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Financial incentives for health providers and households are increasingly used to improve reproductive, maternal, and child health service coverage in low- and middle-income countries. This study provides a quantitative synthesis of their effectiveness. A systematic review was conducted of the effects of performance-based financing, voucher, and conditional cash transfer programs on six reproductive, maternal, and child health service indicators, with eligible evidence coming from randomized controlled trials and studies using double-difference, instrumental variables, and regression discontinuity designs. Four literature searches were conducted between September 2016 and March 2021 using seven academic databases, Google Scholar, development agency and think tank websites, and previous systematic reviews. Random effects meta-analysis was used to obtain mean effect sizes. From 58 eligible references 212 impact estimates were extracted, which were synthesized into 130 program-specific effect sizes. Financial incentives increase coverage of all considered reproductive, maternal, and child health indicators, but mean effects sizes are of modest magnitude. Effect size heterogeneity is typically low to moderate, and there is no indication that study bias risk, baseline indicator levels, or a combination of provider- and household-level incentives impact effect sizes. There is, however, weak evidence that mean effect sizes are somewhat smaller for performance-based financing than for voucher and conditional cash transfer programs, and that the increase in income, rather than the incentive itself, drives coverage improvements. Financial incentives improve reproductive, maternal, and child health service coverage. If future research confirms the preliminary finding that performance-based financing has smaller effects, voucher and conditional cash transfer programs are the preferred policy option among incentive interventions to achieve higher reproductive, maternal, and child health service coverage. The relative effectiveness and efficiency of incentives compared with unconditional increases of provider and household incomes, however, need to be studied further.

Universal Health Coverage is one of the key targets of the Sustainable Development Goals and it implies that everyone can access the healthcare they need without suffering financial hardship. In this paper, we use a large set of household surveys to examine if older populations are facing different degrees of financial hardship compared to younger populations. We find that while differences in average age structures between countries are not systematically associated with higher financial risk related to out-of-pocket health expenditures, there are large differences in financial hardship between younger and older households within countries. Households with more elderly members are more likely to face catastrophic and impoverishing out-of-pocket health payments compared to younger households, and this age gradient is stronger for the poorest segments of the population. Making progress toward Universal Health Coverage will require extension and improved targeting of benefit packages and financial protection to meet the health needs of older adults, and especially the poorest and most vulnerable segments of elderly populations.

Prior to the Sustainable Development Goals (SDG) era, considerable progress was made toward the Millennium Development Goals (MDGs) health indicators. Despite these achievements, many countries failed to meet the MDG target levels, between-country inequalities in health outcomes did not improve, and many countries making progress in average indicator levels did so while at the same time seeing increasing within-country inequalities. We build on the existing literature documenting levels and trends in health inequalities by expanding the number of data-points under focus, and we contribute to this literature by analyzing the extent to which inequalities in child health outcomes are related to socioeconomic inequalities, and to aggregate income growth. The objective of this paper is to examine long-run trends in average population levels and within-country inequalities for two child health outcomes-the under-five mortality rate (U5MR) and stunting-in 102 countries across 6 regions. We find that only about a third of countries in our sample managed to both reduce U5MR levels and inequalities, and only a quarter did so for stunting. The fact that inequality in service coverage seems to follow a more favorable trend than inequality in health outcomes suggests that policies aiming to reduce health inequities should not only foster more equitable service coverage but also focus on the social determinants of health. Moreover, there is no strong correlation between changes in health inequalities and income growth, suggesting that income generating development policies alone will typically not suffice to improve health outcomes and reduce health inequalities.

Evidence on households’ ability to smooth consumption over health shocks is mostly obtained from environments where there is little or no formal insurance of either medical expenses or sickness-related earnings losses. To establish whether households remain economically vulnerable to illness after the introduction of universal health coverage (UHC), we examine the impact of health shocks of different severity on informal workers in Thailand who are entitled to comprehensive public medical care but lack social protection of earnings. Using three years of panel data, we find that the most severe illness that strikes an initially healthy worker reduces household earnings by almost one third and, despite UHC, raises out-of-pocket spending on medical care by around two thirds. However, households are able to protect spending on goods other than medical care by drawing on informal insurance, credit and savings. These coping strategies substitute for the lack of formal earnings insurance and fill gaps in the effective health care coverage. On average, the combination of UHC and informal insurance of the residual risks does a reasonably good job of protecting living standards from the economic impact of illness, at least in the short term.

Like other countries seeking a progressive path to universalism, Peru has attempted to reduce inequalities in access to health care by granting the poor entitlement to tax-financed basic care without charge. We identify the impact of this policy by comparing the target population's change in health care utilization with that of poor adults already covered through employment-based insurance. There are positive effects on receipt of ambulatory care and medication that are largest among the elderly and the poorest. The probability of getting formal health care when sick is increased by almost two fifths, but the likelihood of being unable to afford treatment is reduced by more than a quarter. Consistent with the shallow coverage offered, there is no impact on use of inpatient care. Neither is there any effect on average out-of-pocket health care expenditure, but medical spending is reduced by up to 25% in the top quarter of the distribution. Copyright © 2017 John Wiley & Sons, Ltd.

