Great idea…but will it save lives?

On July 25, 2011, in Uncategorized, by Karen Grepin

I am on my way down to DC to attend the Saving Lives at Birth Development Expo and Exchange. I am part of a research team that is a finalist for one of the integrated grants. Our partner, Changamka, is an impressive organization that has developed microsaving products to enable people to save money for health services to use when they need it. In addition, they are currently developing a mobile phone enabled version of their product specifically for pregnant women to help pay for maternity services, including antenatal, delivery, and postnatal care: mhealth meets microfinance!

You can find out more about Changamka by watching this moving video, which was produced by Al Jezeera:

Seems like a great idea, right? I think so, but of course, we won’t actually know until the program is properly evaluated. There have been many great and noble attempts to reduce financial barriers to maternity services. In fact, introducing voucher programs or user fee exemptions have become extremely popular across sub-Saharan African countries to expand access to maternal and child health programs.

Despite all of the fan fare that these programs have received (including this piece in the NYTimes last week chronicling the experience of Sierra Leone) it is not clear if we really know if these programs really work and under which conditions. Most of the programs have not been evaluated. Even if we do believe that they are effective, given that they are hugely expensive programs, it would also be good to know if they generate enough impact to justify the resources expended on them. These are all things that we believe we will be able to better understand with our proposed project.

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The masterful marketers at the Gates Foundation have put the following video together to raise the profile with what is probably one of the most important and least sexy issues in global health – how to get billions of people to poop in the right place. Their idea: the world needs a need toilet that is better suited to resource constrained environments – in their words the Toilet 2.0.

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A couple of months back, you may have seen some publicity for an exciting new grant program launched by USAID, the Gates Foundation, Norway, Grand Challenges Canada, and the World Bank called “Saving Lives at Birth” – a Grand Challenges program to find and scale-up innovative solutions to reducing both child and maternal mortality in low income countries.

Stop for one minute and think about it: if you could do something tomorrow, what would you do to save the lives the millions of children and women who die during childbirth?

Well if you can’t decide yourself, you can share your views on what others think might work. There were over 600 applications to this program and from the initial list of applications, 77 projects have made it to the final round. Some of the projects have been submitted for smaller proof of concept grants while others have been submitted for larger integrated solutions that can be brought to scale and evaluated for impact. The organizers are asking for your opinion – which of these programs would you support? Next week in DC there will be a Development Expo where the finalists will be displaying their ideas. Projects with the most votes are eligible to win a people’s choice award.

Full disclosure: while I wanted to help get word out about this program, I also wanted to let you know about some of the work I’ve been doing the past few months. I am part of a team that was selected among the finalists for this program. Working with an amazing health microfinance organization in Kenya – called Changamka – and some economists from Georgetown, we are proposing the development of an e-voucher that can be deployed by mobile phones in rural areas of Kenya that will subsidize the costs of maternity services. In addition, we are also proposing a series of informational interventions, which we believe can be cost-effective means of increasing demand. Most innovatively, we are also proposing the development of a crowd-sourced application that allows users to share information on the quality of health services received. And we have developed a plan to rigorously evaluate it to see what really works and why. If you like our ideas, I can promise you a free subscription to my blog for life. :) Go vote – and vote often!

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I wanted to bring to your attention another special supplement that I think will be of interest to many readers of this blog. Sponsored by ICAP, the Journal of Acquired Immune Deficiency Syndromes has released a special supplement on the topic of HIV and Health Systems.

As you all know the scale up of HIV programs in low-income settings has been unprecedented in global health and by most metrics incredibly successful. While others, including myself, have wondered if the ends have really justified the means. There are no easy answers to these questions and so the debate continues, many of the articles in the supplement further this debate. All of the articles are available to readers free of charge.

The success of the HIV programs has lead many to wonder whether these investments should be used to begin to deliver a broader package of health services. Many of the articles talk about the prospects of integration of other health services, especially non-communicable disease services, through existing HIV infrastructure. I have an article in this supplement where I caution against moving forward with these well intentioned efforts without fully considering the potential trade-offs.

The supplement will be officially launched this upcoming weekend a special pre-IAS conference meeting on HIV and Non-Communicable Diseases. Sadly, I won’t be able to attend, but I am looking forward to getting updates on the debates.

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As a follow-on to my post yesterday, I also wanted to link to a special supplement of Health Policy and Planning that was released last week that contains more research articles on the role of the private health care sector in various international contexts.

I particularly enjoyed the review of the role of the private sector in the delivery of vaccinations in low income countries, an activity that I have always ascribed exclusively to the public sector. I think this further emphasizes the point I tried to make yesterday: that efforts to improve health in low income countries need to be aware the role the private sector is playing and needs to engage them as appropriate.

