03. Journals
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These are journal articles published in World Bank journals as well as externally by World Bank authors.
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Publication
Looking into the performance-based financing black box: Evidence from an impact evaluation in the health sector in Cameroon
(Oxford University Press, 2021-07)Performance-based financing (PBF) is a complex health systems intervention aimed at improving the coverage and quality of care. Several studies have shown a positive impact of PBF on health service coverage, often coupled with improvements in quality, but relatively little is known about the mechanisms driving those results. This article presents results of a randomized impact evaluation in Cameroon designed to isolate the role of specific components of the PBF approach with four study groups: (i) PBF with explicit financial incentives linked to results, (ii) direct financing with additional resources available for health providers not linked to performance, (iii) enhanced supervision and monitoring without additional resources and (iv) a control group. Overall, results indicate that, when compared with the pure control group, PBF in Cameroon led to significant increases in utilization for several services (child and maternal vaccinations, use of modern family planning), but not for others like antenatal care visits and facility-based deliveries. In terms of quality, PBF increased the availability of inputs and equipment, qualified health workers, led to a reduction in formal and informal user fees but did not affect the content of care. However, for many positively impacted outcomes, the differences between the PBF group and the group receiving additional financing not linked to performance are not significant, suggesting that additional funding rather than the explicit incentives might be driving improvements. In contrast, the intervention group offering enhanced supervision, coaching and monitoring without additional funding did not experience significant impacts compared to the control group. -
Publication
Disruptions in Maternal and Child Health Service Utilization during COVID-19: Analysis from Eight Sub-Saharan African Countries
(Oxford University Press, 2021-06-19)The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March–July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning. -
Publication
External Validity and Policy Adaptation: From Impact Evaluation to Policy Design
(Published by Oxford University Press on behalf of the World Bank, 2020-07)With the growing number of impact evaluations worldwide, the question of how to apply this evidence in policy making processes has arguably become the main challenge for evidence-based policy making. How can policy makers predict whether a policy will have the same impact in their context as it did elsewhere, and how should this influence the policy’s design and implementation? This paper suggests that failures of external validity (both in transporting and scaling up policy) can be understood as arising from an interaction between a policy’s theory of change and a dimension of the context in which it is being implemented. The paper surveys existing approaches to analyzing external validity, and suggests that there has been more focus on the generalizability of impact evaluation results than on the applicability of evidence to specific contexts. To help fill this gap, the study develops a method of “mechanism mapping” that maps a policy’s theory of change against salient contextual assumptions to identify external validity problems and suggest appropriate policy adaptations. In deciding whether and how to adapt a policy, there is a fundamental informational trade-off between the strength of evidence on the policy from other contexts and the policy maker’s information about the local context. -
Publication
Quality of Clinical Assessment and Child Mortality: A Three-Country Cross-Sectional Study
(Oxford University Press, 2020-06)This analysis describes specific gaps in the quality of health care in Central Africa and assesses the association between quality of clinical care and mortality at age 2–59 months. Regionally representative facility and household surveys for the Democratic Republic of the Congo, Cameroon and Central African Republic were collected between 2012 and 2016. These data are novel in linking facilities with households in their catchment area. Compliance with diagnostic and danger sign protocols during sick-child visits was observed by trained assessors. We computed facility- and district-level compliance indicators for patients aged 2–59 months and used multivariate multi-level logistic regression models to estimate the association between clinical assessment quality and mortality at age 2–59 months in the catchment areas of the observed facilities. A total of 13 618 live births were analysed and 1818 sick-child visits were directly observed and used to rate 643 facilities. Eight percent of observed visits complied with 80% of basic diagnostic protocols, and 13% of visits fully adhered to select general danger sign protocols. A 10% greater compliance with diagnostic protocols was associated with a 14.1% (adjusted odds ratio (aOR) 95% CI: 0.025–0.244) reduction in the odds of mortality at age 2–59 months; a 10% greater compliance with select general danger sign protocols was associated with a 15.3% (aOR 95% CI: 0.058–0.237) reduction in the same odds. The results of this article suggest that compliance with recommended clinical protocols remains poor in many settings and improvements in mortality at age 2–59 months could be possible if compliance were improved. -
Publication
Predicting Dynamic Patterns of Short-Term Movement
