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Understanding the spatio-temporal dynamics of land use and land cover (LULC) and their drivers is instrumental in synthesizing knowledge for informed natural resource management, planning, and associated decisions. The objective of this study was to analyze LULC dynamics and their drivers in the Nyangatom district of southwest Ethiopia. This study adopted a mixed-method approach, comprising remote sensing and geographic information system-based analysis, focus-group discussions, key informant interviews, and structured interviews covering 384 agro-pastoral households. Land use and land cover maps were compiled with Landsat image data from 1992, 1999, 2010, and 2020 using supervised pixel-based classification with a maximum likelihood algorithm. The study revealed that grassland (33%) and shrub land (27%) are the dominant LULC classes in the study periods. The results show a significant increase in settlement, cropland, and bare land, between 1992 and 2020 following demand for fertile lands, overgrazing, and climate changes. Reductions in the water body, open woodland, riverine forest, and dense woodland of − 23%, − 18%, − 18%, and − 7%, respectively, were observed for the same period with an overall accuracy of 80%. Agro-pastoralists identified agricultural expansion, overgrazing, and drought as the main drivers of LULC changes, followed by conflicts, invasion of alien plant species, and change in policy institutions. The impacts of unplanned LULC change can be reduced through appropriate land-use planning with genuine stakeholder engagement. Updated information on present and future LULC dynamics can support these social dynamics and align a shared understanding among stakeholders that replaces polarization and erosion of mutual trust.

Background The Coronavirus Disease 2019 (COVID-19) pandemic and associated mitigation policies created a global economic and health crisis of unprecedented depth and scale, raising the estimated prevalence of depression by more than a quarter in high-income countries. Low- and middle-income countries (LMICs) suffered the negative effects on living standards the most severely. However, the consequences of the pandemic for mental health in LMICs have received less attention. Therefore, this study assesses the association between the COVID-19 crisis and mental health in 8 LMICs. Methods and findings We conducted a prospective cohort study to examine the correlation between the COVID-19 pandemic and mental health in 10 populations from 8 LMICs in Asia, Africa, and South America. The analysis included 21,162 individuals (mean age 38.01 years, 64% female) who were interviewed at least once pre- as well as post-pandemic. The total number of survey waves ranged from 2 to 17 (mean 7.1). Our individual-level primary outcome measure was based on validated screening tools for depression and a weighted index of depression questions, dependent on the sample. Sample-specific estimates and 95% confidence intervals (CIs) for the association between COVID-19 periods and mental health were estimated using linear regressions with individual fixed effects, controlling for independent time trends and seasonal variation in mental health where possible. In addition, a regression discontinuity design was used for the samples with multiple surveys conducted just before and after the onset of the pandemic. We aggregated sample-specific coefficients using a random-effects model, distinguishing between estimates for the short (0 to 4 months) and longer term (4+ months). The random-effects aggregation showed that depression symptoms are associated with a increase by 0.29 standard deviations (SDs) (95% CI [−.47, −.11], p-value = 0.002) in the 4 months following the onset of the pandemic. This change was equivalent to moving from the 50th to the 63rd percentile in our median sample. Although aggregate depression is correlated with a decline to 0.21 SD (95% CI [−0.07, −.34], p-value = 0.003) in the period thereafter, the average recovery of 0.07 SD (95% CI [−0.09, .22], p-value = 0.41) was not statistically significant. The observed trends were consistent across countries and robust to alternative specifications. Two limitations of our study are that not all samples are representative of the national population, and the mental health measures differ across samples. Conclusions Controlling for seasonality, we documented a large, significant, negative association of the pandemic on mental health, especially during the early months of lockdown. The magnitude is comparable (but opposite) to the effects of cash transfers and multifaceted antipoverty programs on mental health in LMICs. Absent policy interventions, the pandemic could be associated with a lasting legacy of depression, particularly in settings with limited mental health support services, such as in many LMICs. We also demonstrated that mental health fluctuates with agricultural crop cycles, deteriorating during “lean”, pre-harvest periods and recovering thereafter. Ignoring such seasonal variations in mental health may lead to unreliable inferences about the association between the pandemic and mental health.

Panel data are rarely available for developing countries. Departing from traditional pseudo-panel methods that require multiple rounds of cross-sectional data to study poverty mobility at the cohort level, we develop a procedure that works with as few as two survey rounds and produces point estimates of transitions along the welfare distribution at the more disaggregated household level. Validation using Monte Carlo simulations and real cross-sectional and actual panel survey data – from several countries, spanning different income levels and geographical regions – perform well under various deviations from model assumptions. The method could also inform investigation of other welfare outcome dynamics.

ackground: Out-of-pocket health expenditures (OOPs) constitute a significant proportion of total health expenditures in many low- and middle-income countries (LMICs), leading to an increased likelihood of exposure to financial catastrophe in the event of illness. Health insurance has the potential to reduce catastrophic health expenditures (CHE), but rigorous evidence of its sustained impact is limited, especially in LMICs. This study examined the short- and longer-term effects of a health insurance program in Kwara State, Nigeria on CHE. Methods: The analysis is based on a panel dataset consisting of 3 waves of household surveys in program and comparison areas. The balanced data consists of 1,039 households and 3,450 individuals. We employed a difference-in-differences (DiD) regression approach to estimate intention-to-treat effects, and then computed average treatment effects on the treated by combining DiD with propensity score weighting and an instrumental variables analysis. CHE was measured as OOPs exceeding 10% of household consumption and 40% of capacity-to-pay (CTP). Results: Using 10% of consumption as a CHE measure, we found that living in the program area was associated with a 4.3 percentage point (pp) decrease in CHE occurrence (p < 0.05), while the effect on insured households was 5.7 pp (p < 0.05). The longer-term impact four years after program introduction was not significant. Heterogeneity analyses show a reduction in CHE of 7.2 pp (p < 0.01) in the short-term for the poorest tercile. No significant effects were found for the middle and richest terciles, nor in the longer-term. Households with a chronically ill member experienced a reduction in CHE of 9.4 pp (p < 0.01) in the short-term, but not in the longer-term. Most estimates based on the 40% of CTP measure were not statistically significant. Conclusion: These findings highlight the critical role of health insurance in reducing the likelihood of catastrophic health expenditures, especially for vulnerable populations such as the poor and the chronically ill, and by extension in achieving universal health coverage. They also show that the beneficial impacts of health insurance may attenuate over time, as households potentially adjust their health-seeking behavior to the new scheme.