Here is a list of the articles, all of which are free to download (Kudos HPP), contained in this supplement. Happy Reading!

B C Forsberg, D Montagu, and J Sundewall: Moving towards in-depth knowledge on the private health sector in low- and middle-income countries

Ann Levin and Miloud Kaddar: Role of the private sector in the provision of immunization services in low- and middle-income countries

Anna Heard, Maya Kant Awasthi, Jabir Ali, Neena Shukla, and Birger C Forsberg: Predicting performance in contracting of basic health care to NGOs: experience from large-scale contracting in Uttar Pradesh, India

Sachiko Ozawa and Damian G Walker: Comparison of trust in public vs private health care providers in rural Cambodia

Bruno Meessen, Maryam Bigdeli, Kannarath Chheng, Kristof Decoster, Por Ir, Chean Men, and Wim Van Damme: Composition of pluralistic health systems: how much can we learn from household surveys? An exploration in Cambodia

Gerald Bloom, Hilary Standing, Henry Lucas, Abbas Bhuiya, Oladimeji Oladepo, and David H Peters: Making health markets work better for poor people: the case of informal providers

Ha Nguyen: The principal-agent problems in health care: evidence from prescribing patterns of private providers in Vietnam

Nirali M Shah, Wenjuan Wang, and David M Bishai: Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?

Sara Sulzbach, Susna De, and Wenjuan Wang: The private sector role in HIV/AIDS in the context of an expanded global response: expenditure trends in five sub-Saharan African countries

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I am currently in Toronto, Canada where I am attending the biannual International Heath Economics Association conference. It has so far been two very full and engaging days of running from session to session and catching up with colleagues and friends from around the world.

A few days before the conference, I also attending a special one day session on the role of the Private Sector in Health. What was clear from attending these sessions is that the private sector is currently playing an important role in health service delivery in most developing countries and therefore any health system intervention aimed at improving health service delivery must at least figure out how to engage with this important part of the sector.

The conference was a research conference so there were papers presented on what do we know about this sector, how is it changing, and experiences some actors have had working within or with the private sector. The powerpoint presentations from this conference, including one by a particular blogger who knows very little about this topic, have been uploaded here and are available to all to view.

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Last week, I attended a conference in Rabat entitled “Reducing Maternal Mortality in Morocco: Sharing Experiences and Sustaining Progress”. Morocco is one of the few developing countries that can legitimately argue that it is on track to achieve MDG5 – a three quarters reduction in maternal mortality from 1990 to 2015 – so I was very excited to get first hand knowledge of what I could learn from the Moroccan experience that could then be generalized to other countries.

In the early 1990s, the maternal mortality ratio (MMR) in Morocco was estimated in the vicinity of 330. According to the most estimates, the MMR in Morocco is now around 112 – which means that they have reduced their MMR by a whopping 60%! Much of the reduction has actually taken place during the past 5-7 years, coinciding with intensified efforts on the part of the government to reduce MMR. Given its trajectory, many people think that it will be able to go the rest of the way and actually achieve MDG5.

At this point I am sure a lot of you are thinking about measurement and data issues and whether or not we can actually say that Morocco has reduced its maternal mortality. This is a valid concern (and one which will plague all assessments of performance against MDG5) but all of the currently available sources of data on the MMR in Morocco seem to suggest that real declines have occurred: the UN Intra-Agency estimates, the IHME estimates (i.e. Hogan et al. 2010), and Morocco’s own estimate all point to similar trends.

So how did Morocco do it? After decades of incremental efforts there was a big shift in priority given to maternal mortality in 2008 when the government launched the ambitious strategy for accelerating reduction in maternal and child health (PARMMI). The strategy involves three major components: addressing physician and financial barriers, improving quality of care, and improving the management of governance of the programs themselves.

The government implemented just about every programmatic activity that has ever been thought to be effective using a “whole-of health-systems” approach: making obstetric care free, rolling out ambulances, training of health workers, increasing the number and distribution of health workers, implementing a mobile phone enable monitoring system, launching efforts to improve service quality, increasing awareness of the issues, and dramatically strengthening the information base available to the government to monitor progress. This last point also included a very intensive effort to track and audit all maternal deaths – a system one international expert called the “Cadillac” national maternal mortality surveillance system. They did it all and they did it quickly and effectively using resources from mainly the government but also from their development partners.

