Global Health research

Financing Global Health

Researchers: Philipa Mladovsky and Maymouna Bâ
Date: 2017
Region: Africa
Publication details: Social Science and Medicine, 188. pp. 91-99. ISSN 0277-9536
LSE department: Department of International Development & LSE Health
Keywords: Healthservices, Affordability, Senegal, Health Inequity

Plan Sésame (PS) is a user fee exemption policy launched in 2006 to provide free access to health services to Senegalese citizens aged 60 and over. However, analysis of a household survey evaluating PS echoes findings of other studies showing that user fee removal can be highly inequitable. 34 semi-structured interviews and 19 focus group discussions with people aged 60 and over were conducted in four regions in Senegal (Dakar, Diourbel, Matam and Tambacounda) over a period of six months during 2012. They were analysed to identify underlying causes of exclusion from/inclusion in PS. These point to three steps at which exclusion occurs: (i) not being informed about PS; (ii) not perceiving a need to use health services under PS; and (iii) inability to access health services under PS, despite having the information and perceived need.

This study identifies lay explanations for exclusion at these different steps. Some lay explanations point to social exclusion, defined as unequal power relations; poor access to PS was seen to be caused by corruption, patronage, poverty, lack of social support, internalised discrimination and adverse incorporation. Other lay explanations do not point to social exclusion, for example: poor implementation; inadequate funding; high population demand; incompetent bureaucracy; and PS as a favour or moral obligation to friends or family. Within a critical realist paradigm, the study interprets these lay explanations as empirical evidence for the presence of the following hidden underlying causal mechanisms: lacking capabilities; mobilisation of institutional bias; and social closure. However, social constructionist perspectives leads the investigators to critique this paradigm by drawing attention to contested health, wellbeing and corruption discourses. These differences in interpretation lead to subsequent differential policy recommendations. This demonstrates the need for the adoption of a “multi-epistemological” perspective in studies of health inequity and social exclusion.

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Reasearchers: Dr. Clare Wenham & Dr. Justin Parkhurst
Date:2018
Region: Africa
LSE Department/Centre: Department of Health Policy
Keywords: Africa, Health Sciences, Health Systems Research, CARI

LSE Health researchers have been commissioned by the Wellcome Trust to lead a project to understand and improve investment mechanisms for health sciences research in Africa. Significant investment in health sciences research across the continent remains low, and this project will investigate a range of case studies to identify good practice and local challenges to improve health research outputs in Africa. The aim is to draw lessons of how to develop health sciences research effectively, such as: how best to implement initial investments (for example whether to focus on infrastructure, human resource development, or other priorities); or how to incentivise greater investment in health sciences research. It will further explore conditions in place in a range of country cases that appear to facilitate the development of health science research. Finally, to build capacity itself, and achieve greater local ownership, the project will engage with leading policymakers to facilitate peer learning for achieving institutional change for improving health sciences research at the national level in selected countries.

Findings from the project will support the establishment of the Coalition for African Research and Innovation (CARI), an initiative under the auspices of the Alliance for Accelerating Excellence in Science in Africa (AESA). CARI aims to accelerate scientific breakthroughs through the creation of a platform within Africa from which stakeholders can catalyze a highly coordinated, well-funded, innovative African R&D community together.

The project will be led by Dr Justin Parkhurst and Dr Clare Wenham in LSE’s Department of Health Policy,

For more information, please contact Clare Wenham (c.wenham@lse.ac.uk)

Researchers: Tim Allen, Melissa Parker
Date: 2012
Region: Africa
Publication details: The Lancet, Volume 379, No. 9821, p1097–1098, 24 March 2012
LSE department: Department of International Development

On Jan 21, 2012, the UK's Department for International Development announced a fivefold increase in its support for programmes to control neglected tropical diseases (NTDs). The Department's press release claimed that the new funding will initially provide 400 million treatments to protect 100 million people from lymphatic filariasis, and to help save 10 million lives that would otherwise be lost to schistosomiasis. Onchocerciasis and dracunculiasis are also to be targeted.

