Person: Shapira, Gil
Development Research Group
Loading...
Author Name Variants
Shapira, Gil
Fields of Specialization
Health Economics, Economic Demography
Degrees
ORCID
External Links
Departments
Development Research Group
Externally Hosted Work
Contact Information
Last updated:October 10, 2023
Biography
Gil Shapira is an Economist in the Human Development Team of the Development Research Group. He received his B.A. in Economics from Columbia University in 2005, and his Ph.D. in Economics from the University of Pennsylvania in 2011. His current research focuses on analyzing demographic and health issues in developing countries, with an emphasis on Sub-Saharan Africa. More specifically, in his current research he studies decision-making in the context of the HIV/AIDS epidemic, the transition from adolescence to adulthood in Malawi, and the impact of interventions to improve maternal and child health in different countries.
16 results
Publication Search Results
Now showing1 - 10 of 16
Publication Improving Effective Coverage in Health: Do Financial Incentives Work?(Washington, DC: World Bank, 2022-05-11) de Walque, Damien; Kandpal, Eeshani; Wagstaff, Adam; Friedman, Jed; Neelsen, Sven; Piatti-Fünfkirchen, Moritz; Sautmann, Anja; Shapira, Gil; Van de Poel, EllenIn many low- and middle-income countries, health coverage has improved dramatically in the last two decades, but health outcomes have not. As such, effective coverage -- a measure of service delivery that meets a minimum standard of quality -- remains unacceptably low. This Policy Research Report examines one specific policy approach to improving effective coverage: financial incentives in the form of performance-based financing (PBF) or financial incentives to health workers on the front lines. The report draws on a rich set of rigorous studies and new analysis. When compared to business-as-usual, in low-income settings with centralized health systems PBF can result in substantial gains in effective coverage. However, the relative benefits of PBF are less clear when it is compared to two alternative approaches, decentralized facility financing which provides operating budget to frontline health services with facility autonomy on allocation, and demand-side financial support for health services (i.e., conditional cash transfers and vouchers). While PBF often results in improvements on the margins, closing the substantial gaps in effective health coverage is not yet within reach for many countries. Nonetheless, there are important lessons learned and experiences from the roll-out of PBF over the last decade which can guide health policies into the future.Publication Impacts of Performance‑Based Financing on Health System Performance: Evidence From The Democratic Republic of Congo (Published: 04 October 2023)(BMC Medicine, 2023-10-10) Clarke‑Deelder, Emma; Shapira, Gil; Booto, Baudouin Makuma; Samaha, Hadia; Fritsche, György Bèla; Muvudi, Michel; Baabo, Dominique; Antwisi, Delphin; Ramanana, Didier; Benami, Saloua; Fink, GüntherHealth systems’ weakness remains one of the primary obstacles towards achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) programs have been increasingly used to increase access to quality care in LMICs. However, evidence on the impacts of these programs remains fragmented and inconclusive. We analyze the health system impacts of the PBF program in the Democratic Republic of the Congo (DRC), one of the largest such programs introduced in LMICs to date. We used a health systems perspective to analyze the benefits of PBF relative to unconditional financing of health facilities. Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started at the end of 2016. Follow-up data collection took place in 2021–2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers’ satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain. The PBF program improved the structural quality of health facilities by 4 percentage points (ppts) (95% CI 0.01–0.08), technical process quality by 5 ppts (0.03–0.07), and non-technical process by 2 ppts (0–0.04). PBF also increased coverage of priority health services by 3 ppts (0.02–0.04). Improvements were also observed for facility management (9 ppts, 0.04–0.15), service fee policies, and users’ satisfaction with service affordability (14 ppts, 0.07–0.20). Service fees and health workers’ satisfaction were not affected by the program. The results suggest that well-designed PBF programs can lead to improvements in most health systems domains relative to comparable unconditional financing. However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals.Publication Inequality in the Quality of Health Services: Wealth, Content of Care, and the Price of Antenatal Consultations in the Democratic Republic of Congo(The University of Chicago Press, 2022-02-14) Fink, Gunther; Kandpal, Eeshani; Shapira, GilWe use unique data on direct observations of patient-provider interactions linked to detailed patient exit interviews and household surveys to study the relationship between patients’ socioeconomic status and the quality of antenatal care in the Democratic Republic of Congo. We find a significant wealth-quality gradient: a 1 standard deviation in household wealth is associated with a 1.6–3.2 percentage point increase in protocol compliance, depending on the data source and the definition of the compliance index. A large part of the overall wealth-quality gradient is driven by generally lower facility quality in poorer areas. However, we also find a statistically significant within-village wealth-quality relationship that is primarily driven by wealthier women seeking care at higher-quality facilities even if they are more distant. Finally, we find some evidence that even within the same facilities, poorer women tend to receive worse care but, on average, also pay less for care of a given quality.Publication Financial Incentives, Fertility, and Son Preference in Armenia(World Bank, Washington, DC, 2021-06) Pinto, Maria Florencia; Posadas, Josefina; Shapira, GilArmenia experienced dramatic demographic changes in the past three decades: the share of adults age 65 and over nearly doubled, the total fertility rate reduced by more than 30 percent, and the male-to-female sex ratio at birth increased to one of the world’s highest. Like other middle-income countries concerned with the implications of an aging population for long-term growth and fiscal sustainability, Armenia introduced financial incentives to promote fertility. This paper estimates the effect of the 2009 reform of the universal Childbirth Benefit Program, which increased the amounts of lump sum transfers conditional on birth. The analysis relies on a