In the West Bank, the agricultural sector accounts for the majority of water demand in the region. Where irrigated agriculture covers only 12% of the cultivated area of the West Bank it consumes around 65% of the total water resources. Most of the irrigated area of the Jordan Valley is under Majdool date palm trees, with a total number of about 250,000 trees, half of whom are younger than 5 y. Despite using drip irrigation, which is considered efficient and reduces water loss, improvement of the irrigation schedule can still be realized by a tailored management of the water demand of plants. In the Jordan Valley, the most important irrigated agricultural area in the West Bank, over-irrigation of the crops and trees is a common practice that causes the degradation of the groundwater aqui-fer systems. This study aims to use precise irrigation management to balance water demand with irrigation volumes to avoid water spillage. The Hydrus-2D package was used to develop an irrigation schedule for a 5 y date palm old. Model simulations show that farmers can schedule irrigation with less than the recommended volume of 20 m3/tree·y. By applying around 46% of the currently recommended volume, similar production levels could be obtained in terms of yield and biomass. We conclude that using precision irrigation scheduling, the water demand per tree reduces to a recommended rate of about 12.5 m3/tree·y increasing crop water productivity up to 2.63 kg/m3 as opposed to 1.66 kg/m3 with the traditional irrigation schedule. Additionally, less water drains beneath the root zone.

Health insurance enrollment in many Sub-Saharan African countries is low, even with highly subsidized premiums and exemptions for vulnerable populations. One possible explanation is low service quality, which results in a low valuation of health insurance. Using a randomized control trial in 64 primary health care facilities in Ghana, this study assesses the impact of a community engagement intervention designed to improve the quality of healthcare and health insurance services on households living nearby the facilities. Although the intervention improved the medical-technical quality of health services, our results show that households' subjective perceptions of the quality of healthcare and insurance services did not increase. Nevertheless, the likelihood of illness and concomitant healthcare utilization reduced, and especially households who were not insured at baseline were more likely to enroll in health insurance. The results show that solely increasing the technical quality of care is not sufficient to increase households' subjective assessments of healthcare quality. Still, improving technical quality can directly contribute to health outcomes and further increase health insurance coverage, especially among the previously uninsured.

Food insecurity elimination is a major focus of the Sustainable Development Goals and addresses one of the most pressing needs in developing countries. With the increasing incidence of food insecurity, poverty, and inequalities, there is a need for realignment of agriculture that aims to empower especially the rural poor smallholders by increasing productivity to improving food security conditions. Repositioning the agricultural sector should avoid general statements about production improvement, instead, it should tailor to location-specific recommendations that fully acknowledge the local spatial diversity of the natural resource base that largely determines production potentials under current low input agriculture. This paper aims to deconstruct the complex and multidimensional aspect of food insecurity and provides policymakers with an approach for mapping the spatial dimension of food insecurity. Using a set of GIS-based indicators, and a small-area approach, we combine Principal Component Analysis and GIS spatial analysis to construct one composite index and four individual indices based on the four dimensions of food security (access, availability, stability, and utilization) to map the spatial dimension of food insecurity in Vihiga County, Kenya. Data were collected by the use of a geocoded household survey questionnaire. The results reveal the existence of a clear and profound spatial disparity of food insecurity. Mapping food insecurity using individual dimension indices provides a more detailed picture of food insecurity as compared to the single composite index. Spatially disaggregated data, a small area approach, and GIS-based indicators prove valuable for mapping local-level causative factors of household food insecurity. Effective policy approaches to combat food insecurity inequalities should integrate spatially targeted interventions for each dimension of food insecurity.

BACKGROUND: Diarrhea, pneumonia, malnutrition, tuberculosis, measles, and fever are the leading causes of mortality in children under five-years of age (0-59 months), whereas diarrhea alone is the world's second-biggest cause of mortality in this population. This study is particularly important for Pakistan as it focuses on one of the main causes of infant mortality, diarrhea, which is a major challenge for Pakistan to achieve the Sustainable Development Goals to reduce infant mortality to 12/1000 live births by 2030.AIM: This study was planned to investigate the various household, parental, environmental, and child-related factors causing diarrheal diseases in children aged 0-59 months in Punjab Pakistan.METHODS: The study used the data of 38,405 households from the Multiple Indicator Cluster Survey (MICS) 2017-18, directed by the Punjab Bureau of Statistics. Comprehensive descriptive statistics, i.e., cross-tabulations and logistic regression were used for the detailed analysis.FINDINGS: The results showed that infants are more probable to get diarrhea than older children. A wide range of influences were found to affect the probability of a child getting diarrhea, including child-specific, mother-specific and environment-specific ones. One prominent finding was that, at the mother level, the education of the mother played a significant role in reducing diarrhea among children under five-years of age (0-59 months).DISCUSSION: The results of the study contribute to the literature by highlighting that it is an interplay of factors that result in diarrhea. Hence, improving the source of drinking water, e.g., tap water and bottled water, can decrease the occurrence of diarrhea, especially in poor households. It was also revealed that households with a toilet facility of flush have less probability of their children being diagnosed with diarrhea than toilet facilities in open drains and fields. On the child level, results suggested that birth order matters as well, with the firstborn child having a lower probability of contracting diarrhea than siblings born after.APPLICATION TO PRACTICE: Interventions targeting infants and mothers of infants aimed at reducing diarrhea are expected to be very effective to reduce child mortality, one of the main child health challenges faced by Pakistan.

