The Institute for Global Health and Development
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Item Socio-cultural change in conflict and post conflict settings: Five decades of giving birth in Cambodia(BioMed Central, 2019-11-15) Ros, Bandeth; Lê, Gillian; Fustukian, Suzanne; McPake, BarbaraBackground: This paper explores the changing experience of giving birth in Cambodia over a 53-year period. During this time, Cambodian people experienced armed conflict, extreme privation, foreign invasion, and civil unrest. Methods: An historical perspective was used to explore the changing place and nature of birth assistance given to Cambodian women between 1950 and 2013. Twenty-four life histories of poor and non-poor Cambodians aged 40–74 were gathered and analysed using a grounded thematic approach. Results: In the early lives of the respondents, almost all births occurred at home and were assisted by Traditional Birth Attendants. In modern times, towards the end of their lives, the respondents’ grand-children and great grand-children are almost universally born in institutions in which skilled birth attendants are available. Respondents recognise that this is partly due to the availability of modern health care facilities but also describe the process by which attitudes to institutional and homebirth changed over time. Interviews can also chart the increasing awareness of the risks of homebirth, somewhat influenced by the success of health education messages transmitted by public health authorities. Conclusions: The life histories provide insight into the factors driving the underlying cultural change: a modernising supply side; improving transport and communications infrastructure. In addition, a step-change occurred in the aftermath of the conflict with significant influence of extensive contact with the Vietnamese recognised. Trial registration: None.Item What, why and how do health systems learn from one another? Insights from eight low- and middle-income country case studies(BioMed Central, 2019-01-21) Witter, Sophie; Anderson, Ian; Annear, Peter; Awosusi, Abiodun; Bhandari, Nitin N.; Brikci, Nouria; Binachon, Blandine; Chanturidze, Tata; Gilbert, Katherine; Jensen, Charity; Lievens, Tomas; McPake, Barbara; Raichowdhury, Snehashish; Jones, AlexBackground - All health systems struggle to meet health needs within constrained resources. This is especially true for low-income countries. It is critical that they can learn from wider contexts in order to improve their performance. This article examines policy transfer and evidence use linked to it in low- and middle-income settings. The objective was to inform international investments in improved learning across health systems.Item Why performance-based contracting failed in Uganda: An 'open box' evaluation of a complex health system intervention(Elsevier, 2012-07) Ssengooba, F.; McPake, Barbara; Palmer, N.Performance-based contracting (PBC) is a tool that links rewards to attainment of measurable performance targets. Significant problems remain in the methods used to evaluate this tool. The primary focus of evaluations on the effects of PBC (black-box) and less attention to how these effects arise (open-box) generates suboptimal policy learning. A black-box impact evaluation of PBC pilot by the Development Research Group of the World Bank (DRG) and the Ministry of Health (MOH) concluded that PBC was ineffective.This paper reports a theory-based case study intended to clarify how and why PBC failed to achieve its objectives. To explain the observed PBC implementation and responses of participants, this case study employed two related theories i.e. complex adaptive system and expectancy theory respectively.A prospective study trailed the implementation of PBC (2003-2006) while collecting experiences of participants at district and hospital levels.Significant problems were encountered in the implementation of PBC that reflected its inadequate design. As problems were encountered, hasty adaptations resulted in a . de facto intervention distinct from the one implied at the design stage. For example, inadequate time was allowed for the selection of service targets by the health centres yet they got 'locked-in' to these poor choices. The learning curve and workload among performance auditors weakened the v+alidity of audit results. Above all, financial shortfalls led to delays, short-cuts and uncertainty about the size and payment of bonuses.The lesson for those intending to implement similar interventions is that PBC should not be attempted 'on the cheap'. It requires a plan to boost local institutional and technical capacities of implementers. It also requires careful consideration of the responses of multiple actors - both insiders and outsiders to the intended change process. Given the costs and complexity of PBC implementation, strengthening conventional approaches that are better attuned to low income contexts (financing resource inputs and systems management) remains a viable policy option towards improving health service delivery. 