Bill Gates has also been to London to help renew and expand global commitments. In many respects, these developments are an enormously positive step. However, there is a body of research that highlights hazards associated with current modes of implementing NTD control strategies.

Researchers: Editors: Joan Costa-Font, Christophe Courbage (Eds.)
Date: 2012
Region: Europe
Publication details: Palgrave Macmillan ISBN-10: 0230249469 ISBN-13: 978-0230249462
LSE department: Department of Health Policy
Keywords: Financing, long-term care, Europe

Forecasts predict that those in need of long-term care in Europe will double in the next 50 years. This book offers a full understanding of the institutional responses and mechanisms in place to finance old age and provides analysis of demand and supply factors underpinning the development of financial instruments to cover long-term care in Europe.

Researchers: Mylene Lagarde, Duane Blaauw
Date: 2017
Region: Africa
Publication details: Soc Sci Med. 2017 Apr;179:147-159. doi: 10.1016/j.socscimed.2017.03.002. Epub 2017 Mar 2.
LSE Department/Centre: Department of Health Policy
Keywords: Altruism; Capitation; Fee-for-service; Real effort experiment; Salary; South Africa

Because compensation policies have critical implications for the provision of health care, and evidence of their effects is limited and difficult to study in the real world, laboratory experiments may be a valuable methodology to study the behavioural responses of health care providers.

With this experiment undertaken in 2013, we add to this new literature by designing a new medically framed real effort task to test the effects of different remuneration schemes in a multi-tasking context. We assess the impact of different incentives on the quantity (productivity) and quality of outputs of 132 participants. We also test whether the existence of benefits to patients influences effort.

The results show that salary yields the lowest quantity of output, and fee-for-service the highest. By contrast, we find that the highest quality is achieved when participants are paid by salary, followed by capitation.We also find a lot of heterogeneity in behaviour, with intrinsically motivated individuals hardly sensitive to financial incentives.

Finally, we find that when work quality benefits patients directly, subjects improve the quality of their output, while maintaining the same levels of productivity. This paper adds to a nascent literature by providing a new approach to studying remuneration schemes and modelling the medical decision making environment in the lab.

Researchers: Bhaven N. Sampat & Kenneth C. Shadlen Date: 2018 Region: India Publication details: PLoS ONE, 13 (4). https://doi.org/10.1371/journal.pone.0194714 LSE department: Department for International Development Keywords: India, Pharmaceutical Patents, medical supplies, Medical Systems

India, like many developing countries, only recently began to grant pharmaceutical product patents. Indian patent law includes a provision, Section 3(d), which tries to limit grant of “secondary” pharmaceutical patents, i.e. patents on new forms of existing molecules and drugs. Previous research suggests the provision was rarely used against secondary applications in the years immediately following its enactment, and where it was, was redundant to other aspects of the patent law, raising concerns that 3(d) was being under-utilized by the Indian Patent Office. This paper uses a novel data source, the patent office’s first examination reports, to examine changes in the use of the provision. We find a sharp increase over time in the use of Section 3(d), including on the main claims of patent applications, though it continues to be used in conjunction with other types of objections to patentability. More surprisingly, see a sharp increase in the use of the provision against primary patent applications, contrary to its intent, raising concerns about potential over-utilization.

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Health Inequality

Researchers: Gemma Williams, Philipa Mladovsky and colleagues
Date: 2014
Region: Africa, India
Publication details: In: Towards equitable coverage and more inclusive social protection in health. Studies in Health Services Organisation and Policy (SHSOP)(32). ITG Press, Antwerp, Belgium, pp. 10-22. ISBN 9789076070438
LSE department: LSE Health
Keywords: health, health financing, equity, India, Senegal, Ghana

This volume presents findings from the project Socially inclusive health care financing in West Africa and India (with acronym Health Inc) under the European Commission’s seventh framework programme. This book comprises five parts:

The first explores the concept of social exclusion and presents the overall Health Inc research framework, including the innovative SPEC-by-step framework (the acronym SPEC stands for “Social, Political, Economic and Cultural”).
The second part is a presentation of the four country (or, in the case of India, state) case studies.
The third part discusses some of the most prominent determinants of people’s exclusion from social health protection while the fourth one looks into the experiences of specific vulnerable population groups.
Finally, in a fifth part, the Health Inc Consortium attempts to identify some of the mechanisms shaping social exclusion, summarizes the principal research conclusions and highlights the main policy recommendations.