This dissertation covers topics related to education in Indonesia. Each chapter puts forward empirical evidence relevant to policies. The first essay attempts to capture learning progress from Indonesia’s PISA results from 2012 to 2018. The essay specifically examines the robustness of Indonesia’s PISA trends from changes in demographic composition, enrollment rate, and representativity of the PISA sample. The second and third essays study supply-side policies to improve education outcomes. The second essay investigates whether doubling teachers’ salary through a teacher certification program enhances learning outcomes. The third essay studies whether there are spillover effects of establishing new early childhood services in poor rural areas on the outcome of children not participating in those centers. The dissertation appeals to a broader debate of what works and what does not to enhance learning outcomes in Indonesia.

Rapid global urbanisation has seen a growing number of urban poor who lack natural endowments to cope with food shortages. Broadening their safety nets merits urgent political attention but requires understanding their profiles. A survey among 88 urban poor in Benin found that they had low educational and income levels, overcrowded and unsanitary housing conditions, and limited access to social services and health facilities; 76 per cent of them were food insecure, influenced by city, gender, ownership of a motorbike, and access to health facilities. Engaging them in allotment gardens requires farming skills, financial capital, and safety issues.

In Massafer Yatta–Hebron Governorate, around 1,400 Palestinian people are herding sheep and goats and live in caves and movable tents without a water network or sewer system. In the winter season rainwater is harvested for drinking purposes and stored in underground cisterns. Yet, spo-radic water quality tests indicated a contamination level of micro-organisms ranging from 20 to 100 Colony Forming Unit (CFU/100 mL). In this area, rife with political conflicts, connection to a piped network seems unsure, at best, and calls for using natural and available resources to filter clean and potable water are justified. This study addresses these social requests by testing the efficiency of Thermo Tolerant Coliform removal (TTC) using bio-sand filters (BSFs) under real conditions in a full factorial design of experiment. The dependent variables are charge volume, age of BSF, the outside temperature, residential time, turbidity, water sources, and free chlorine contents. The inde-pendent variables are volume of BSF and sand grain size. The result shows that the 5 h residence time of water and the media age of more than one month is significant to remove the TTC from drinking water with P-values of 0.0439 and 0.0089, respectively. Water with 500 CFU/100 mL, TTC needs more than 5 h residence time to reduce the TTC below the 10 CFU/100 mL. Turbidity and sources of drinking water did not affect the removal of TCC, yet, using 0.18 mm effective sand grain size was significant in removing TTC. The adoption of a 23 h water residency period was the most important of all operating parameters including the 0.18 mm effective sand size to remove about 99.8% of TTC. This study recommends a BSF that generates more than 20 L in 23 h, and the BSF Schmutzdeke should be replaced every 4 y.

In this paper we evaluate the impact of road development on household welfare in rural Papua New Guinea (PNG) between 1996 and 2010, using two geocoded cross-sectional national household surveys and corresponding road maps. We make use of time-variation in road surface type and condition as recorded in PNG’s National Road Asset Management System, focusing on routes that connect rural households to urban areas. To tackle endogenous placement of road infrastructure programs, we employ a correlated random effects model that controls for the location-specific average road quality over the period of analysis. We also use a newly developed generalised quantile regression method to investigate whether road works favour the poor. Our estimates show that better roads to nearest towns lead to higher consumption levels and housing quality, and to less reliance on subsistence farming. The effects are stronger among poor and remote households.

Background Out- of-pocket health expenditures (OOPs) constitute a significant proportion of total health expenditures in many low- and middle-income countries (LMICs), leading to an increased likelihood of exposure to financial catastrophe in the event of illness. Health insurance has the potential to reduce catastrophic health expenditures (CHE), but rigorous evidence of its sustained impact is limited, especially in LMICs. This study examined the short- and longer-term effects of a health insurance program in Kwara State, Nigeria on CHE. Methods The analysis is based on a panel dataset consisting of 3 waves of household surveys in program and comparison areas. The balanced data consists of 1,039 households and 3,450 individuals. We employed a difference-in-differences (DiD) regression approach to estimate intention-to-treat effects, and then computed average treatment effects on the treated by combining DiD with propensity score weighting and an instrumental variables analysis. CHE was measured as OOPs exceeding 10% of household consumption and 40% of capacity-to-pay (CTP). Results Using 10% of consumption as a CHE measure, we found that living in the program area was associated with a 4.3 percentage point (pp) decrease in CHE occurrence (p p p p Conclusion These findings highlight the critical role of health insurance in reducing the likelihood of catastrophic health expenditures, especially for vulnerable populations such as the poor and the chronically ill, and by extension in achieving universal health coverage. They also show that the beneficial impacts of health insurance may attenuate over time, as households potentially adjust their health-seeking behavior to the new scheme.

Background Bangladesh has experienced tremendous change in child nutrition over the past few decades, but there are large differences between different regions in progress made. The question is whether continuation of current policies will bring the progress needed to reach national and international targets on child nutrition security. Data and methods Using national data BDHS 1996/97, 2014, and 2017, this study attempts to map such reductions across Bangladesh and to explore the distribution of covariate effects (joint effects) that are associated with childhood stunting over these two periods, overall and by region. The main contribution of this paper is to link observed stunting scores to a household profile. This implies that different variables are evaluated jointly with stunting to assess the likelihood of being associated with stunting. Results Overall, the covariates: ‘Parental levels of education’, ‘children older than one year old’, ‘children live in rural area’, ‘children born at home’ formed the country winning profile in 1996/97, whereas parental levels of education disappear in the winning profile for children stunted in 2014. This implies that over the years, Bangladesh has been successful in addressing parental education for long-term reductions in child undernutrition. In addition, the diversity of profiles of households with stunted children increases over time, pointing at successful targeting of policies to increase food security among children over the period. However, in areas where improvements have been insignificant, also the profiles remain stable, indicating a failure of policies to reach the target populations. The analysis for 2017 confirms this picture: the diversity of profiles remains high, with little change in the dominant profiles. Conclusion Further decline in stunting is possible through region specific multipronged interventions, targeting children older than one year among vulnerable groups, in addition with strengthening family planning programs as larger families also have a higher risk to have stunted children. In general, the profiles in 2014 and 2017/18 are much more diverse than in 1996, which can be explained by the relative success of specific targeted policies in some divisions, while being much less successful in other regions. In sum, our results suggest that the challenge lies in the implementation of policies, rather than in the generic approach and assumed theory of change.

