Does results-based financing in health work?

I’ve been reading “An overview of research on the effects of results-based financing,” published by the Norwegian Knowledge Centre for Health Services, which discusses ten reviews of RBF schemes in low and middle-income countries (LMIC). What did they find?

  • “Conditional cash transfer (CCT) programmes have been found to be effective at increasing the uptake of some preventive services which were already free.”
  • “The success of CCT depends on the existence of effective primary health services and local infrastructures.”
  • “Although financial incentives are considered to be an important element of strategies to change professional practice, there are relatively few well-designed studies and overall the evidence is weak.
  • “A small number of more rigorous evaluations have examined relatively simple preventive interventions, such as the impact on rates of immunizations and screenings, as opposed to more complex interventions. The success of a financial incentive is likely to be inversely related to the complexity of the tasks it seeks to motivate.”

Overall, it appears the quality of evaluation of RBF schemes has been relatively poor. The available evidence suggests we need to look more carefully at the (perhaps very specific) conditions under which RBF can work. I’m afraid RBF might not work well in the public sector in the absence of fairly strong government support and political commitment to the project. But that is something to be explored…

inspiration: Kennedy and Maathai

As I finished reading Ted Kennedy‘s True Compass in the early hours of the morning, I also poured over the hundreds of tweets and articles about the passing of the Kenyan environmentalist and Nobel Peace Prize winner, Wangari Maathai. Both battled cancer, and both, through their life’s work and struggle, have provided inspiration to millions. As a new day, a new week, and a new quarter begins, I want to keep in mind some of the lessons, hopes, and challenges they have shared.

This is the greatest lesson a child can learn. It is the greatest lesson anyone can learn. It is the greatest lesson I have learned: if you persevere, stick with it, work at it, you have a real opportunity to achieve something. Sure, there will be storms along the way. And you might not reach your goal right away. But if you do your best and keep a true compass, you’ll get there.

Edward M. Kennedy, True Compass


The revolution I propose requires the development of policies that work for the benefit of all citizens rather than the advantage of a few. It necessitates standing up to international interests that seek access to the considerable natural resources with which Africa is blessed for less than their fair market value. It entails implementing decisions that encourage the dynamism and entrepreneurship of African peoples, protecting them from unfair competition, and nurturing economies that add value to the commodities that the rest of the world desires so much…Perhaps the most important quality that the African leadership needs to embrace, and which is desperately lacking across the continent, is a sense of service to their people.

Wangari Maathai, The Challenge for Africa



palo alto baby

In my dazed and jet-lagged stupor yesterday afternoon, I flipped through a recent issue of Vanity Fair in a desperate attempt to stay awake until a bedtime-worthy hour. They had a fun little graphic of my hometown, replete with the silicon valley hotspots (the online version has a full list). Somehow they forgot my house. And Alpine Inn!

What would you add?

it’s about that time again

Time to make the trek across the globe that is. Entebbe-San Francisco, via Addis and Dubai. I’m getting back just in time for classes to begin on Monday, and looking forward to TAing for a new crop of students in Democracy, Development, and the Rule of Law, taught by Larry Diamond and Kathryn Stoner-Weiss.

In other news?

  • Opposition leader Michael Sata wins the presidency in Zambia. My good friend and fellow grad student Ken Opalo was in Zambia this week and has been writing about the election here. He suggests following @LoiusRedvers for updates.
  • Some snooping around suggests the flu that is still harassing me is quite widespread around Kampala. Friends who have gone to the Surgery and IHK with symptoms said they were told there is a severe strain going around. Perhaps it has peaked by now, but I wonder if the Ministry of Health shouldn’t have put out some kind of message. A fever that jumps from normal to 102 F (with ibuprofen!) in a matter of hours is no joke, especially for young kids and the elderly. Ok, end rant.
  • For those of you in the Bay Area, Stanford Professor Beatriz Magaloni and several others are organizing a conference on violence in Mexico: “Violence, Drugs, and Governance: Mexican Security in Comparative Perspective.” Speakers include Steve Krasner, Francis Fukuyama, David Kennedy, Karl Eikenberry, and many more. Not to be missed!
  • Another conference to put on the calendar is “Redefining Security Along the Food/Health Nexus,” hosted by Stanford’s Freeman Spogli Institute. Keynote speakers include Kofi Annan and Robert Gates.