quasi-experimental strategy exploiting the timing of the policy change and eligibility rule—women get a larger transfer for third and higher-order births. The findings show that the annual probability of an additional birth among women with at least two other children increased between 1.4 and 1.6 percentage points in the five years following the policy change. These effects are equivalent to 58 and 64 percent of the pre-reform birth probability for women who had at least two children. Given the previously demonstrated relationship between fertility level and sex ratio in societies with strong son preference, the reform may potentially alleviate the sex imbalance without directly targeting it. Parents who already have at least one son and are less likely to engage in sex selection and more likely to have additional births; however, the findings do not indicate a significant increase in the likelihood of having daughters.Publication Incentivizing Quantity and Quality of Care: Evidence from an Impact Evaluation of Performance-Based Financing in the Health Sector in Tajikistan(University of Chicago Press, 2022-02) Ahmed, Tashrik; Arur, Aneesa; de Walque, Damien; Shapira, GilTo improve utilization and quality of health services, a growing number of low- and middle-income countries have been experimenting with financial incentives tied to providers’ performance. Relying on a difference-in-differences approach, we estimate the impacts of the performance-based financing pilot in Tajikistan. Primary care facilities were given financial incentives conditional on the quality and quantity of selected services. Significant improvements are found on quality indicators, including elements of the content of care. While the communities in the pilot districts reported higher satisfaction with the local primary care facilities, and despite the improvements in quality, the impact on utilization was limited.Publication How Many Infants May Have Died in Low-Income and Middle-Income Countries in 2020 Due to the Economic Contraction Accompanying the COVID-19 Pandemic? Mortality Projections Based on Forecasted Declines in Economic Growth(BMJ Publishing Group, Ltd., 2021-08) Shapira, Gil; de Walque, Damien; Friedman, JedWhile COVID-19 has a relatively small direct impact on infant mortality, the pandemic is expected to indirectly increase mortality of this vulnerable group in low-income and middle-income countries through its effects on the economy and health system performance. Previous studies projected indirect mortality by modelling how hypothesized disruptions in health services will affect health outcomes. We provide alternative projections, relying on modelling the relationship between aggregate income shocks and mortality. The findings underscore the vulnerability of infants to the negative income shocks such as those imposed by the COVID-19 pandemic. While efforts towards prevention and treatment of COVID-19 remain paramount, the global community should also strengthen social safety nets and assure continuity of essential health services.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) Ahmed, Tashrik; Shapira, Gil; Drouard, Salome Henriette Paulette; Fernandez, Pablo Amor; Nzelu, Charles; Kandpal, Eeshani; Sanford Wesseh, Chea; Mohamud, Nur Ali; Smart, Francis; Mwansambo, Charles; Baye, Martina L; Diabate, Mamatou; Yuma, Sylvain; Ogunlayi, Munirat; De Dieu Rusatira, Rwema Jean; Hashemi, Tawab; Vergeer, Petra; Friedman, JedThe 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 The Intergenerational Mortality Tradeoff of COVID-19 Lockdown Policies(World Bank, Washington, DC, 2021-05) Ma, Lin; Shapira, Gil; de Walque, Damien; Do, Quy-Toan; Friedman, Jed; Levchenko, Andrei A.In lower-income countries, the economic contractions that accompany lockdowns to contain the spread of COVID-19 can increase child mortality, counteracting the mortality reductions achieved by the lockdown. To formalize and quantify this effect, this paper builds a macro-susceptible-infected-recovered model that features heterogeneous agents and a country-group-specific relationship between economic downturns and child mortality, and calibrate it to data for 85 countries across all income levels. The findings show that in low-income countries, a lockdown can potentially lead to 1.76 children’s lives lost due to the economic contraction per COVID-19 fatality averted. The ratio stands at 0.59 and 0.06 in lower-middle and upper-middle income countries, respectively. As a result, in some countries lockdowns can actually produce net increases in mortality. In contrast, the optimal lockdown that maximizes the present value of aggregate social welfare is shorter and milder in poorer countries than in rich ones, and never produces a net mortality increase.Publication Quality of Clinical Assessment and Child Mortality: A Three-Country Cross-Sectional Study(Oxford University Press, 2020-06) Perales, Nicole A.; Wei, Dorothy; Khadka, Aayush; Leslie, Hannah H.; Hamadou, Saidou; Chamberlin Yama, Gervais; Robyn, Paul Jacob; Shapira, Gil; Kruk, Margaret E.; Fink, GuntherThis 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 Incentivizing Quantity and Quality of Care: Evidence from an Impact Evaluation of Performance-Based Financing in the Health Sector in Tajikistan(World Bank, Washington, DC, 2019-07) Ahmed, Tashrik; Arur, Aneesa; de Walque, Damien; Shapira, GilThis paper presents the results of an impact evaluation of a performance-based financing pilot in rural areas of two regions of Tajikistan. Primary care facilities were given financial incentives conditional on general quality and the quantity provided of selected services related to reproductive, maternal and child health, and hypertension-related services. The study relies on a difference-in-difference design and large-scale household and facility-based surveys conducted before the launch of the pilot in 2015 and after three years of implementation. The performance-based financing pilot had positive impacts on quality of care. Significant impacts are measured on facility infrastructure, infection prevention and control standards, availability of equipment and medical supplies, provider competency, provider satisfaction, and even some elements of the content of care, measured through direct observations of provider-patient interactions. While the communities in the performance-based financing districts reported higher satisfaction with the local primary care facilities, and despite the improvements in quality, the findings suggest moderate effects on utilization: among the incentivized utilization indicators, only timely postnatal care and blood pressure measurements for adults were significantly impacted.