India has been hard-hit by the Covid-19 pandemic. The virus has exacted a heavy toll in terms of lives lost and deteriorating health outcomes. The economic consequences of the pandemic have been similarly grim. In this paper we attempt an initial, interim, assessment of the impacts of the crisis on poverty. We review the growing literature that considers emerging poverty impacts, noting that there remain significant knowledge gaps due to limited evidence on current welfare outcomes. We analyze pre-Covid survey data to examine the incidence of chronic poverty and downward mobility during a period of rapid economic growth and declining poverty. A profile of poverty during such a period might offer a plausible, partial, window on population groups currently at risk. We suggest that, notwithstanding the severe initial impacts of the crisis on poverty, there are grounds for expecting further consequences going forward. As the virus has spread out of the relatively affluent cities, and as economic stagnation persists, rural areas, with historically higher rates of chronic poverty and vulnerability, may see particularly sharp increases in poverty. While recent vaccination developments offer some grounds for optimism, there remains an urgent need to identify, implement and amplify effective policy alleviation measures.

The COVID-19 pandemic has painfully exposed the constraints of fragile health systems in low- and middle-income countries, where global containment measures largely set by high-income countries resulted in disproportionate collateral damage. In Africa, a shift is urgently needed from emergency response to structural health systems strengthening efforts, which requires coordinated interventions to increase access, efficiency, quality, transparency, equity, and flexibility of health services. We postulate that rapid digitalization of health interventions is a key way forward to increase resilience of African health systems to epidemic challenges. In this paper we describe how PharmAccess' ongoing digital health system interventions in Africa were rapidly customized to respond to COVID-19. We describe how we developed: a COVID-19 App for healthcare providers used by more than 1,000 healthcare facilities in 15 African countries from May–November 2020; digital loans to support private healthcare providers with USD 20 million disbursed to healthcare facilities impacted by COVID-19 in Kenya; a customized Dutch mobile COVID-19 triage App with 4,500 users in Ghana; digital diaries to track COVID-19 impacts on household expenditures and healthcare utilization; a public-private partnership for real-time assessment of COVID-19 diagnostics in West-Kenya; and an expanded mobile phone-based maternal and child-care bundle to include COVID-19 adapted services. We also discuss the challenges we faced, the lessons learned, the impact of these interventions on the local healthcare system, and the implications of our findings for policy-making. Digital interventions bring efficiency due to their flexibility and timeliness, allowing co-creation, targeting, and rapid policy decisions through bottom-up approaches. COVID-19 digital innovations allowed for cross-pollinating the interests of patients, providers, payers, and policy-makers in challenging times, showing how such approaches can pave the way to universal health coverage and resilient healthcare systems in Africa.

Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of the United Nations Sustainable Development Goal 3. Value-based healthcare (VBHC) has the potential to outperform traditional supply-driven approaches in changing this dismal situation, and significantly improve maternal, neonatal and child health (MNCH) outcomes. We developed a theory of change and used a cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated in Kenya. At the core of the approach was a value-based care bundle for maternity care, with predefined cost and quality of care using WHO guidelines and adjusted to the risk profile of the pregnancy. The care bundle was implemented using a digital exchange platform that connects pregnant women, clinics and payers. The platform manages financial transactions, enables bi-directional communication with pregnant women via SMS, collects data from clinics and shares enriched information via dashboards with payers and clinics. While the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a predictable cost per enrolled person. This community case study shows that implementation of the VBHC framework in an LMIC setting is possible for MNCH. The incremental, cohort-based approach enabled iterative learning processes. This can support the restructuring of health systems in low resource settings from an output-driven model to a value based financing-driven model.

Introduction Inadequate, inefficient and slow processing of claims are major contributors to the cost of health insurance schemes, and therefore undermining their sustainability. This study uses the Technology, Organisation and Environment (TOE) framework to examine the preparedness of health facilities of the Christian Health Association of Ghana (CHAG) to implement a digital mobile health insurance claims processing software (CLAIM-it), which aims to increase efficiency. Methods The study used a cross-sectional mixed method design to collect data (technology and human capital capacity and baseline operational performance of claims management) from a sample of 20 CHAG health facilities across Ghana. While quantitative data was analysed using simple descriptive statistics statistics (frequencies, mean, minimum and maximum values), qualitative interviews were recorded, transcribed and abstracted into two major themes that were reported to re-enforce the quantitative findings. Results The quantitative results revealed challenges including inadequate computers and accessories, adequate numbers and skills for claims processing, poor intranets and internet access, absence of a robust post-implementation support system and inadequate standard operating procedures (SOPs) for seamless automation of claims processing. In addition to the above, the qualitative results emphasised the need to make CLAIM-it more flexible and capable of being integrated into third-party softwares. Notwithstanding the challenges, decision-makers in CHAG health facilities see the CLAIM-it software as having better functionality and superior capabilities compared to existing claims processing systems in Ghana. Conclusion Notwithstanding the challenges, the CLAIM-it software is more likely to be adopted by decision-makers, given the positive perception in terms of superior functionality. It is important that key actors in claims management at the National Health Insurance collaborate with relevant stakeholders to adopt the CLAIM-it software for claims processing and management in Ghana.

