•There is little causal evidence of the impact of maternal education on health and child health outcomes in settings with both high fertility and high child mortality rates.•Using age specific ...exposure to educational reforms that greatly increased rates of maternal secondary education in Zimbabwe, we identify causal evidence of the impact of maternal secondary education on child health, health seeking behavior, fertility, and other outcomes.•We find that an additional year of maternal secondary education is associated with a large decline (21% decline) in child mortality.•Evidence suggests that increased education leads to improved health outcomes by primarily influencing fertility and economic outcomes.•Expanding access to secondary education may greatly accelerates rates of child mortality in the developing world today.
In 1980, Zimbabwe rapidly expanded access to secondary schools, providing a natural experiment to estimate the impact of increased maternal secondary education on child mortality. Exploiting age specific exposure to these reforms, we find that children born to mothers most likely to have benefited from the policies were about 21% less likely to die than children born to slightly older mothers. We also find that increased education leads to delayed age at marriage, sexual debut, and first birth and that increased education leads to better economic opportunities for women. We find little evidence supporting other channels through which increased education might affect child mortality. Expanding access to secondary schools may greatly accelerate declines in child mortality in the developing world today.
Coordinated action among states in an interconnected world underpins effective prevention, detection, and control of disease outbreaks across countries.5 As parties to the IHR, governments agree that ...coordination is important to ensure that measures do not unnecessarily disrupt international trade and travel. ...during major disease outbreaks, part of WHO's role is to provide evidence-informed guidance on cross-border measures. ...the impacts of cross-border measures are not well understood. ...beyond public health rationales, explanations for why governments adopt travel restrictions are largely limited to economic interests and political pressure to “do something”.
Despite high overall COVID-19 vaccine coverage, the continuously low elderly vaccination rate in mainland China remains a dangerous threat as the country shifts away from its zero-Covid policy. This ...retrospective study uses the Multiple Streams Framework to examine how macro-level factors may explain poor elderly vaccination outcomes. We performed a thematic analysis of qualitative data obtained from 95 official press conferences from October 20, 2020, to February 27, 2023, vaccination-related policy documents, and media coverage, using both inductive and deductive coding approaches. Our findings suggest that in the problem stream, elderly vaccination was not a "focusing event" during the initial vaccine rollout, resulting in delayed outreach to this population. Additionally, ideologically driven complacency and discrepancies in top-down implementation undermined elderly vaccination in the political stream. In the policy stream, precautious and ambiguous statements, inconsistent policy content, radical shifting media messages, and less age-friendly digital technologies also affected elderly vaccination. The poor convergence of the three streams led the elderly to be the Achilles' heel of China's COVID-19 containment strategy. Future studies should focus on priority identification, adoption of enforcement measures, and timely and effective policy dissemination. The empirical lessons from China can inform and optimize elderly vaccination policy design and implementation in the post-pandemic era.
•Full vouchers and conditional cash transfers were highly effective at increasing institutional deliveries among poor, rural women in Kenya.•Co-payments reduced the effectiveness of vouchers and ...unconditional transport subsidies were not effective.•A free care policy instituted by the government also demonstrated no effect on institutional deliveries.•SMS text reminders did not have any effect on institutional deliveries.
We conducted a randomized controlled experiment to test whether vouchers, cash transfers, and SMS messages were effective in boosting facility delivery rates among poor, pregnant women in rural Kenya. We find a strong effect of the full vouchers and the conditional cash transfers: 48% of women with access to both interventions delivered in a health facility, while only 36% of those with neither did. Amongst women who did not receive a cash transfer, we find that a small copayment dramatically reduced voucher effectiveness, suggesting a discontinuous impact of cost-sharing on the demand for health services. Both the unconditional cash transfer and the text messages had limited effect on the use of health services. Finally, we also find no evidence that a government policy to eliminate user fees increased demand for maternal health services.
Monitoring progress towards the Sustainable Development Goals by 2030 requires the global community to disaggregate targets along socio-economic lines, but little has been published critically ...analyzing the appropriateness of wealth indices to measure socioeconomic status in low- and middle-income countries. This critical interpretive synthesis analyzes the appropriateness of wealth indices for measuring social health inequalities and provides an overview of alternative methods to calculate wealth indices using data captured in standardized household surveys. Our aggregation of all published associations of wealth indices indicates a mean Spearman’s rho of 0.42 and 0.55 with income and consumption, respectively. Context-specific factors such as country development level may affect the concordance of health and educational outcomes with wealth indices and urban–rural disparities can be more pronounced using wealth indices compared to income or consumption. Synthesis of potential future uses of wealth indices suggests that it is possible to quantify wealth inequality using household assets, that the index can be used to study SES across national boundaries, and that technological innovations may soon change how asset wealth is measured. Finally, a review of alternative approaches to constructing household asset indices suggests lack of evidence of superiority for count measures, item response theory, and Mokken scale analysis, but points to evidence-based advantages for multiple correspondence analysis, polychoric PCA and predicted income. In sum, wealth indices are an equally valid, but distinct measure of household SES from income and consumption measures, and more research is needed into their potential applications for international health inequality measurement.