(Published by Oxford University Press on behalf of the World Bank, 2020-02)Short-term human mobility has important health consequences, but measuring short-term movement using survey data is difficult and costly, and use of mobile phone data to study short-term movement is only possible in locations that can access the data. Combining several accessible data sources, Senegal is used as a case study to predict short-term movement within the country. The focus is on two main drivers of movement—economic and social—which explain almost 70 percent of the variation in short-term movement. Comparing real and predicted short-term movement to measure the impact of population movement on the spread of malaria in Senegal, the predictions generated by the model provide estimates for the effect that are not significantly different from the estimates using the real data. Given that the data used in this paper are often accessible in other country settings, this paper demonstrates how predictive modeling can be used by policy makers to estimate short-term mobility. -
Publication
Linguistic Fractionalization and Health Information in Sub-Saharan Africa
(Published by Oxford University Press on behalf of the World Bank, 2020-02)This paper explores the relationship between linguistic diversity and the stock of health information in society. Information is measured using individual-level knowledge about the oral rehydration product for treating children with diarrhea. Exploiting an individual woman-level dataset from the Demographic and Health Surveys for 14 sub-Saharan African countries combined with a novel high-resolution dataset on the spatial distribution of linguistic groups at a 1 km × 1 km level, this study shows that linguistic diversity has an inverted U-shaped relationship with the stock of information in society. -
Publication
Quality of Care for Children with Severe Disease in the Democratic Republic of the Congo
(Springer Nature, 2019-12)Despite the almost universal adoption of Integrated Management of Childhood Illness (IMCI) guidelines for the diagnosis and treatment of sick children under the age of five in low- and middle-income countries, child mortality remains high in many settings. One possible explanation of the continued high mortality burden is lack of compliance with diagnostic and treatment protocols. We test this hypothesis in a sample of children with severe illness in the Democratic Republic of the Congo (DRC). -
Publication
Cash Transfers and Health: Evidence from Tanzania
(Published by Oxford University Press on behalf of the World Bank, 2019-06)How do cash transfers conditioned on health clinic visits and school attendance impact health-related outcomes? Examining the 2010 randomized introduction of a program in Tanzania, this paper finds nuanced impacts. An initial surge in clinic visits after 1.5 years—due to more visits by those already complying with program health conditions and by non-compliers—disappeared after 2.5 years, largely due to compliers reducing above-minimal visits. The study finds significant increases in take-up of health insurance and the likelihood of seeking treatment when ill. Health improvements were concentrated among children ages 0–5 years rather than the elderly, and took time to materialize; the study finds no improvements after 1.5 years, but 0.76 fewer sick days per month after 2.5 years, suggesting the importance of looking beyond short-term impacts. Reductions in sick days were largest in villages with more baseline health workers per capita, consistent with improvements being sensitive to capacity constraints. These results are robust to adjustments for multiple hypothesis testing. -
Publication
Health and AIDS in 2019 and Beyond
(Taylor and Francis, 2018-12-18)Editorials provide an opportunity for the authors to get ideas out and things off their chests. Between us we have a sobering 70 years of experience working on health, initially in Southern Africa. We watched with horror as the HIV epidemic progressed inexorably in the 1980s through Zimbabwe (where David was based) to South Africa in the 1990s (where Alan worked at the University of Natal). HIV was a new disease but swept through the region with unbelievable speed and ferocity. A survey in Northern KwaZulu-Natal in 1986/87 found no HIV, by 2018 prevalence among pregnant women was over 50 percent. -
Publication
Kenya National Hospital Insurance Fund Reforms: Implications and Lessons for Universal Health Coverage
(Taylor and Francis, 2018-11-06)This article identifies and describes the reforms undertaken by the National Hospital Insurance Fund (NHIF) and examines their implications for Kenya’s quest to achieve universal health coverage (UHC). We undertook a review of published and grey literature to identify key reforms that had been implemented by the NHIF since 2010. We examined the reforms undertaken by the NHIF using a health financing evaluation framework that considers the feasibility, equity, efficiency, and sustainability of health financing mechanisms. We found the following NHIF reforms: (1) the introduction of the Civil Servants Scheme (CSS), (2) the introduction of a stepwise quality improvement system, (3) the health insurance subsidy for the poor (HISP), (4) revision of monthly contribution rates and expansion of the benefit package, and (5) the upward revision of provider reimbursement rates. Though there are improvements in several areas, these reforms raise equity, efficiency, feasibility, and sustainability concerns. The article concludes that though NHIF reforms in Kenya are well intentioned and there has been improvement in several areas, design attributes could compromise the extent to which they achieve their intended goal of providing universal financing risk protection to the Kenyan population.