In Kenya, early coronavirus disease (COVID-19) modeling studies predicted that disruptions in antenatal care and hospital services could increase indirect maternal and neonatal deaths and stillbirths. As the Kenyan government enforced lockdowns and a curfew, many mothers-to-be were unable to safely reach hospital facilities, especially at night. Fear of contracting COVID-19, increasing costs of accessing care, stigma, and falling incomes forced many expectant mothers to give birth at home. MomCare, which primarily serves communities in remote areas and urban slums, links mothers-to-be with payers and health care providers, following a standardized pregnancy program based on World Health Organization guidelines at a predetermined cost and quality. Expectant mothers gain access to care through a mobile wallet on their feature phone (voice, text, and basic internet), and providers are paid after appropriate care is given. Within the first 3 weeks of the pandemic in Kenya, the following services were added to the MomCare bundle: emergency ambulance services during curfew hours, extended bed allowances to encourage early care, phone calls to check on mothers approaching their delivery dates and to promote the generation of a birth plan, SMS messages to inform mothers of open facilities and COVID-19 protocols, and training for clinic staff in managing COVID-19 patients and infection prevention. We compare data collected through the MomCare platform during the 6 months before the first confirmed COVID-19 case in Kenya (September 2019-February 2020) with data collected during the 6 months that followed. This study shows that care-seeking behaviors (enrollment, antenatal/postnatal care, skilled deliveries) increased for mothers-to-be enrolled in MomCare during the COVID-19 lockdowns, while quality of care and outcomes were maintained. Public health practitioners can promote interactive, patient-driven technology like MomCare to augment traditional responses, quickly linking payments with patients and providers in times of crisis.

CONTEXT Since 1980, China has made impressive progress in increasing agricultural production, improving food security and reducing rural poverty. Increased use of chemical fertilizer has played a vital role in this, but presently fertilizer overuse is posing severe challenges for the environment and human health. In response to this, the Chinese government has announced policies to reduce chemical fertilizer use, while at the same time supporting rural incomes and maintaining food self-sufficiency in major grains. OBJECTIVE The objective of the paper is to assess the effectiveness of these policies in reducing the nutrient surpluses, maintaining food self-sufficiency and supporting rural incomes throughout China. METHODS We use a spatially and socially detailed general equilibrium model of the Chinese economy to simulate the potential impact of these policies on agricultural production, environmental pollution and rural incomes. The scenarios are developed in a step-wise fashion to show the contribution of specific measures included in the policies. RESULTS AND CONCLUSIONS Our main results are that nitrate surpluses can be reduced by more than 50% and phosphate surpluses even by more than 75% without significant negative impacts on China's food self-sufficiency, provided that the government adopts appropriate policy combinations. At the same time, the income of the average crop farmer goes up slightly compared to the business-as-usual scenario. However, the spatial variability is large, requiring supplementary targeted income support measures, particularly in poverty-stricken provinces like Shaanxi, Chongqing, Guizhou and Yunnan where also the income gains of the new policies are below average. SIGNIFICANCE The results show that appropriate policy combinations should address both the efficiency of chemical fertilizer use and the intensity of organic fertilizer use. Hence, substantial efforts are necessary in mobilizing stakeholder involvement in implementing the policies.

The Nyangatom, in South Omo, Ethiopia, are a group of agro-pastoralists whose access to land is affected by large-scale sugarcane development projects. An informed selection of appropriate livestock management measures by local communities requires a spatially explicit representation of prevailing and changing supply–demand relationships for livestock herds among the Nyangatom. This study addresses this caveat and identifies seasonal and location-specific ‘hotspots’ in Nyangatom, where fodder demand exceeds supply. Assessments of fodder production are based on primary data collected through focus group discussions, key informant interviews, and field observations. Overall, annual fodder availability is estimated at 508,967 tonnes against the requirement of 584,205 tons, resulting in a deficit of 12.9% annually after out-migration. Under the implementation of the Omo-V sugarcane project and climate change, the fodder supply deficit will worsen to 219,977 tonnes annually. The most critical dry matter hotspots are found in the western and central parts of Nyangatom near the Kibish River, which shows the highest livestock density. In contrast, better fodder supply is estimated around the southwestern and northeastern parts. Change in policy, the frequency of droughts, conflict, and the large-scale irrigation schemes-induced reduction of the Omo River floods are accounted for the changes. Thus, there are strong signals to the local community and government to collaborate to reduce the potential constraints that affect sustainable rangeland management and food security and ensure sufficient attention to the interest of the agro-pastoralists.

PurposeChina's Government in 2015 announced its goal of stabilizing the use of fertilizers and pesticide by the year 2020. However, implementation of effective policies is not straightforward, while one may even argue that the policy goal is by far not ambitious enough. Hence, it is useful to look at experiences of other countries that have gone through a similar process. In this paper, the authors explicitly consider the case of European Union's (EU’s) policies aimed at greening agriculture. The choice for the EU is motivated by the fact that the EU is about 35 years ahead of China in implementing a policy agenda to counter the problems China is facing now.Design/methodology/approachIn this paper, the authors focus on agricultural inputs, in particular fertilizer and pesticides, as well as land use and their impact on food safety, air and water quality, soil degradation, greenhouse gas (GHG) emissions and biodiversity. Policies related to those issues are discussed for both, China and the EU. Given that implementation and monitoring are critical for the success of policies, the authors also discuss how policies are implemented and monitored under different governance and institutional conditions.FindingsFrom the EU experiences, positive and negative, three central lessons are drawn: (1) China should strive for cross compliance but in two steps. In the first step, arrangements for on-farm monitoring must be made, coupled with a pilot program of cross-compliance conditions for large farms in selected counties; in the second step, cross-compliance requirements must be introduced for all farmers, with additional funds for rural development in vulnerable areas. (2) Strong stakeholder commitment should be sought in the formulation as well as implementation of greening policies. (3) Monitoring of greening results should be harmonized and standardized across the country, with a limited number of indicators.Originality/valueThis paper contributes to the policy discussion by comparing the agricultural greening measures in the EU (which was some 35 years ago in the same situation as China now) with the measures taken in China so far.