Summary Background The goal of universal health coverage (UHC) requires that everyone receive needed health services, and that families who get needed services do not suffer undue financial hardship. Tracking progress towards UHC requires measurement of both these dimensions, and a way of trading them off against one another. Methods We measured service coverage by a weighted geometric average of four prevention indicators (antenatal care, full immunisation, and screening for breast and cervical cancers) and four treatment indicators (skilled birth attendance, inpatient admission, and treatment for acute respiratory infection and diarrhoea), financial protection by the incidence of catastrophic health expenditures (those exceeding 10% of household consumption or income), and a country's UHC performance as a geometric average of the service coverage index and the complement of the incidence of catastrophic expenditures. Where possible, we adjusted service coverage for inequality, penalising countries with a high level of inequality. The bulk of data used in this study were from the World Bank's Health Equity and Financial Protection Indicators database (2019 version), comprising data from household surveys. Gaps in the data were supplemented with other survey data and (where necessary) non-survey data from other sources (administrative, modelled, and imputed data). Findings A low incidence of catastrophic expenses sometimes reflects low service coverage (often in low-income countries) but sometimes occurs despite high service coverage (often in high-income countries). At a given level of service coverage, financial protection also varies. UHC index scores are generally higher in higher-income countries, but there are variations within income groups. Adjusting the UHC index for inequality in service coverage makes little difference in some countries, but reduces it by more than 10% in others. Seven of the 12 countries for which we were able to produce trend data have increased their UHC index over time (with the greatest average yearly increases seen in Ghana [1·43%], Indonesia [1·85%], and Vietnam [2·26%]), mostly by improving both financial protection and service coverage. Some increased their UHC index, despite reductions in financial protection, by substantially increasing their service coverage. The UHC index decreased in five of 12 countries with trend data, mostly because financial protection worsened with stagnant or declining service coverage. Our UHC indicators (except inpatient admissions) are significantly and positively associated with GDP per capita, and most are correlated with the share of health spending channelled through social health insurance and government schemes. However, associations of our UHC indicators with the share of GDP spent on health and the shares of health spending channelled through non-profit and private insurance are ambiguous. Interpretation Progress towards UHC can be tracked using an index that captures both service coverage and financial protection. Although per-capita income is a good predictor of a country's UHC index score, some countries perform better than others in the same income group or even in the income group above their own. Strong UHC performance is correlated with the share of a country's health budget that is channelled through government and social health insurance schemes. Funding None.

This paper outlines changes that have been made in the 2019 version of the Health Equity and Financial Protection Indicators database. On the financial protection side, the changes include an increase in the number of indicators from five to 14; revisions to several previous data points, reflecting the analysis of new surveys (or adaptations thereof); and refinements to the estimation of out-of-pocket expenditures. On the health equity side, the 2019 database includes 198 more data points than the 9,733 in the 2018 database, reflecting the addition of 535 new datapoints, and the dropping of 337 previously included data points now considered to be substandard.

The Greek Famine of 1941-1942 provides a natural experiment to test the fetal origins hypothesis. This hypothesis states that exposure to detrimental conditions during the fetal stage leads to worse health and socioeconomic outcomes in adulthood. This chapter first describes the Greek famine's causes. It then reviews the impact of the Greek famine on the education and labor market outcomes of the individuals exposed to the famine in utero or in early childhood. Corroborating Barker's hypothesis, the evidence indicates that the Greek famine significantly reduced educational attainment for those who experienced it before their third year of life. The famine also reduced labor market success for those with famine exposure in their early childhood. This finding is partly driven by a shift towards rural birthplaces in the famine years. The sum of the findings underscores the importance of averting early childhood malnourishment.

The 2018 database on Health Equity and Financial Protection indicators provides data on equity in the delivery of health service interventions and health outcomes, and on financial protection in health. This paper provides a brief history of the database, gives an overview of the contents of the 2018 version of the database, and then gets into the details of the construction of its two sides -- the health equity side and the financial protection side. The paper also provides illustrative uses of the database, including the extent of and trends in inequity in maternal and child health intervention coverage, the extent of inequities in women's cancer screening and inpatient care utilization, and trends and inequalities in the incidence of catastrophic health expenditures.

