cell Trait (SCT) has been shown to be protective against malaria. A growing literature suggests that malaria exposure can reduce educational attainment. This study assessed the relationship and interactions between malaria, SCT and educational attainment in north-eastern Tanzania.


Seven hundred sixty seven children were selected from a list of individuals screened for SCT. Febrile illness and malaria incidence were monitored from January 2006 to December 2013 by community health workers. Education outcomes were extracted from the Korogwe Health and Demographic Surveillance system in 2015. The primary independent variables were malaria and SCT. The association between SCT and the number of fever and malaria episodes from 2006 to 2013 was analyzed. Main outcomes of interest were school enrolment and educational attainment in 2015.


SCT was not associated with school enrolment (adjusted OR 1.42, 95% CI [0.593,3.412]) or highest grade attained (adjusted grade difference 0.0597, 95% CI [−0.567, 0.686]). SCT was associated with a 29% reduction in malaria incidence (adjusted IRR 0.71, 95% CI [0.526, 0.959]) but not with fever incidence (adjusted IRR 0.905, 95% CI [0.709-1.154]). In subgroup analysis of individuals with SCT, malaria exposure was associated with reduced school enrollment (adjusted OR 0.431, 95% CI [0.212, 0.877]).


SCT appears to reduce incidence of malaria. Overall, children with SCT do not appear to attend more years of school; however children who get malaria despite SCT appear to have lower levels of enrolment in education than their peers.

Croke K, Hicks JH, Hsu E, Kremer M, Miguel E. Should the WHO withdraw support for mass deworming?. PLOS Neglected Tropical Diseases. 2017;11 (6) :e0005481. Publisher's Version plos_ntds.pdf
Croke K, Hsu E, Kremer M. More Evidence on the Effects of Deworming: What Lessons Can We Learn?. American Journal of Tropical Medicine and Hygiene. 2017;96 (6) :1265-66. Publisher's Version what_lessons_can_we_learn.pdf
Croke K. Commentary: Exploiting randomized exposure to early childhood deworming programmes to study long-run effects: A research programme in progress. International Journal of Epidemiology. 2017. Publisher's Version ije_final_pre-print.pdf
Croke K. Tools of Single Party Hegemony in Tanzania: Evidence from Surveys and Survey Experiments. Democratization. 2017; 24 (2) :189-208. Publisher's VersionAbstract

Political systems dominated by a single party are common in the developing world, including in countries that hold regular elections. Yet we lack knowledge about the strategies by which these regimes maintain political dominance. This article presents evidence from Tanzania, a paradigmatic dominant party regime, to demonstrate how party institutions are used instrumentally to ensure the regime's sustained control. First, I show that the ruling party maintains a large infrastructure of neighbourhood representatives, and that in the presence of these agents, citizens self-censor about their political views. Second, I provide estimates of the frequency with which politicians give goods to voters around elections, demonstrating that such gifts are more common in Tanzania than previous surveys suggest. Third, I use a survey experiment to test respondents’ reaction to information about corruption. Few voters change their preferences upon receipt of this information. Taken together, this article provides a detailed picture of ruling party activities at the micro-level in Tanzania. Citizens conceal opposition sympathies from ten cell leaders, either because they fear punishment or seek benefits. These party agents can monitor citizens’ political views, facilitating clientelist exchange. Finally, citizens’ relative insensitivity to clientelism helps explain why politicians are not punished for these strategies.

Croke K, Grossman G, Larreguy HA, Marshall J. Deliberate Disengagement: How Education Can Decrease Political Participation in Electoral Authoritarian Regimes. American Political Science Review. 2016;110 (3) :579-600. Publisher's VersionAbstract

A large literature examining advanced and consolidating democracies suggests that education increases political participation. However, in electoral authoritarian regimes, educated voters may instead deliberately disengage. If education increases critical capacities, political awareness, and support for democracy, educated citizens may believe that participation is futile or legitimizes autocrats. We test this argument in Zimbabwe—a paradigmatic electoral authoritarian regime—by exploiting cross-cohort variation in access to education following a major educational reform. We find that education decreases political participation, substantially reducing the likelihood that better-educated citizens vote, contact politicians, or attend community meetings. Consistent with deliberate disengagement, education’s negative effect on participation dissipated following 2008’s more competitive election, which (temporarily) initiated unprecedented power sharing. Supporting the mechanisms underpinning our hypothesis, educated citizens experience better economic outcomes, are more interested in politics, and are more supportive of democracy, but are also more likely to criticize the government and support opposition parties.

cglm_sept2015.pdf onlineappendix.pdf