This paper examines the child development outcomes of two cohorts of children who were exposed to the same intervention at different points in time. One cohort was eligible to access playgroups during the first year of a five-year project cycle, beginning at age four. The other cohort became eligible to access these services during the third year of a five-year project cycle, beginning at age three. The younger cohort was more likely to be exposed to playgroups for longer and at more age-appropriate times relative to the older cohort. The paper finds that enrollment rates and enrollment duration in preprimary education increased for both cohorts, but the enrollment effects were larger for the younger cohort. In terms of child development outcomes, there were short-term effects at age five that did not last until age eight, for both cohorts. Moreover, the younger cohort had substantially higher test scores during the early grades of primary school, relative to the older cohort. We document the extent to which program impacts can vary as a result of differences in project implementation.

In previous studies mainly focusing on determinants of adaptation, evidence of the dynamic process of adaptation decision-making is negligible. The objective of this study was to investigate the effects of socio-cultural factors, changes in household characteristics, and climate variables on the transition from non-use to use of adaptation strategies. The study integrated primary data collected from households with secondary rainfall and temperature data. The quantitative and qualitative data were analysed using a dynamic random-effects probit model and a thematic approach, respectively. The result shows strong evidence of path dependence in which use of a strategy during the previous year significantly increases its current use. Climate-related risk perception and factual knowledge may not necessarily prompt adaptation action, whereas access to financial resources and farming-related trainings were consistent positive predictors of farmers&rsquo, adaptation decisions. The findings entail that economic capacity and the associated intrinsic motivation help few farmers to utilise robust and contesting adaptation strategies. For most households, economic problems and the consequent fatalistic attitude and risk-avoidance behaviour induce either non-use or use of responsive and accommodating strategies aimed at ensuring survival. Path dependence in non-use of adaptation strategies and sub-optimal adaptation actions demand effective institutional supports to address the behavioural and economic barriers of these households in order to build overall community resilience.

In sub-Saharan Africa, accessibility to affordable quality care is often poor and health expenditures are mostly paid out of pocket. Health insurance, protecting individuals from out-of-pocket health expenses, has been put forward as a means of enhancing universal health coverage. We explored the utilization of different types of healthcare providers and the factors associated with provider choice by insurance status in rural Nigeria. We analysed year-long weekly health diaries on illnesses and injuries (health episodes) for a sample of 920 individuals with access to a private subsidized health insurance programme. The weekly diaries capture not only catastrophic events but also less severe events that are likely underreported in surveys with longer recall periods. Individuals had insurance coverage during 34% of the 1761 reported health episodes, and they consulted a healthcare provider in 90% of the episodes. Multivariable multinomial logistic regression analyses showed that insurance coverage was associated with significantly higher utilization of formal health care: individuals consulted upgraded insurance programme facilities in 20% of insured episodes compared with 3% of uninsured episodes. Nonetheless, regardless of insurance status, most consultations involved an informal provider visit, with informal providers encompassing 73 and 78% of all consultations among insured and uninsured episodes, respectively, and individuals spending 54% of total annual out-of-pocket health expenditures at such providers. Given the high frequency at which individuals consult informal providers, their position within both the primary healthcare system and health insurance schemes should be reconsidered to reach universal health coverage.

Introduction:a subsidized community health insurance programme in Kwara State, Nigeria was temporarily suspended in 2016 in anticipation of the roll-out of a state-wide health insurance scheme. This article reports the adverse consequences of the scheme´s suspension on enrollees´ healthcare utilization. Methods:a mixed-methods study was carried out in Kwara State, Nigeria, in 2018 using a semi-quantitative cross-sectional survey amongst 600 former Kwara community health insurance clients, and in-depth interviews with 24 clients and 29 participating public and private healthcare providers in the program. Both quantitative and qualitative data were analyzed and triangulated. Results:most of former enrollees (95.3%) kept utilizing programme facilities after the suspension, mainly because of the high quality of care. However, majority of the enrollees (95.8%) reverted to out-of-pocket payment while 67% reported constraints in payment for healthcare services after suspension of the program. In the absence of insurance, the most common coping mechanisms for healthcare payment were personal savings (63.3%), donations from friends and families (34.7%) and loans (11.8%). Being a male enrollee (odd ratio=1.61), living in a rural community (odd ratio =1.77), exclusive usage of Kwara Community Health Insurance Programme (KCHIP) prior to suspension (odd ratio=1.94) and suffering an acute illness (odd ratio=3.38) increased the odds of being financially constrained in accessing healthcare. Conclusion:after the suspension of the scheme, many enrollees and health facilities experienced financial constraints. These underscore the importance of sustainable health insurance schemes as a risk-pooling mechanism to sustain access to good quality health care and financial protection from catastrophic health expenditures.

Ever since the introduction of the concept of the Water-Energy-Food Nexus in 2011, interlinkages between water, energy and food supply have gained increasing attention in scholarly articles. This attention is fully justified, given the many connections between the need to feed another 2 billion people, the need to adapt to climate change and the need to achieve a successful energy transition. However, so far, the outcomes of the Water-Energy-Food Nexus research are not concrete enough to guide actual policy making. This lack of concrete results applies not only to economy-wide research but also to sectoral studies, including those on crop farming.Therefore, we present in this chapter the structure of a farm optimization model as tool of analysis for assessing the reaction of a ‘representative’ farmer in a specific region to changing conditions of water availability, energy supply and food markets. Model simulations can be used as input for policy discussions; specifically, it has been designed to study the impact of water shortages and water salinity on food production and farm incomes, while it also accounts for the possibility for farmers to install solar panels on their land. Although the application discusses the Jordan River Basin, the approach is applicable also to other regions, with their own characteristics and own policy choices.The model is rooted in micro-economic theory, but relies heavily also on agronomic knowledge and process-based data of, for example, irrigation capacities and solar panel yields. In the model, the farmer makes an optimal choice of competing cropping and solar panel activities, at given quality and quantity of land and water resources, technical constraints and market prices.