We estimate the impact on out-of-pocket (OOP) medical expenditure of a major reform in Thailand that greatly extended health insurance coverage to achieve universality while implementing supply-side measures intended to deliver cost-effective care from an increased, but modest, public health budget. Difference-in-differences comparison of groups to whom coverage was extended or deepened with those whose coverage did not change indicates that the reform reduced OOP expenditure by 28% on average and by 42% at the 95th percentile of the conditional distribution. Simulations suggest that exposure to medical expenditure risk was reduced by three-fifths, on average, generating a social welfare gain equivalent to 80–200% of the approximate deadweight loss from financing the reform. Estimated effects on health care access suggest that the policy managed to reduce households' medical expenses while also raising their utilization of both inpatient and ambulatory care.

In this paper we estimate long-run effects of fetal exposure to the 1918/19 influenza pandemic for a European country. Using data from the 1970 Swiss census, we find that the male 1919 cohort that had a strongly increased likelihood of fetal exposure to the pandemic performs significantly worse in terms of educational attainment and has a lower chance of marriage than the surrounding cohorts. Further, we find similar results when we in addition use regional differences in influenza severity to test for the impact of influenza on later-life outcomes. A set of robustness tests confirm our findings.

This paper examines the long run education and labor market effects from early-life exposure to the Greek 1941-42 famine. Given the short duration of the famine, we can separately identify the famine effects for cohorts exposed in utero, during infancy and at one year of age. We find that adverse outcomes due to the famine are largest for infants. Further, in our regression analysis we exploit the fact that the famine was more severe in urban than in rural areas. Consistent with our prediction, we find that urban-born cohorts show larger negative impacts on educational outcomes than the rural-born cohorts.

This paper aims to shed light on the nexus of electricity, firm performance, and economic development in a dynamic rural area in Southern Uganda. Using quantitative firm-level data on 200 micro-enterprises complemented by qualitative case studies we find that modern energy increases the importance of electricity-using capital and alters the sectoral distribution of economic activities. By contrast, we find no evidence for an expansionary effect of electrification on firm profits or worker remuneration. In fact, many entrepreneurs consider the direct gain from connecting to the grid to be small. Qualitative information, however, suggests that a positive indirect impact of electrification on firm performance is induced by the overall expansive effect electrification has on local demand. The demand increase can be partly assigned to people moving into the electrified community from surrounding non-electrified areas. We conclude that if productive energy promotion policies are put in place they should address drawing up thorough business plans to enable local entrepreneurs to take informed connection and investment decisions.

Der Umbau des US-amerikanischen Gesundheitssystems ist eines der Vorhaben der gegenwärtigen US-Regierung. Der folgende Beitrag stellt die Organisation und die Leistungsfähigkeit des derzeitigen Gesundheitswesens vor und diskutiert die aktuellen Reformvorschläge.

Like other countries seeking a progressive path to universalism, Peru has attempted to reduce inequalities in access to healthcare by granting the poor entitlement to tax-financed basic care without charge. We identify the impact of this policy by comparing the target population’s change in healthcare utilization with that of poor adults already covered through employment-based insurance. There are positive effects on receipt of ambulatory care and medication that are largest among the elderly and the poorest. The probability of getting formal healthcare when sick is increased by almost two fifths, while the likelihood of being unable to afford treatment is reduced by more than a quarter. Consistent with the shallow cover offered, there is no impact on use of inpatient care. Mean out-of-pocket (OOP) expenditure on healthcare is unaffected but spending is reduced by up to one quarter at some points of the distribution. Among healthcare users, medical spending is reduced across much of the distribution and in relative terms falls most at lower quantiles, which is consistent with limited nominal and effective coverage of expensive treatments.

We examine economic vulnerability to illness when, as for informal sector workers in Thailand, there is universal coverage for health care but earnings losses are uninsured. Even with comprehensive health care entitlement, severe illness that strikes an initially healthy worker is found to raise out-of-pocket medical expenses by around two thirds and increase the probability that medical spending absorbs more than a tenth of the household budget by nine percentage points. Moreover, severe illness reduces the probability of remaining in employment by 18 points and precipitates a reduction in household labor income of almost one third. Despite the rise in medical expenses and fall in earnings, households are able to maintain expenditure on goods and services other than medical care by drawing on remittances and informal transfers, cutting back on saving, and by borrowing. In the short term, informal insurance fills gaps left uncovered by formal insurance but there is likely to be substantial exposure to economic risks associated with long-term illness.

We estimate the impact on health care utilization and out-of-pocket (OOP) expenditures of a major reform in Thailand that extended health insurance to one-quarter of the population to achieve universal coverage while keeping health spending below 4% of GDP. Identification is through comparison of changes in outcomes of groups to whom coverage was extended with those of public sector employees and their dependents whose coverage was not affected. The reform is estimated to have reduced the probability that a sick person goes without formal treatment by 3.2 percentage points (11%). It increased the probability of receiving public ambulatory care by 2.7 ppt (5%) and of admission to a public hospital by 1 ppt (18%). OOP expenditures were reduced by one-third on average, as was the probability of spending more than 10% of the household budget on health care, while spending at the very top of the OOP distribution was reduced by one-half representing substantial reductions in exposure to medical expenditure risk. Supply-side measures implemented with the coverage extension are likely to have helped realize these effects from an increased, but still very tight, budget.