Reasearchers: Shankar Prinja, Panos Kanavos, and Rajesh Kumar
Date: 2012
Region: Asia
Publication details: Indian Journal of Medical Research, 136. pp. 421-431. ISSN 0971-5916
LSE department: Department of Health Policy
Keywords: Equity - hospitalization expenditure - India - service utilization - user charges

Background & objectives

Income inequality is associated with poor health. Inequities exist in service utilization and financing for health care. Health care costs push high number of households into poverty in India. We undertook this study to ascertain inequities in health status, service utilization and out-of-pocket (OOP) health expenditures in two States in north India namely, Haryana and Punjab, and Union Territory of Chandigarh.

Methods

Data from National Sample Survey 60th Round on Morbidity and Health Care were analyzed by mean consumption expenditure quintiles. Indicators were devised to document inequities in the dimensions of horizontal and vertical inequity; and redistribution of public subsidy. Concentration index (CI), and equity ratio in conjunction with concentration curve were computed to measure inequity.

Results

Reporting of morbidity and hospitalization rate had a pro-rich distribution in all three States indicating poor utilization of health services by low income households. Nearly 57 and 60 per cent households from poorest income quintile in Haryana and Punjab, respectively faced catastrophic OOP hospitalization expenditure at 10 per cent threshold. Lower prevalence of catastrophic expenditure was recorded in higher income groups. Public sector also incurred high costs for hospitalization in selected three States. Medicines constituted 19 to 47 per cent of hospitalization expenditure and 59 to 86 per cent OPD expenditure borne OOP by households in public sector.Public sector hospitalizations had a pro-poor distribution in Haryana, Punjab and Chandigarh.

Interpretation & conclusions

Our analysis indicates that public sector health service utilization needs to be improved. OOP health care expenditures at public sector institutions should to be curtailed to improve utilization of poorer segments of population. Greater availability of medicines in public sector and regulation of their prices provide a unique opportunity to reduce public sector OOP expenditure.

Researcher: Wei Yang
Date: 2013
Region: Asia
Publication details: International Journal for Equity in Health 12 (1). p. 20. ISSN 1475-9276
LSE department: Department of Social Policy
Keywords: The NCMS, Insurance, Access to health care, Inequity, The rural population, China

China's New Cooperative Medical Scheme (NCMS) was brought to life in 2003 in response to the deterioration in access to health services in rural areas. Despite its fast expansion, the scheme’s impacts on access to health care have raised growing concerns, in particular regarding whether and to what extent the scheme has reduced inequity in access to health care in rural China.

Methods

This study examines income-related inequity in access to health care from 2004 (before the national rollout of NCMS) to 2009 (after the expansion of NCMS across the rural China) by estimating Concentration Indices over both formal health care (outpatient care, prevention care) and informal health care use (folk doctor care). Data were drawn from a longitudinal household survey dataset - China Health and Nutrition Survey (CHNS).

Results

The study suggested that the level of inequity remained the same for outpatient care, and an increased favouring-poor gap in terms of folk doctor care was observed. In terms of preventive care, a favouring-rich inequity was observed both in 2004 and 2009, but the effects of inequity were narrowed. The NCMS had some effects in reducing income-related health inequity in folk doctor care and preventive care, but the contribution was rather small. The study also found that the rural better-off had started to seek for commercial insurance to cover possible financial risks from the burden of diseases.

Conclusion

The study concludes that the impacts of the NCMS on improving access to formal care for the poor are limited. Without a more comprehensive insurance package that effectively targets the rural poor, the intended equity goals expected from the scheme will be difficult to realize.