I can now no longer put off packing, so that’s all for now.

I’ll see if I can get some wi-fi in Dubai. Otherwise, I’ll see you on the other side.


I know, you thought I was packing. So did I. But I just read that the Uganda Shilling has fallen to an 18-year low – Ushs2901 to the dollar, according to Reuters. Annnnnd, the power just went out. Tough times indeed.

review this: Kampala online

Well, after 24 hours of the worst flu I’ve had since childhood, I’m back. There is a serious virus(es?) going around this town (Kampala that is); several people are reporting symptoms on twitter and a number of friends have been taken ill. Wash those hands! The good news is the worst symptoms (namely, high fever with the usual chills and aches) seem short-lived. But that’s not much comfort when you’re in the middle of the thing.

Anywayyyy… what I really wanted to share is an email I got from TripAdvisor after reviewing Endiro (coffee shop in Kisementi) online. After I wrote a post on Uganda’s online tourism presence, I decided I should do my part in sharing information online about the places I frequent. Ideally, there should be a forum other than TripAdvisor to do this, but I had a feeling more people would read reviews on that popular platform than elsewhere. It might be useful for the managers/owners of the restaurants/hotels/etc. to see what others are saying about them online as well (the second review of Endiro, for example, is rather scathing).

Yesterday, I got this email from TripAdvisor:

What I found most interesting, of course, was that there were “3,105 travelers looking for information about Kampala this week”.

I don’t know how they calculate the number of “travelers” (as opposed to clicks on Kampala-related sites on their page) but at least this gives us a clue as to how many people are seeking information about Uganda online. First of all, this figure is only for Kampala, and second of all, it is only for TripAdvisor, suggesting that the number of folks looking for information online on Uganda is in the multiple thousands every week.

I had not previously found data regarding online searches for Uganda tourism, but this at least gives us a rough idea, and provides further evidence that Uganda’s online tourism presence matters! Over to you, UTB.

On a related note, Bernard Tabaire (@btabaire) has an interesting column on Uganda’s tourism sector in last Sunday’s Daily Monitor, link here.

felled by fever

As my partner-in-crime was felled by a fever this weekend, I got to wondering how often people treat themselves for malaria when they really have a nasty virus, flu or otherwise. If you don’t have the time, resources, or energy, it might seem like a good idea to pop some anti-malarials (assuming you can get them) just in case.

I gave a presentation about health services and malaria in Uganda several weeks ago, in which, among other things, I bemoaned the lack of attention malaria receives from government. Browsing various publications, studies, and policy reports, I mentioned several stats, including the following:

  • Malaria is the cause of 32% of child deaths in Uganda (DHS Child Verbal Autopsy 2007)
  • 42% of children tested positive for malaria during the DHS Malaria Indicator Survey 2009 , compared to 0.7% in Ethiopia, 2.6% in Rwanda, 7.6% in Kenya, and 18% in Tanzania.
  • Malaria is responsible for 30-50% of all outpatient visits, 15-20% of all admissions, and 9-14% of all inpatient deaths
  • Uganda ranks third in the world in terms of malaria deaths

One of the audience members asked about the accuracy of reporting of malaria cases in Uganda. While malaria is undeniably one of the most important health challenges Uganda faces, it is important to acknowledge that the capacity to diagnose malaria is generally weak, and many if not most of the malaria cases and deaths are not laboratory confirmed. There is probably a sizable chunk of these “malaria cases” that are not actually malaria, but rather a flu or some other virus or infection.

The 2009 Malaria Indicator Survey found that of the 3,727 children included in the survey, 44.7% were reported to have had a fever in the preceding two weeks. While 70% of children with fever were taken to a health facility or health provider, only 17% were reported as having been tested for malaria through a finger or heel prick. 60% of children with fever ended up taking anti-malarials, and 15% took antibiotics.

