International Development

Using Comparative Analysis to Address Health System Caricatures

Using Comparative Analysis to Address Health System Caricatures
International Journal of Health Services; 44(3): 547–559. doi: http://dx.doi.org/10.2190/HS.44.3.g

Gusmano, MK. Rodwin, VG. and Weisz, D.
07/29/2014

To learn from health care systems abroad, we must move beyond simplistic characterizations and compare different systems with respect to salient performance measures. Despite findings from recent cross-national studies suggesting that many health care systems outperform the United States, claims by U.S. public officials often fail to acknowledge the actual accomplishments of health care systems abroad. We document significant variation among the United States and France, Germany, and England, which provide universal coverage, albeit in different ways. As previously documented, the United States has the highest rate of mortality amenable to health care. We extend this work by adding two indicators: (a) access to timely and effective primary care as measured by hospital discharges for avoidable hospital conditions; and (b) use of specialty services as indicated by coronary revascularization (bypass surgery and angioplasty), adjusted for the burden of coronary artery disease. Our findings indicate that: (a) the United States suffers the gravest consequences of financial barriers to primary care; (b) in all four countries, older people (65+) receive fewer revascularizations than their younger counterparts once we account for disease burden; and (c) in France, patients receive the most revascularizations, after adjusting for the burden of disease.

Decentralization in Uganda: Reforms, Reversals, and an Uncertain Future

Decentralization in Uganda: Reforms, Reversals, and an Uncertain Future
In Tyler Dickovich and James Wunsch, eds., Decentralization in Africa: A Comparative Perspective. (Boulder, CO: Lynne Rienner Publishers, 2014).

Smoke, P., W. Muhumuza and E. Ssewankambo
07/25/2014

Uganda was long considered one of the most successful cases of public sector devolution in the developing world. The post-conflict national government began robust empowerment of local governments in the early 1990s. The drive for reform emerged largely from domestic political forces with little involvement of the external donor agencies that have often promoted decentralization in countries with similar development profiles. Two decades after this highly touted reform began, the system has severely deteriorated on almost every aspect by which decentralization is usually judged. This chapter documents the economic, political and social dynamics that led to the rise of decentralization and also laid the foundation for its decline. The chapter concludes by suggesting possible future scenarios for the intergovernmental system in Uganda and drawing potential lessons for other countries considering such bold reforms.

‘Big Push’ To Reduce Maternal Mortality In Uganda And Zambia Enhanced Health Systems But Lacked A Sustainability Plan

‘Big Push’ To Reduce Maternal Mortality In Uganda And Zambia Enhanced Health Systems But Lacked A Sustainability Plan
doi: 10.1377/hlthaff.2013.0637 Health Aff June 2014 vol. 33 no. 6 1058-1066

Margaret E. Kruk, Miriam Rabkin, Karen Ann Grépin, Katherine Austin-Evelyn, Dana Greeson, Tsitsi Beatrice Masvawure, Emma Rose Sacks, Daniel Vail and Sandro Galea
06/01/2014

In the past decade, “big push” global health initiatives financed by international donors have aimed to rapidly reach ambitious health targets in low-income countries. The health system impacts of these efforts are infrequently assessed. Saving Mothers, Giving Life is a global public-private partnership that aims to reduce maternal mortality dramatically in one year in eight districts in Uganda and Zambia. We evaluated the first six to twelve months of the program’s implementation, its ownership by national ministries of health, and its effects on health systems. The project’s impact on maternal mortality is not reported here. We found that the Saving Mothers, Giving Life initiative delivered a large “dose” of intervention quickly by capitalizing on existing US international health assistance platforms, such as the President’s Emergency Plan for AIDS Relief. Early benefits to the broader health system included greater policy attention to maternal and child health, new health care infrastructure, and new models for collaborating with the private sector and communities. However, the rapid pace, external design, and lack of a long-term financing plan hindered integration into the health system and local ownership. Sustaining and scaling up early gains of similar big push initiatives requires longer-term commitments and a clear plan for transition to national control.

The global cancer divide: relationships between national healthcare resources and cancer outcomes in high-income vs. middle- and low-income countries

The global cancer divide: relationships between national healthcare resources and cancer outcomes in high-income vs. middle- and low-income countries
Journal of Epidemiology & Global Health, Vol 4, no. 2, pp. 115-124. DOI: 10.1016/j.jegh.2013.10.004

Batouli, A., P. Jahanshahi, C.P. Gross, D.V. Makarov, and J.B.Yu
06/01/2014

Background: Cancer continues to rise as a contributor to premature death in the developing world. Despite this, little is known about whether cancer outcomes are related to a country’s income level, and what aspects of national healthcare systems are associated with improved cancer outcomes.

Methods: The most recent estimates of cancer incidence and mortality were used to calculate mortality-to-incidence ratio (MIR) for the 85 countries with reliable data. Countries were categorized according to high-income (Gross Domestic Product (GDP) > $15,000) or middle/low-income (GDP < $15,000), and a multivariate linear regression model was used to determine the association between healthcare system indicators and cancer MIR. Indicators study included per capita GDP, overall total healthcare expenditure (THE), THE as a proportion of GDP, total external beam radiotherapy devices (TEBD) per capita, physician density, and the year 2000 WHO healthcare system rankings.