Reasearchers: Members of the WHO Consultative Group including LSE’s Alex Voorhoeve
Date: 2014
Region: Global
Publication details: World Health Organization ISBN 978 92 4 150715 8
LSE department: Department of Philosophy

Since 2010, more than one hundred countries have requested policy support and technical advice for universal health coverage (UHC) reform from the World Health Organization (WHO). As part of the response, WHO set up a Consultative Group on Equity and Universal Health Coverage. This final report by the Consultative Group addresses the key issues of fairness and equity that arise on the path to UHC by clarifying these issues and by offering practical recommendations. Read more

HIV/AIDS

Researcher: Hakan Seckinelgin
Date: 2017
Region: Global
Publication details: Social Aspects of HIV , 3 . Springer International Publishing, Switzerland. ISBN 9783319460116
LSE department: Department of Social Policy
Keywords: Political Science, HIV/Aids

This timely book looks critically at the policy response to AIDS and its institutionalization over time. It raises important questions about who benefits, who decides, and in whose interests decisions are made.

Taking the early international response to the epidemic as its starting point, and focusing on the work of agencies such as UNAIDS, it identifies two logics underpinning strategy to date. First, the idea of HIV as a ‘global emergency’ which calls for an extraordinary response. Second, the claim that medicine offers the best way of dealing with it.

The book also identified the rise of something more dominant – namely Global AIDS – or the logic and system that seeks to displace all others. Promulgated by UNAIDS and its partner agencies, Global AIDS claims to speak the truth on behalf of affected persons and communities everywhere.

Researcher: Justin Parkhurst
Date: 2015
Region: Global
Publication details: Journal of the International AIDS Society 2012, 15(Suppl 1):17367
LSE department: Department of Health Policy
Keywords: HIV/AIDS; structural approaches; values; AIDS resilience; capability approach.

The fact that HIV prevention often deals with politicised sexual and drug taking behaviour is well known, but structural HIV prevention interventions in particular can involve alteration of social arrangements over which there may be further contested values at stake. As such, normative frameworks are required to inform HIV prevention decisions and avoid conflicts between social goals.

Methods

This paper provides a conceptual review and discussion of the normative issues surrounding structural HIV prevention strategies. It applies political and ethical concepts to explore the contested nature of HIV planning and suggests conceptual frameworks to inform future structural HIV responses.

Results

HIV prevention is an activity that cannot be pursued without making value judgements; it is inherently political. Appeals to health outcomes alone are insufficient when intervention strategies have broader social impacts, or when incidence reduction can be achieved at the expense of other social values such as freedom, equality, or economic growth. This is illustrated by the widespread unacceptability of forced isolation which may be efficacious in preventing spread of infectious agents, but conflicts with other social values.

Conclusions

While no universal value system exists, the capability approach provides one potential framework to help overcome seeming contradictions or value trade-offs in structural HIV prevention approaches. However, even within the capability approach, valuations must still be made. Making normative values explicit in decision making processes is required to ensure transparency, accountability, and representativeness of the public interest, while ensuring structural HIV prevention efforts align with broader social development goals as well. Read more

Reasearchers: Choolwe Muzyamba, Elena Broaddus and Catherine Campbell
Region: Africa
Publication details: BMC International Health and Human Rights, 15 (26). ISSN 1472-698X
LSE department: Department of Psychological and Behavioural Sciences
Keywords: Human rights – HIV-Prevention – Key populations – Zambia

Human rights approaches now dominate the HIV prevention landscape across sub-Saharan Africa, yet little is known about how they are viewed by the populations they are designed to serve. Health interventions are most effective when they resonate with the worldviews and interests of target groups. This study examined local Zambian understandings of human rights approaches to HIV-prevention among three highly HIV-vulnerable groups: women, youth, and men-who-have-sex-with-men (MSM).

Methods

Focus groups included 23 women, youth, and MSM who had participated in activities organized by local non-governmental organizations (NGOs) using rights-based approaches, and interviews included 10 Zambian employees of these NGOs. Topics included participants’ experiences and views of the utility of these activities. Thematic analysis mapped out diverse ways participants viewed the concept of human rights in relation to HIV-prevention.