Given the number of interventions that were simultaneously launched it is difficult to tease out exactly what work, when, for whom, and why. The academic in me me wished there had been more evaluation of their experience and was left really wondering which interventions had been the most effective and why — but we we may never know.

But I did not leave the country disappointed as in the end I did learn why Morocco was able to achieve such a miraculous decline in maternal mortality: strong political commitment. During the conference the Minister of Health, a young woman not too much older than myself, stated that maternal mortality was the most important priority that her Ministry was attempting to address. So much so that victory for her was not achieving MDG5 but rather achieving an even lower MMR that she felt was more appropriate to their level of development. What sets Morocco apart from many other developing countries is the extent to which they have placed maternal mortality on the top of their list of priorities and have exerted significant effort and allocated substantial resources towards the issue. For maternal mortality, it seems that if there is a will, then there is a way.

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In health economics circles, the word Oregon usually has a negative association – it was the site of one of the greatest health economics failures when it tried to making reimbursement decisions according to strict cost-effectiveness criteria. But all that is about to change. Preliminary estimates of what may prove to be the most important study of the impact of health insurance – at least among low-income populations – on outcomes were released this week from a group of researchers from the NBER, Harvard, and MIT (the NBER working paper is here). I first heard about this study a few years ago and I have been eagerly awaiting the results ever since.

Back in 2008, Oregon had a long waiting list of low-income adults wanting to enroll in its state Medicaid program. Given severely constrained resources it was not able to provide insurance to everyone who wanted it, so it decided to allocate eligibility to enroll into the program by lottery – it randomly assigned insurance eligibility – creating one of the most incredible opportunities to study the impact of health insurance. Period.

Although there have literally been thousands of studies that have compared outcomes between people with insurance and people without almost all of these studies suffer from selection problems: when enrollment is voluntary, people who have insurance are different than those that do not. Finding opportunities to study health insurance is therefore challenging.

One year after the randomization, the authors find:

Being selected through the lottery is associated with a 25 percentage point increase in the probability of having insurance during our study period. This net increase in insurance appears to come entirely through a gross increase in Medicaid coverage, with little evidence of crowd-out of private insurance. Using lottery selection as an instrument for insurance coverage, we find that insurance coverage is associated with a 2.1 percentage point (30 percent) increase in the probability of having a hospital admission, an 8.8 percentage point (15 percent) increase in the probability of taking any prescription drugs, and a 21 percentage point (35 percent) increase in the probability of having an outpatient visit; we are unable to reject the null of no change in emergency room utilization, although the point estimates suggest that such use may have increased. In addition, insurance is associated with three-tenths of a standard deviation increase in reported compliance with recommended preventive care such as mammograms and cholesterol monitoring. Insurance also results in decreased exposure to medical liabilities and out-of-pocket medical expenses, including a 6.4 percentage point (25 percent) decline in the probability of having an unpaid medical bill sent to a collection agency and a 20 percentage point (35 percent) decline in having any out-of-pocket medical expenditures.

So health insurance seems to increase the use of services – notably of both preventive and treatment services – and seems to increase financial risk protection (arguably the main purpose of health insurance). In addition, they find:

Finally, we find that insurance is associated with improvements across the board in our measures of self-reported physical and mental health, averaging two-tenths of a standard deviation improvement. These results appear to reflect improvements in mental health and also at least partly a general sense of improved well being; they may also reflect improvements in objective, physical health, but this is more difficult to determine with the data we now have available.

These early findings thus provide some pretty convincing evidence that – at least among a low-income uninsured population who has expressed interest in having health insurance – the Oregon Medicaid program has provided important health and non-health benefits to those who enroll. Of course the strict generalizability of these findings to other contexts might be somewhat limited in terms of the populations it targeted, the program design in Oregon, and the environment in which it was given – but in many ways many governments are grappling with issues about how to specifically address similar kinds of populations so the findings are likely relevant elsewhere as well.

I was recently talking to a colleague about the impact of user-fees on outcomes and he mentioned that politically it would never be feasible to run an experiment that randomly assigned different user-fee regimes in populations. But I think this experiment is further evidence that you can – and perhaps should – as not only does it allow for amazing research opportunities such as this but it might also be a more fair way to allocate limited resources.

These preliminary results are from one year after the randomization. I am eagerly awaiting the more medium term impact results as well.

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A new study has provided evidence that a drug that is currently being deployed in countless villages across Sub-Saharan Africa might actually be effective at reducing the transmission of malaria. The drug, ivermectin, has been a powerful tool in the global health armory for many years as the drug of choice in the mass drug administration (MDA) programs against onchocerciasis – or Riverblindess. Working off a hunch, the investigators spent a year sucking mosquitoes out of households in rural Senegal to see what impact ivermectin – notably delivered as part of the regular MDA programs – had upon the transmission of malaria in mosquitoes. Lo and behold they found a relatively large reduction in the prevalence of the malaria parasite in mosquitoes in the ivermectin treated villages and the effect seems to last a few weeks.