2012 Elsevier Ltd.Item Renaming non-communicable diseases [Letter](2017-07-01) Zou, Guanyang; Decoster, Kristof; McPake, Barbara; Witter, SophieItem Leaving no one behind: Lessons on rebuilding health systems in conflict- and crisis-affected states(BMJ, 2017-07-28) Martineau, Tim; McPake, Barbara; Theobald, Sally; Raven, Joanna; Ensor, Tim; Fustukian, Suzanne; Ssengooba, Freddie; Chirwa, Yotamu; Vong, Sreytouch; Wurie, Haja; Hooton, Nick; Witter, SophieConflict and fragility are increasing in many areas of the world. This context has been referred to as the 'new normal' and affects a billion people. Fragile and conflict-affected states have the worst health indicators and the weakest health systems. This presents a major challenge to achieving universal health coverage. The evidence base for strengthening health systems in these contexts is very weak and hampered by limited research capacity, challenges relating to insecurity and apparent low prioritisation of this area of research by funders. This article reports on findings from a multicountry consortium examining health systems rebuilding post conflict/crisis in Sierra Leone, Zimbabwe, northern Uganda and Cambodia. Across the ReBUILD consortium's interdisciplinary research programme, three cross-cutting themes have emerged through our analytic process: communities, human resources for health and institutions. Understanding the impact of conflict/crisis on the intersecting inequalities faced by households and communities is essential for developing responsive health policies. Health workers demonstrate resilience in conflict/crisis, yet need to be supported post conflict/crisis with appropriate policies related to deployment and incentives that ensure a fair balance across sectors and geographical distribution. Postconflict/crisis contexts are characterised by an influx of multiple players and efforts to support coordination and build strong responsive national and local institutions are critical. The ReBUILD evidence base is starting to fill important knowledge gaps, but further research is needed to support policy makers and practitioners to develop sustainable health systems, without which disadvantaged communities in postconflict and postcrisis contexts will be left behind in efforts to promote universal health coverage.Item Cost-effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya(World Health Organization, 2015-08-03) McPake, Barbara; Edoka, Ijeoma P.; Witter, Sophie; Kielmann, Karina; Taegtmeyer, Miriam; Dieleman, Marjolein; Vaughan, Kelsey; Gama, Elvis; Kok, Maryse; Datiko, Daniel; Otiso, Lillian; Ahmed, Rukhsana; Squires, Neil; Suraratdecha, Chutima; Cometto, GiorgioObjective To assess the cost-effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. Methods Incremental cost-effectiveness ratios for the three programmes were estimated from a government perspective. Cost data were collected for 2012. Life years gained were estimated based on coverage of reproductive, maternal, neonatal and child health services. For Ethiopia and Kenya, estimates of coverage before and after the implementation of the programme were obtained from empirical studies. For Indonesia, coverage of health service interventions was estimated from routine data. We used the Lives Saved Tool to estimate the number of lives saved from changes in reproductive, maternal, neonatal and child health-service coverage. Gross domestic product per capita was used as the reference willingness-to-pay threshold value. Findings The estimated incremental cost per life year gained was 82 international dollars ($)in Kenya, $999 in Ethiopia and $3396 in Indonesia. The results were most sensitive to uncertainty in the estimates of life-years gained. Based on the results of probabilistic sensitivity analysis, there was greater than 80% certainty that each programme was cost-effective. Conclusion Community-based approaches are likely to be cost-effective for delivery of some essential health interventions where community-based practitioners operate within an integrated team supported by the health system. Community-based practitioners may be most appropriate in rural poor communities that have limited access to more qualified health professionals. Further research is required to understand which programmatic design features are critical to effectiveness.Item Ebola in the context of conflict affected states and health systems: Case studies of Northern Uganda and Sierra Leone(BioMed Central, 2015-08) McPake, Barbara; Witter, Sophie; Ssali, S.; Wurie, H.; Namakula, Justine; Ssengooba, F.Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it. The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response. Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone). These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings.Item How do dual practitioners divide their time? The cases of three African capital cities(Elsevier, 2014-10-18) McPake, Barbara; Russo, Giuliano; Tseng, Fu-MinHealth professionals dual practice has received increasing attention, particularly in the context of the universal health coverage movement. This paper explores the determinants of doctors' choices to become a dual practitioner and of dual practitioners' choices to allocate time to the private sector in the capital cities of Mozambique, Guinea Bissau and Cape Verde. The data are drawn from a survey conducted in 2012 among 329 physicians. We use a two-part model to analyse the decision of both public and private practitioners to become dual practitioners, and to allocate time between public and private sectors. We impute potential earnings in public and private practice by using nearest-neighbour propensity score matching. Our results show that hourly wage in the private sector, number of dependents, length of time as a physician, work outside city, and being a specialist with or without technology all have a positive association with the probability of being a dual physician, while number of dependents displays a negative sign. Level of salaries in the public sector are not associated with dual practice engagement, with important implications for attempts aimed at retaining professionals in the public sector through wage increases. As predicted by theory that recognises doctors' role in price setting, earnings rates are not significant predictors of private sector time allocation; personal characteristics of physicians appear more important, such as age, number of dependents, specialist without technology, specialist with technology, and three reasons for not working more hours in the private sector. Answers to questions about the factors that limit working hours in the private sector have significant predictive power, suggesting that type of employment in the private sector may be an underlying determinant of both dual practice engagement and time allocation decisions.Item Pattern recognition in health systems research for panel session: 'How can we achieve scientific rigour in health systems research'?