Results

Whilst NGO workers noted the need for human rights programs to address the complex drivers of the HIV epidemic, they struggled to tailor them to the Zambian context due to donor stipulations. Women program beneficiaries noted that the concept of human rights helped challenge harmful sexual practices and domestic abuse, and youth described rights-based approaches as more participatory than previous HIV-prevention efforts.

However, they criticized the approach for conflicting with traditional values such as respect for elders and ‘harmonious’ marital relationships. They also critiqued it for threatening the social structures and relationships that they relied on for material survival, and for failing to address issues like poverty and unemployment. In contrast, MSM embraced the rights approach, despite being critical of its overly confrontational implementation.

Conclusions

A rights-based approach seeks to tackle the symbolic drivers of HIV—its undeniable roots in cultural and religious systems of discrimination. Yet, it fails to resonate with youth and women’s own understandings of their needs and priorities due to its neglect of material drivers of HIV such as poverty and unemployment.MSM, who suffer extreme stigma and discrimination, have less to lose and much to gain from an approach that challenges inequitable social systems.

Developing effective HIV-prevention strategies requires careful dialogue with vulnerable groups and greater flexibility for context-specific implementation rather than a one-size-fits-all conceptualization of human rights.

Researchers: Simon Gregson, Owen Mugurungi, Jeffrey Eaton, Albert Takaruza, Rebecca Rhead, Rufurwokuda Maswera, Junior Mutsvangwa, Justin Mayini, Morten Skovdal, Robin Schaefer, Timothy Hallett, Lorraine Sherr, Shungu Munyati, Peter Mason, Catherine Campbell, Geoffrey P Garnett and Constance Anesu Nyamukapa
Date: 2017
Region: Africa
Publication details: Health BMJ Open 7 (10) ISSN 2044-6055
LSE department: Department of Psychological and Behavioural Sciences & LSE Health
Keywords: HIV, preventative care, treatment, coverage

Purpose

The Manicaland cohort was established to provide robust scientific data on HIV prevalence and incidence, patterns of sexual risk behaviour and the demographic impact of HIV in a sub-Saharan African population subject to a generalised HIV epidemic. The aims were later broadened to include provision of data on the coverage and effectiveness of national HIV control programmes including antiretroviral therapy (ART).

Participants

General population open cohort located in 12 sites in Manicaland, east Zimbabwe, representing 4 major socioeconomic strata (small towns, agricultural estates, roadside settlements and subsistence farming areas). 9,109 of 11,453 (79.5%) eligible adults (men 17-54 years; women 15–44 years) were recruited in a phased household census between July 1998 and January 2000. Five rounds of follow-up of the prospective household census and the open cohort were conducted at 2-year or 3-year intervals between July 2001 and November 2013. Follow-up rates among surviving residents ranged between 77.0% (over 3 years) and 96.4% (2 years).

Findings to date

HIV prevalence was 25.1% at baseline and had a substantial demographic impact with 10-fold higher mortality in HIV-infected adults than in uninfected adults and a reduction in the growth rate in the worst affected areas (towns) from 2.9% to 1.0%pa. HIV infection rates have been highest in young adults with earlier commencement of sexual activity and in those with older sexual partners and larger numbers of lifetime partners. HIV prevalence has since fallen to 15.8% and HIV incidence has also declined from 2.1% (1998-2003) to 0.63% (2009-2013) largely due to reduced sexual risk behaviour. HIV-associated mortality fell substantially after 2009 with increased availability of ART.

Future plans

It is planned to extend the cohort to measure the effects on the epidemic of current and future HIV prevention and treatment programmes. Proposals for access to these data and for collaboration are welcome.

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Reproductive Health

Reasearchers: Dr. Clare Wenham, Dr. Ernestina Coast, Dr. Tiziana Leone & Sonia Corrêa
Date:2018
Region: Global
LSE Department/Centre: Department of Health Policy
Keywords: Zika, Abortion, Regulation, Disease Control, Medical Abortion

An inter-disciplinary team from LSE have received funding from Wellcome Trust for a seed project to understand the impact of the Zika outbreak on how women access medical abortion, and how national regulation has impacted on women’s choices and abortion service provider’s activity during this health emergency.