Results: Cancer MIR in high-income countries (0.47) was significantly lower than that of middle/low-income countries (0.64), with a p < 0.001. In high-income countries, GDP, health expenditure and TEBD showed significant inverse correlations with overall cancer MIR. A $3040 increase in GDP (p = 0.004), a $379 increase in THE (p < 0.001), or an increase of 0.59 TEBD per 100,000 population (p = 0.027) were all associated with a 0.01 decrease in cancer MIR. In middle/low-income countries, only WHO scores correlated with decreased cancer MIR (p = 0.022); 12 specific cancer types also showed similar significant correlations (p < 0.05) as overall cancer MIR.

Conclusions: The analysis of this study suggested that cancer MIR is greater in middle/low-income countries. Furthermore, the WHO healthcare score was associated with improved cancer outcomes in middle/low-income countries while absolute levels of financial resources and infrastructure played a more important role in high-income countries.

The Impact of Microcredit on the Poor in Bangladesh: Revisiting the Evidence

The Impact of Microcredit on the Poor in Bangladesh: Revisiting the Evidence
Journal of Development Studies 50 (4), April 2014: 583-604.

David Roodman and Jonathan Morduch
04/01/2014

We replicate and reanalyse the most influential study of microcredit impacts (Pitt and Khandker, 1998). That study was celebrated for showing that microcredit reduces poverty, a much hoped-for possibility (though one not confirmed by recent randomized controlled trials). We show that the original results on poverty reduction disappear after dropping outliers, or when using a robust linear estimator. Using a new program for estimation of mixed process maximum likelihood models, we show how assumptions critical for the original analysis, such as error normality, are contradicted by the data. We conclude that questions about impact cannot be answered in these data.

Is Micro Too Small? Microcredit vs. SME Finance

Is Micro Too Small? Microcredit vs. SME Finance
World Development 43: 288-297. 2013.

Bauchet, Jonathan and Jonathan Morduch
12/15/2013

Microcredit and SME finance are often pitched as alternative strategies to create employment opportunities in low-income communities. So far, though, little is known about how employment patterns compare. We integrate evidence from three surveys to show that, compared to Bangladeshi microcredit customers, typical SME employees in Bangladesh have more education and professional skills, and live in households that are notably less poor. SME jobs also require long work weeks, clashing with family responsibilities. The evidence from Bangladesh rejects the idea that SME finance more efficiently creates jobs for the population currently served by microcredit.

Hospitalization for ambulatory-care sensitive conditions (ACSC) in Île-de-France: A view from across the Atlantic

Hospitalization for ambulatory-care sensitive conditions (ACSC) in Île-de-France: A view from across the Atlantic
Revue française des affaires sociales; 3(3): 108-125.

Rodwin, VG., Gusmano, MK., and Weisz, D.
12/03/2013

This article presents an indicator used in the United States and other OECD nations (hospitalizations for ambulatory-care sensitive conditions – ACSC) to assess access to primary care services and their capacity to handle a set of medical conditions before they require acute hospital treatment. Based on a study of Ile de France, which relies on residence-based hospital discharge data on patient diagnoses and treatments, the indicator identifies areas where hospitalizations for ACSC appear particularly high. Such hospital stays are considered potentially avoidable. Based on data from the Programme de m.dicalisation des syst.mes d’information (PMSI), disparities are measured. We rely on logistic regression analysis to identify a range of individual factors and neighborhood-level factors that explain these disparities. Access to primary care appears to be worse among residents in areas with average household income in the lowest quartile and among those hospitalized in public hospitals. This raises an important question for the future of health policy. Should areas with higher hospital discharge rates of ACSC be understood as having populations with poor health-seeking behaviors or health care systems not well enough organized to target higher-risk populations?

Parallel paths to enforcement: Private compliance, public regulation, and labor standards in the Brazilian sugar sector

Parallel paths to enforcement: Private compliance, public regulation, and labor standards in the Brazilian sugar sector
Politics & Society

Coslovsky, Salo and Richard Locke
09/16/2013

In recent years, global corporations and national governments have been enacting a growing number of codes of conduct and public regulations to combat dangerous and degrading work conditions in global supply chains. At the receiving end of this activity, local producers must contend with multiple regulatory regimes, but it is unclear how these regimes interact and what results, if any, they produce. This paper examines this dynamic in the sugar sector in Brazil. It finds that although private and public agents rarely communicate, let alone coordinate with one another they nevertheless reinforce each other’s actions. Public regulators use their legal powers to outlaw extreme forms of outsourcing. Private auditors use the trust they command as company insiders to instigate a process of workplace transformation that facilitates compliance. Together, their parallel actions block the low road and guide targeted firms to a higher road in which improved labor standards are not only possible but even desirable.

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