Economic theory predicts that abortion laws affect sexual behavior since they change the marginal cost of having risky sex. We estimate the impact of abortion laws on sexual behavior by reported gonorrhea incidence. Our data panel includes 41 countries for which consistent gonorrhea data are available for 1980--2000. Compared with laws permitting abortion only to save the pregnant woman's life or her physical health, the switch to more liberal abortion laws is associated with large increases in reported gonorrhea incidence. Our results help explain why birth rates do not decline at the same rate abortions increase when laws are liberalized. Copyright 2012, Oxford University Press.

This chapter examines education and labor market outcomes for cohorts with early-life exposure to the Greek 1941-42 famine. Given the short duration of the famine, we can separately identify effects for cohorts exposed as fetuses, infants and one-year-olds. Our empirical analysis uses data from the 1971, 1981, 1991, and 2001 Greek National Population Housing Censuses. For our main specification that includes birthplace controls, we find negative cohort effects on the likelihood of completing upper secondary school for the cohorts exposed as infants and one-year-olds. Because the famine was more severe in urban areas, we also estimate separate models for urban- and rural-born individuals. Consistent with our prediction, the negative cohort effects for the early-life famine exposed cohorts are larger in the urban-born subsample. The negative cohort effects increase in specifications without birthplace controls. We attribute a part of this increase to a rising share of individuals from areas with negative education and labor market prospects in the cohorts with early-life famine exposure. The cohort effect difference between specifications with and without birthplace controls is largest for the 1942 cohort, a large part of which was conceived during the famine. We suggest that this finding is due to the fact that negative birthplace selection into this cohort occurred not only through famine mortality, like in the other cohorts with early-life exposure, but also through famine-related falls in fertility.

In this paper we estimate the long-run effects of prenatal exposure to the 1918/19 influenza wave for a European country. Using data from the 1970 Swiss census and comparing cohort outcomes, we find that the male Swiss-born cohort with in utero exposure to the pandemic performs significantly worse in terms of educational attainment and has a lower chance of marriage than the surrounding cohorts. Further, we find similar results when we in addition use regional differences in influenza severity to test for the impact of influenza on later in life outcomes. Finally, a set of robustness tests confirm our findings.

This paper examines the long run education and labor market effects from early-life exposure to the Greek 1941-42 famine. Given the short duration of the famine, we can separately identify the famine effects for cohorts exposed in utero, during infancy and at one year of age. We find that adverse outcomes due to the famine are largest for infants. Further, in our regression analysis we exploit the fact that the famine was more severe in urban than in rural areas. Consistent with our prediction, we find that urban-born cohorts show larger negative impacts on educational outcomes than the rural-born cohorts.

Most industrialized countries have increased access to abortion over the past 30 years. Economic theory predicts that abortion laws affect sexual behavior since they change the marginal cost of having risky sex. We use gonorrhea incidence as a metric of risky sexual behavior. Using a panel of 41 North American, European and Central Asian countries over the period 1980-2000, we estimate the impact of abortion law reform on risky sex. Compared to the most restrictive legislation that permits abortion only to save the pregnant woman’s life or her physical health, more liberal abortion laws are associated with at least thirty additional gonorrhea cases per 100,000 individuals. The marginal effect of laws which make abortion available on request is larger than the effect of laws which allow abortion on socioeconomic and mental health grounds. Our results are robust against a set of alternative sample constructions and model specifications.

Most industrialized countries have increased access to abortion over the past 30 years. Economic theory predicts that abortion laws affect sexual behavior since they change the marginal cost of having risky sex. We use gonorrhea incidence as a metric of risky sexual behavior. Using a panel of 41 North American, European and Central Asian countries over the period 1980-2000, we estimate the impact of abortion law reform on risky sex. Compared to the most restrictive legislation that permits abortion only to save the pregnant woman’s life or her physical health, more liberal abortion laws are associated with at least thirty additional gonorrhea cases per 100,000 individuals. The marginal effect of laws which make abortion available on request is larger than the effect of laws which allow abortion on socioeconomic and mental health grounds. Our results are robust against a set of alternative sample constructions and model specifications.

This study was prepared by Sven Neelsen while he was working with the ifo Institute for Economic Research. It was completed in December 2011 and accepted as a doctoral thesis by the Department of Economics at the University of Munich in May 2012. The study investigates long-run effects of early-life living conditions using micro-datasets from three countries. The employed empirical strategies aim to identify causal relationships between early-life living conditions and the outcomes of interest.