Courtesy of Brian Foy/Kevin Kobylinski

Of course no one thinks that this is going to be a silver bullet in the fight against malaria, however, there are a number of remarkable aspects of this finding which are relevant to malaria control programs. First, this is a drug that is cheap and has been widely used across the continent. Literally billions of tablets have been distributed over the years since Merck and the Onchocerciasis Control Program/African Programme on Onchocerciasis Control began distributing the drug. In addition, APOC has also spent many years building up infrastructure – a vast network of community based drug distributors – to help get these drugs to some of the most remote villages on the planet on a shoe string budget. The use of ivermectin in malaria control programs could begin with little new investment.

Courtesy of Brian Foy/Kevin Kobylinski

Second, the drug seems to specifically target the mosquitoes that are biting humans, which might be a useful way of specifically targeting the mosquitoes that transmit malaria. Right now most people only receive ivermectin once or twice a year and this would have to be scaled up for this to become a useful treatment against malaria. The strategy might become a useful complementary tool in areas that have high seasonal spikes in transmission (by the way, there is also evidence that ivermectin can interrupt transmission of onchocerciasis as well).

What should also be said here is that this work had been supported by a Gates Grand Challenges Explorations project – you know those high-risk high-reward funding programs that the Gates Foundation has been touting the past few years. Anyone can apply, the application process is easy, and it is meant to support bold and innovative ideas. The photos that have accompanied the press release for this study shows two very young researchers from Colorado – Brian Foy and Kevin Kobylinski (with a Canadian T-shirt no less) – hard at work aspirating mosquitoes. I don’t know the guys – and although I am sure they are brilliant – but as another junior researcher I know how hard it is to get funding to support early stage work. These guys appear to be exactly the kind of people – with exactly the kind of crazy ideas – that this program was meant to support. So hats off to the Foundation for helping to support this work.

Courtesy of Brian Foy/Kevin Kobylinski

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My return trip from Morocco to the United States last Friday began with an hour and a half road trip from my hotel in Rabat to the airport in Casablanca. Once outside of the old city of Rabat the trip it was an easy drive on a modern highway all the way to the airport.

I have family in France and I was struck by how similar the roads were to those I am accustomed to in the South of France: they use the same signs, albeit with arabic writing, the same “Aires de Repos” and restaurants, the same “peage” booths and the same speed limits. A photograph of these road might easily be mistaken for the highway between Aix and Nice, including the high concentration of brand new Renaults and Citroens on the roads.

Except of course for the enormous differences in the way in which these roads are used: nobody respects the speed limits, cars weave insanely in and out of the lanes, it is common practice to drive with the lane markers down the middle of the car, cars drive inches apart from one another, and I even witnessed dozens of pedestrians, including a woman with a child on her back, making sprints to try to cross the road. My driver talked incessantly on his cell phone while modern arabic music blasted on the radio. At one point I let out a loud “Monsieur!!” as my driver attempted to pass another car in a single merge lane. No…this was not a leisurely drive across the South of France….this was definitely road travel in a developing country.

Last week the CDC distributed a list of the top 10 achievements in global public health. Listed down near the bottom was: Increased Awareness and Response for Improving Global Road Safety. I could not agree more with this being on the list, although I probably would have placed it a bit higher on the list. Some of the evidence they provide to justify this item was:

…From 2001 to 2009, the number of annual traffic-related deaths in the European Union declined 36%, from 55,700 to 34,900. The largest declines in the traffic-related mortality rates from 2000 to 2009 were observed in Spain and Portugal; rates decreased 59.2% in Spain, from 14.5 deaths per 100,000 population to 5.9, and 47% in Portugal, from 12.9 deaths per 100,000 to 6.8.

I still find it remarkable that road traffic safety and injury control continues to receive so little attention from health ministries around the world, this despite the fact that it kills over a million people each and every year, seriously injures millions more, and is completely visible to just about everyone — it was a Ministry of Health driver from Morocco in a Ministry of Health car who drove me to the airport!

The road traffic safety improvements mentioned above, plus those that have also occurred in France, were due to concerted effort from government to reduce the burden of disease from this condition – sometimes just by enforcing road traffic rules that were already on the books. Let these international experiences should be a lesson to others – road traffic injuries can be addressed through effective public health policies.

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