This LSE Health research will be undertaken by Clare Wenham (Department of Health Policy), Ernestina Coast (Department of International Development), Tiziana Leone (Department of International Development) and Sonia Correa (LSE Gender Institute), and will analyse medical abortion (the use of mifepristone and misoprostol to terminate pregnancy) during the Zika outbreak, to consider the impact different regulatory environments had on women's reproductive health at a time of uncertainty.

The project will analyse the intersection of Zika, regulation and medical abortion through a comparative case study of Brazil, Colombia and El Salvador. Each of these states had Zika infected women (albeit with differing incidence) yet represent diverse regulatory environments for medical abortion, ranging from legalisation in Colombia to criminalisation in El Salvador to medical abortion drugs being on the list of prohibited smuggled drugs in Brazil.

In spite of regulation, however, it is believed that women have still been accessing medical abortion during the Zika epidemic, assumed through civil society groups, pharmacies and the black market. The research will assess women’s choices and provider activity in the case study locations, and in doing so, produce a conceptual framework for understanding the regulation of abortion during health emergencies.

The project will start in Summer 2018, and will begin with a research workshop with leading abortion and Zika academics and activists to determine pathways to understanding the impact of the outbreak on medical abortion, and suitable study sites.

For more information, please contact Clare Wenham c.wenham@lse.ac.uk

Researchers: Ernestina Coast, Allison H. Norris, Ann M. Moore and Emily Freeman
Date: 2018
Region: Global
Publication details: Social Science and Medicine, 200 pp. 199-210 ISSN 0277-9536
LSE department: Department of International Development & LSE Health
Keywords: Induced abortion, Conceptual framework, Systematic mapping

This study presents a new conceptual framework for studying trajectories to obtaining abortion-related care. It assembles for the first time all of the known factors influencing a trajectory and encourages readers to consider the ways these macro- and micro-level factors operate in multiple and sometimes conflicting ways. Based on presentation to and feedback from abortion experts (researchers, providers, funders, policymakers and advisors, advocates) (n = 325) between 03/06/2014 and 22/08/2015, and a systematic mapping of peer-reviewed literature (n = 424) published between 01/01/2011 and 30/10/2017, the framework synthesises the factors shaping abortion trajectories, grouped into three domains: abortion-specific experiences, individual contexts, and (inter)national and sub-national contexts

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Researchers: Ernestina Coast, Nathalie Kapp, Kelly Blanchard, Bella Ganatra, Jane Harries, Katharine Footman, Ann Moore, Onikepe Owolabi, Clementine Rossier, Kristen Shellenberg, Britt Wahlin and Cynthia Woodsong
Date: 2018
Region: Global
Publication details: Contraception, 97 (2) pp. 184-188 ISSN 0010-7824
LSE department: Department of International Development & LSE Health
Keywords: Medical abortion self-us, eearly medical abortion research gaps, non-prescription medical abortion

In December 2016, following the “Africa Regional Conference on Abortion: From Research to Policy,” a group of 20 global abortion researchers, representing nine different international organizations and universities, convened to discuss current and future research on medical abortion self-use. While recognizing the meaning of “self-use” to be evolving, we considered women's self-use of medical abortion as provision of drugs from pharmacies, drug sellers or through online services or other outlets, without a prescription from a clinician, followed by a woman's self-management of the abortion process, including care-seeking for any complications.

Research has not kept abreast of women's self-use of medical abortion, leaving many gaps in the scientific literature regarding the ideal conditions for safe and effective use. Therefore, our main objectives were to assess the research gaps highlighted during the conference, identify specific challenges to conducting research on medical abortion self-use and share promising research methodologies to advance this research. Although there are overlaps with the recommended and well-researched practice of women's self-management of the abortion process at home after receiving medical abortion medicines, screening and information from a clinician, our intent was focused on the emerging practice of self-use.

The challenges laid out in this document — a list of identified research gaps and methodologic considerations in addressing them — are intended to inform both ongoing and future research by the participants in this meeting; in sharing them, we hope to inform and validate not only our future work but also that of other researchers.

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