I’m still astounded that 42% of the children in the survey tested positive for malaria (62% were anemic). This figure is especially high when you compare it with other countries in the East African region (see above). Prevalence varies quite a bit by region as well.

Source: Uganda Malaria Indicator Survey 2009, page 61.

The internet has slowed to a crawl, but I’ll post some more links on this soon.

Uganda’s entrepreneurs

In Uganda it seems like everyone and their mother (I do mean that literally) has their own business. In fact, the 2010 Global Entrepreneurship Monitor Report on Uganda finds that 31 of every 100 working age Ugandans are involved in some kind of entrepreneurial activity, making Uganda the 6th highest in terms of entrepreneurship out of the 59 countries surveyed.

Interestingly, there appears to be a strong relationship between GDP per capita and entrepreneurial activity, as can be seen below.

Source: 2010 GEM Uganda report, page 32. Download here.

So what does this mean?

High TEAs [Early Stage Entrepreneurial Activity] are mainly registered in developing countries. And there’s a group of scholars that have argued that the greater the poverty, the higher the TEA of the country concerned. GEM Uganda team does not wholly agree with these scholars as its number of entrepreneurs motivated by opportunity is also high and so is that of Ghana, Zambia and Angola.

Although the team believes that necessity is a factor in Uganda’s high TEA, some entrepreneurs are keen to pursue business opportunities in the country. The positive relationship between economic growth and entrepreneurship is unquestioned; it is the causality, the measures used, and the role of the state that need to be explored further.

I’m curious about the relationship between the Doing Business scores and entrepreneurship as well. I would imagine that while it may be difficult to set up a business formally (i.e. following all the rules/wading through bureaucracy) in countries like Uganda, the relative lack of regulation encourages entrepreneurs to try their luck in business, especially in the informal sector.

Your thoughts?

141,000 child deaths in Uganda per year

That according to the recently released 2011 UN report, “Levels and Trends in Child Mortality“. For a relatively small country of around 32 million inhabitants, Uganda gets a terribly large chunk of the pie, as seen below (page 8 of the report). Uganda is the 10th largest contributor to child deaths worldwide.

The good news?

In Sub-Saharan Africa the average annual rate of reduction in under-five mortality has accelerated, doubling from 1990-2000 to 2000-2010. Six of the fourteen best-performing countries are in Sub-Saharan Africa, as are four of the five countries with the largest absolute reductions (more than 100 deaths per 1,000 live births).

The six best performers for a reduction in the rate of mortality are Madagascar, Malawi, Eritrea, Liberia, Niger, and Tanzania. The countries with the greatest reduction in child deaths in absolute terms are Niger, Malawi, Liberia, and Sierra Leone. What are they doing right?

reading in global health: ACCESS

Several months ago I downloaded ACCESS: How do good health technologies get to poor people in poor countries?, a book listed on Karen Grepin‘s excellent global health recommended reading list, but only just now have gotten around to reading it.

What is “access” in this context?

Stated simply, access refers to people’s ability to obtain and appropriately use good quality health technologies when they are needed. Access is not only a technical issue involving the logistics of transporting a technology from the manufacturer to the end-user. Access also involves social values, economic interests, and political processes. Access requires a product as well as services and is linked to how health systems perform in practice. We think of access not as a single event but as a process involving many activities and actors over time. Access is not a yes-or-no dichotomous condition, but rather a continuous condition of different degrees; more like a rheostat than an on-off switch.

Understanding the factors that help or hinder access to health technologies is a topic I am hoping to explore further in my own dissertation, so I’m looking forward to reading the rest of the book. ACCESS is available as a free download.

Earlier this summer, I read another of Karen Grepin’s suggestions, The Making of a Tropical Disease: A Short History of Malaria. It was fascinating, and highly recommended. I will post some excerpts and “fun” facts I learned soon. This one isn’t available as a free download, but is available on Kindle. And yes, I am a Kindle Convert.

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