(2009) McPake, Barbara; Blaauw, D.; Sheaff, R.Experimental approaches such as randomised controlled trials have been successful in identifying and testing medical technologies. There is enthusiasm for use of similar approaches for health systems policies and programmes. This enthusiasm is a current manifestation of the attempt to model social science on physical science. It fails to appreciate the social nature of health system intervention where everything depends on how people interpret and implement policy, and users respond to new programmes and services. Health systems research needs to build more effectively on thinking from social science. This paper suggests a model through which to conceptualise the health systems research problem, identifies some methods that are consistent with studying its inherent complexity and shows, using a case study, how this approach can inform policy.Item Two tier issues in low income country health systems.(2009) McPake, BarbaraTwo-tier situations, defined as those in which a single provider offers two services or price discriminates in selling one service are commonplace in low income countries' health systems. Examples include the provision of public and private wards in public hospitals, exemptions, and sliding scale charging systems and health facilities that negotiate separately with multiple third party payers. Analysis of these situations and their outcomes for access, quality of care and equity for health services has under emphasised the importance of the supply side incentives created. These are complex because demands for the services involved are likely to be inter-related with respect to price and quality and a provider cannot alter price or quality levels of one service without considering the implications for the other. A model (previously published) designed to better understand the implications of the offer of more than one quality level in public hospitals suggests that low quality users may not benefit, especially where there are strong inter-relationships between the demands for the two services. Only subsidy levels responding to the utilisation of the low quality service can protect low quality service users, to some extent. The model raises concerns for the implications of exemption policy, informal charging, insurance reform and pharmaceutical pricing. The incentives for providers to reduce quality of services provided to exempted patients have generally not been considered. The role of market structure in ensuring that all demands are catered for in an environment of informal pricing has not been studied. Insurance reforms have taken little account of product differentiation incentives inherent in models designed to produce universal access. Strategies that determine international differences in pharmaceutical prices may be undermined by changes in the economic conditions in high income countries. In each area a number of important areas of further research are suggested. A model of two-tier strategies operating within a public hospital environment suggested that the implications for allocation of resources between the two tiers could be regressive given levels of cross quality and price elasticity between the two services of unknown plausibility (McPake et al., 2007 ). This paper explores the broader implications of the model for the wider range of scenarios crossing public and private sectors, reviewing relevant literature for instances of analytically similar market situations, evidence of cross-price and quality elasticity and analyses of impact in terms of resource allocation. Analytically similar market situations arise in insurance, where alternative packages are offered in competition with each other by the same and competing insurance agencies. Choices made by consumers between alternative insurance packages reveal risk information (Rothschild and Stiglitz, 1976 ). They also reveal consumer preference information in ways that allow insurers to maximise producer (insurer) surplus through price discrimination. Insurers' reactions to the information revealed in both respects have implications for resource allocation and the equity of outcomes. Other analytically similar situations arise in the pricing strategies of not-for-profit providers seeking to manage exemption systems in a manner that aims to cross-subsidise from richer to poorer users and in the 'Ramsay pricing' strategy argued to be operated by the pharmaceutical industry in pricing pharmaceuticals for different national markets. Cross-price elasticities can be inferred from some studies of demand for health services and pharmaceuticals, hence can be identified at some points in relation to level of health service demanded (pharmacy shop, primary, secondary etc.); market structure (more and less competitive), and shares of public and private in total expenditure. However, implications of the pricing strategies of market players, including public sector ones for resource allocation and equity are rarely evaluated except for in the cases of a few public policy areas such as changing basic fee levels in the public sector and to a limited extent with respect to the pharmaceutical pricing debate. This paper argues that there is significant scope to gain better understanding of the scope and strategies for cross-subsidy of poorer health system users by developing better models with wider applicability of inter-dependent demand functions and focusing empirical research on the testing of these models.