There is debate about the role of the private sector in providing services in the health systems of low- and middle-income countries and about how the private sector could help achieve the goal of ...universal health coverage. Yet the role that the private sector plays in the delivery of health services is poorly understood. Using data for the period 1990-2013 from 205 Demographic and Health Surveys in seventy low- and middle-income countries, I analyzed the use of the private sector for the treatment of diarrhea and of fever or cough in children, for antenatal care, for institutional deliveries, and as a source of modern contraception for women. I found that private providers were the dominant source of treatment for childhood illnesses but not for the other services. I also found no evidence of increased use of the private sector over time. There is tremendous variation in use of the private sector across countries and health services. Urban and wealthier women disproportionately use the private sector, compared to rural and poorer women. The private sector plays an important role in providing coverage, but strategies to further engage the sector, if they are to be effective, will need to take into consideration the variation in its use.
Despite recent progress in improving access to maternal health services, the utilization of these services remains inequitable among women in developing countries, and rural women are particularly ...disadvantaged. This study sought to measure i) disparities in the rates of institutional births between rural and urban women in Ghana, ii) the extent to which existing disparities are due to differences in the distribution of the determinants of institutional delivery between rural and urban women, and iii) the extent to which existing disparities are due to discrimination in resource availability.
Using Demographic and Health Survey data from 2003, 2008, and 2014, this study decomposed inequalities in institutional delivery rates among urban and rural Ghanaian woman using the Oaxaca, the Blinder, and related decompositions for non-linear models. The determinants of the observed inequalities were also analyzed.
Institutional delivery rates in urban areas exceeded those of rural areas by 32.4 percentage points due to differences in distribution of the determinants of institutional delivery between the two areas. The main determinants driving the observed disparities were wealth, which contributed to about 16.1% of the gap, followed by education level, and number of antenatal visits.
Relative to urban women, rural women have lower rates of institutional deliveries due primarily to lower levels of wealth, which results in financial barriers in accessing maternal health services. Economic empowerment of rural women is crucial in order to close the gap in institutional delivery between urban and rural women.
To test the impact of a nationwide Long-Lasting Insecticidal Nets LLINs distribution program in the Democratic Republic of Congo DRC on all-cause under-five child mortality exploiting subnational ...variation in malaria endemicity and the timing in the scale-up of the program across provinces.
Geospatial Impact Evaluation using a difference-in-differences approach.
Democratic Republic of the Congo.
52,656 children sampled in the 2007 and 2013/2014 DRC Demographic and Health Surveys.
The analysis provides plausibly causal estimates of both average treatment effects of the LLIN distribution campaign and geospatial heterogeneity in these effects based on malaria endemicity. It compares the under-five, all-cause mortality for children pre- and post-LLIN campaign relative to children in those areas that had not yet been exposed to the campaign using a difference-in-differences model and controlling for year- and province-fixed effects, and province-level trends in mortality.
We find that the campaign led to a 41% decline 3.7 percentage points, 95% CI 1.3 to 6.0 in under-5 mortality risk among children living in rural areas with malaria ecology above the sample median. Results were robust to controlling for household assets and the presence of other health aid programs. No effect was detected in children living in areas with malaria ecology below the median.
The findings of this paper make important contributions to the evidence base for the effectiveness of large scale-national LLIN campaigns against malaria. We found that the program was effective in areas of the DRC with the highest underlying risk of malaria. Targeting bednets to areas with greatest underlying risk for malaria may help to increase the efficiency of increasingly limited malaria resources but should be balanced against other malaria control concerns.
Random digit dial surveys with mobile phones risk under-representation of women. To address this, we compare the characteristics of women recruited directly with those of women recruited through ...referrals from male household members. The referral process improves representation of vulnerable groups, such as young women, the asset poor, and those living in areas with low connectivity. Among mobile phone users, we show a referral (rather than a direct dial) protocol includes more nationally representative proportions of women with these attributes. While seeking intra-household referrals may improve representation, we show that it does so at a higher cost.
•Passing the phone in RDD surveys improves representation of women.•Referrals reach more youth, the asset poor, and those living in low connectivity.•Costs affect scalability of referrals given low completion rates.
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