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  • Author: Abhijit Banerjee, Amy Finkelstein, Rema Hanna, Benjamin A. Olken, Arianna Ornaghi, Sudarno Sumarto
  • Publication Date: 10-2019
  • Content Type: Working Paper
  • Institution: The John F. Kennedy School of Government at Harvard University
  • Abstract: To assess ways to achieve widespread health insurance coverage with financial solvency in developing countries, we designed a randomized experiment involving almost 6,000 households in Indonesia who are subject to a nationally mandated government health insurance program. We assessed several interventions that simple theory and prior evidence suggest could increase coverage and reduce adverse selection: substantial temporary price subsidies (which had to be activated within a limited time window and lasted for only a year), assisted registration, and information. Both temporary subsidies and assisted registration increased initial enrollment. Temporary subsidies attracted lower-cost enrollees, in part by eliminating the practice observed in the no subsidy group of strategically timing coverage for a few months during health emergencies. As a result, while subsidies were in effect, they increased coverage more than eightfold, at no higher unit cost; even after the subsidies ended, coverage remained twice as high, again at no higher unit cost. However, the most intensive (and effective) intervention – assisted registration and a full one-year subsidy – resulted in only a 30 percent initial enrollment rate, underscoring the challenges to achieving widespread coverage.
  • Topic: Government, Health, Health Care Policy, Economy
  • Political Geography: Indonesia, Southeast Asia
  • Author: Katherine Baicker, Theodore Svoronos
  • Publication Date: 07-2019
  • Content Type: Working Paper
  • Institution: The John F. Kennedy School of Government at Harvard University
  • Abstract: Given the complex relationships between patients’ demographics, underlying health needs, and outcomes, establishing the causal effects of health policy and delivery interventions on health outcomes is often empirically challenging. The single interrupted time series (SITS) design has become a popular evaluation method in contexts where a randomized controlled trial is not feasible. In this paper, we formalize the structure and assumptions underlying the single ITS design and show that it is significantly more vulnerable to confounding than is often acknowledged and, as a result, can produce misleading results. We illustrate this empirically using the Oregon Health Insurance Experiment, showing that an evaluation using a single interrupted time series design instead of the randomized controlled trial would have produced large and statistically significant results of the wrong sign. We discuss the pitfalls of the SITS design, and suggest circumstances in which it is and is not likely to be reliable.
  • Topic: Health, Governance, Health Care Policy
  • Political Geography: North America, United States of America
  • Author: Jean Arkedis, Jessica Creighton, Archon Fung, Stephen Kosack, Dan Levy, Courtney Tolmie
  • Publication Date: 05-2019
  • Content Type: Working Paper
  • Institution: The John F. Kennedy School of Government at Harvard University
  • Abstract: We assess the impact of a transparency and accountability program designed to improve maternal and newborn health (MNH) outcomes in Indonesia and Tanzania. Co-designed with local partner organizations to be community-led and non-prescriptive, the program sought to encourage community participation to address local barriers in access to high quality care for pregnant women and infants. We evaluate the impact of this program through randomized controlled trials (RCTs), involving 100 treatment and 100 control communities in each country. We find that on average, this program did not have a statistically significant impact on the use or content of maternal and newborn health services, nor the sense of civic efficacy or civic participation among recent mothers in the communities who were offered it. These findings hold in both countries and in a set of prespecified subgroups. To identify reasons for the lack of impacts, we use a mixed-method approach combining interviews, observations, surveys, focus groups, and ethnographic studies that together provide an in-depth assessment of the complex causal paths linking participation in the program to improvements in MNH outcomes. Although participation in program meetings was substantial and sustained in most communities, and most attempted at least some of what they had planned, only a minority achieved tangible improvements and fewer still saw more than one such success. Our assessment is that the main explanation for the lack of impact is that few communities were able to traverse the complex causal paths from planning actions to accomplishing tangible improvements in their access to quality health care.
  • Topic: Health, Health Care Policy, Children, Randomized Controlled Trials
  • Political Geography: Africa, Indonesia, Tanzania, Southeast Asia
  • Author: Michael Woolcock
  • Publication Date: 02-2018
  • Content Type: Working Paper
  • Institution: The John F. Kennedy School of Government at Harvard University
  • Abstract: In rich and poor countries alike, a core challenge is building the state’s capability for policy implementation. Delivering high-quality public health and health care – affordably, reliably, at scale, for all – exemplifies this challenge, since doing so requires deftly integrating refined technical skills (surgery), broad logistics management (supply chains, facilities maintenance), adaptive problem solving (curative care) and resolving ideological differences (who pays? who provides?), even as the prevailing health problems themselves only become more diverse, complex and expensive as countries become more prosperous. The current state of state capability in developing countries, however, is demonstrably alarming, with the strains and demands only likely to intensify in the coming decades. Prevailing ‘best practice’ strategies for building implementation capability – copying and scaling putative successes from abroad – are too often part of the problem, while individual training (‘capacity building’) and technological upgrades (e.g., new management information systems) remain necessary but deeply insufficient. An alternative approach is outlined, one centered on building implementation capability by working iteratively to solve problems nominated and prioritized by local actors.
  • Topic: Health, Developing World, State, Public Policy, Policy Implementation
  • Political Geography: Global Focus
  • Author: Shireen Al-Adeim
  • Publication Date: 01-2017
  • Content Type: Journal Article
  • Journal: Harvard Journal of Middle Eastern Politics and Policy
  • Institution: The John F. Kennedy School of Government at Harvard University
  • Abstract: This is the second of a three-part series of essays on Yemen highlighting the magnitude and impact of the civil war on Yemenis. Starting in March 2015, Saudi Arabia led a coalition of several Arab countries in bombing Yemen, its neighbor to the south. The coalition’s indiscriminate bombing has targeted countless homes, schools, markets, and even hospitals. Yemenis have become accustomed to double-tap and triple-tap strikes that target rescuers after an attack. One notable case was a double-tap strike that killed at least 140 mourners at a large funeral home in Sana’a, Yemen’s capital. The number of deaths resulting from US/Saudi airstrikes and fighting between Saudi-allied and Saleh/Houthi-allied forces has been conservatively estimated at 10,000 deaths and 40,000 injuries. The hidden costs of war, however, are much greater.
  • Topic: Health, Poverty, War, International Affairs
  • Political Geography: Middle East, Yemen, Saudi Arabia, North America, United States of America, Gulf Nations
  • Author: Seema Jayachandran, Rohini Pande
  • Publication Date: 04-2015
  • Content Type: Working Paper
  • Institution: The John F. Kennedy School of Government at Harvard University
  • Abstract: India's child stunting rate is among the highest in the world, exceeding that of many poorer African countries. In this paper, we analyze data for over 174,000 Indian and Sub-Saharan African children to show that Indian firstborns are taller than African firstborns; the Indian height disadvantage emerges with the second child and then increases with birth order. This pattern persists when we compare height between siblings, and also holds for health inputs such as vaccinations. Three patterns in the data indicate that India's culture of eldest son preference plays a key role in explaining the steeper birth order gradient among Indian children and, consequently, the overall height deficit. First, the Indian firstborn height advantage only exists for sons. Second, an Indian son with an older sibling is taller than his African counterpart if and only if he is the eldest son. Third, the India-Africa height deficit is largest for daughters with no older brothers, which reflects that fact that their families are those most likely to exceed their desired fertility in order to have a son.
  • Topic: Health, Poverty, Children, International Development
  • Political Geography: Africa, South Asia, India