ObjectivesTo examine the determinants of the continuum of maternal care from an integrated perspective, focusing on how key components of an adequate journey are interrelated.DesignA facility-based prospective cohort study.Setting25 health facilities across three counties of Kenya: Nairobi, Kisumu and Kakamega.ParticipantsA total of 5 879 low-income pregnant women aged 13–49 years.Outcome measuresOrdinary least squares, Poisson and logistic regression models were employed, to predict three key determinants of the continuum of maternal care: (i) the week of enrolment at the clinic for antenatal care (ANC), (ii) the total number of ANC visits and (iii) utilisation of skilled birth attendance (SBA). The interrelationship between the three outcome variables was assessed with structural equation modeling.ResultsEach week of delayed enrolment in ANC reduced the number of ANC visits by 3% (incidence rate ratio=0.967, 95% CI 0.965 to 0.969). A higher number of ANC visits increased the relative probability of using SBA (odds ratio=1.28, 95% CI 1.22 to 1.34). The direct association between late enrolment and SBA was positive (odds ratio=1.033, 95% CI 1.02 to 1.04). Predisposing factors (age, household head’s education), enabling factors (wealth, shorter distance, rural area) and need factors (risk level of pregnancy, multigravida) were positively associated with adherence to ANC.ConclusionThe results point towards a domino-effect and underscore the importance of enhancing the full continuum of maternal care. A larger number of ANC visits increases SBA, while early initiation of the care journey increases the number of ANC visits, thereby indirectly supporting SBA as well. These beneficial pathways counteract the direct link between enrolment and SBA, which is partly driven by pregnant teenagers who both enrol late and are at heightened risk of complications, stressing the need for specific attention to this vulnerable population.

This study employs a synthetic panel approach based on nationally representative micro-level data to track poverty and income mobility in Malaysia in 2004–16. On aggregate, there were large reductions in chronic poverty and increases in persistent economic security, but those who remained poor in 2016 were increasingly likely to be poor in a structural sense. Further, the poverty and income dynamics differ notably across geographic dimensions. Such disparities are most striking when comparing affluent urban Peninsular Malaysia with poorer rural East Malaysia. Although there are important differences in welfare levels between the main ethnic groups in Malaysia, the mobility trends generally point in the same direction. While the findings show that there is still scope for poverty reduction through the reduction of interethnic inequalities, the study underscores the importance of taking regional inequalities into account to ensure a fairer distribution of socioeconomic opportunities for poor and vulnerable Malaysians. Hence, addressing chronic poverty is likely to require additional attention to less developed geographic areas, as a complement to the current policies that are largely ethnicity-based.

Harsh weather patterns that are unpredictable owing to climate change, remoteness, dependence on food imports and limited local food production place Arctic and Subarctic food systems under serious pressure. The model of food sovereignty provides a surprisingly interesting contribution to address the food insecurity in these regions; it promotes long-term stable provision of healthy foods (sustainable) that are accessible to all (equity) and fosters local food production–consumption patterns (localisation). This study aims to deepen the understanding of food insecurity in the Subarctic regions and explores the possibilities for a food sovereignty approach at both individual and regional level. The study focuses on Whitehorse, capital of Yukon, Canada, and uses a cross-sectional online survey among residents of Whitehorse and semi-structured in-depth interviews with food-systems experts in Yukon. The findings indicated a need for affordable year-round local food production. Application of food sovereignty has provided the opportunities for local food procurement, innovation hubs, and several types of greenhouses including hydroponics and vertical farming, to work towards a more localised food system, thereby improving food security and sovereignty in Yukon. The findings constitute the scientific knowledge base for the formulation of prospective scenarios in the spirit of the food sovereignty theory.

This symposium issue speaks to the topic of poverty dynamics and vulnerability during an unusual, unexpected and damaging global pandemic. We provide here an introduction and overview to the symposium.

Background Universal Health Coverage ensures access to quality health services for all, with no financial hardship when accessing the needed services. Nevertheless, access to quality health services is marred by substantial resource shortages creating service delivery gaps in low-and middle-income countries, including Kenya. The Innovative Partnership for Universal Sustainable Healthcare (i-PUSH) program, developed by AMREF Health Africa and PharmAccess Foundation (PAF), aims to empower low-income women of reproductive age and their families through innovative digital tools. This study aims to evaluate the impact of i-PUSH on maternal and child health care utilization, women’s health including their knowledge, behavior, and uptake of respective services, as well as women’s empowerment and financial protection. It also aims to evaluate the impact of the LEAP training tool on empowering and enhancing community health volunteers’ health literacy and to evaluate the impact of the M-TIBA health wallet on savings for health and health insurance uptake. Methods This is a study protocol for a cluster randomized controlled trial (RCT) study that uses a four-pronged approach—including year-long weekly financial and health diaries interviews, baseline and endline surveys, a qualitative study, and behavioral lab-in-the-field experiments—in Kakemega County, Kenya. In total, 240 households from 24 villages in Kakamega will be followed to capture their health, health knowledge, health-seeking behavior, health expenditures, and enrolment in health insurance over time. Half of the households live in villages randomly assigned to the treatment group where i-PUSH will be implemented after the baseline, while the other half of the households live in control village where i-PUSH will not be implemented until after the endline. The study protocol was reviewed and approved by the AMREF Ethical and Scientific Review Board. Research permits were obtained from the National Commission for Science, Technology and Innovation agency of Kenya. Discussion People in low-and middle-income countries often suffer from high out-of-pocket healthcare expenditures, which, in turn, impede access to quality health services. Saving for healthcare as well as enrolment in health insurance can improve access to healthcare by building capacities at all levels—individuals, families, and communities. Notably, i-PUSH fosters savings for health care through the mobile-phone based “health wallet,” it enhances enrolment in subsidized health insurance through the mobile platform—M-TIBA—developed by PAF, and it seeks to improve health knowledge and behavior through community health volunteers (CHVs) who are trained using the LEAP tool—AMREF’s mHealth platform. The findings will inform stakeholders to formulate better strategies to ensure access to Universal Health Coverage in general, and for a highly vulnerable segment of the population in particular, including low-income mothers and their children. Trial registration Registered with Protocol Registration and Results System (protocol ID: AfricanPHRC; trial ID: NCT04068571: AEARCTR-0006089; date: 29 August 2019) and The American Economic Association’s registry for randomized controlled trials (trial ID: AEARCTR-0006089; date: 26 June 2020).

The Indonesian government has made some ambitious steps to achieve Universal Health Coverage through the newly formed National Health Insurance [Jaminan Kesehatan Nasional (JKN)], establishing a single-payer insurance agency and prospective provider payment mechanism. This study aims to assess the benefit incidence of healthcare funding in the JKN era, and its distribution by socio-economic status considering regional variation in unit costs. We evaluate whether the benefit incidence of funding is skewed towards urban and wealthier households. We also investigate whether standard benefit incidence analysis using national unit costs underestimates regional disparities in healthcare funding. Lastly, we examine whether the design of the JKN provider payment system exacerbates regional inequalities in healthcare funding and treatment intensity. The analysis relies on Indonesia’s annual National Socio-economic Survey (Susenas) and administrative data on JKN provider payments from 2015 to 2017, combined at district level for 466 districts. We find that the benefit incidence of healthcare expenditure favours the wealthier groups. We also observe substantial variation in hospital unit costs across regions in Indonesia. As a result, standard benefit incidence analysis (using national average unit transfers) underestimates the inequality due to regional disparities in healthcare supply and intensity of treatment. The JKN provider payment seems to favour relatively wealthier regions that harbour more advanced healthcare services. Urban dwellers and people living in Java and Bali also enjoy greater healthcare benefit incidence compared to rural areas and the other islands.

This paper develops a model of healthcare demand to study healthcare choices in resourcelimited settings with poor health indicators, especially for women. Using data from rural Nigeria on individual illnesses and injuries as well as the entire portfolio of locally available providers, we estimate the effect of price, distance and quality on access to care, focussing on the heterogeneous responses to these three factors by gender. We find that women are more price sensitive than men, in particular in households where they have low bargaining power, while being equally responsive to quality or distance. Using our model to simulate ex-ante the impacts of price interventions, we predict that a full price subsidy in public clinics would substantially increase both men's and women's access to formal care, and almost eliminate the observed gender gap in formal healthcare utilization. Subsidizing both public and private clinics only marginally improves overall access, but it fully eliminates the observed gender gap in addition to broadening the capacity of the health sector to respond to increased demand when public facilities have limited capacity.

© 2021 by the authors. Licensee MDPI, Basel, Switzerland.A Rapid Food Security Appraisal among 240 rural and urban dwellers in southern Benin was conducted, using univariate and bivariate analyses, to evaluate the effects of the imposed COVID-19 ‘cordon sanitaire’ on food consumption patterns. As this is one of the first empirical studies on the COVID-19 food security nexus, we found that the raging pandemic has affected the food security pillars (availability, accessibility, utilization, and stability) in both rural and urban areas, within and outside the cordon sanitaire. The steepest decline was observed among respondents who live inside the cordon sanitaire, where rural producers and urban inhabitants without access to allotment gardens were hit hard. Increased food prices, disruptions in food logistics, and inability to work due to movement restrictions were most frequently indicated as reasons for the decline. Access to allotment gardens effectively supported households in mitigating the effects of the COVID-19 pandemic on the food crisis.

The push towards the transformation of subsistence smallholder farming into market-oriented agribusiness has been in the public policy debates of many low- and middle-income countries, including Kenya. While various studies have highlighted the lack of livelihood capital as a reason for most smallholders not to diversify into agribusiness. How these livelihood capitals influence smallholders' decisions and choices have, however, only been partially researched. Using systematic random sampling, 392 households in Western Kenya were interviewed through a researcher-administered questionnaire. The multinomial logistic regression method was used to analyze the data. The findings reveal that livelihood capitals acted in parallel and jointly to determine the decisions of smallholders to participate in agribusiness. Results show that education level, gender, landholding size, distance to markets, farm input access, and agriculture extension services positively and significantly influenced the decision choices of households to participate in agribusiness. Households with higher livelihood capital accumulation resulted in a higher probability of participating in agribusiness while those with limited livelihood capital resulted in a lower probability to participate in agribusiness. We argue that designing appropriate pro-poor targeted policy interventions to improve households’ livelihood capital could address the problem of non-participation of poor rural smallholders in agribusiness markets.

Although most micro-level studies show the positive impact of adaptation on food security and household income, these are only a few of the outcomes adaptation is intended to achieve. Farmers’ livelihoods function in complex ways such that an understanding the multidimensional outcome of adaptation is important. These necessitate the use of multiple indicators in the evaluation of the impact of adaptation. Based on data collected from 810 randomly selected households in central Ethiopia, this study investigates the impacts of adaptation strategies on the sustainability of the livelihoods of farmers. The economic, social, and environmental outcomes were integrated to construct the Livelihood Sustainability Index. The endogenous switching regression model, which accounts for unobserved heterogeneity and possible endogeneity, was used to examine the impact of using adaptation strategies. With a mean score of 41, the farmers had lower levels of livelihood sustainability. Farmers switching crop type, diversifying crops, planting improved seeds, engaging in land management activities, and using irrigation had a higher livelihood sustainability index compared to the counterfactual case in which they did not use them. Non-farm employment and migration significantly increased livelihood sustainability for the using households. However, had these factors been used by the non-users, it would have resulted in reduced livelihood sustainability. Farmers using more than four adaptation strategies had more sustainable livelihoods than using fewer strategies. The findings affirm that adaptation contributes to livelihood improvement. However, since the farmers are far from achieving a higher level of sustainable livelihoods, policies shall focus on maximizing the returns to be obtained from using adaptation strategies. This includes improving access to ecosystem services through environmental protection measures, increasing production efficiency through improved access to and proper utilization of farm inputs, expanding irrigation facilities, creating decent employment opportunities, and enhancing farmers’ skills through entrepreneurial training.

Smallholder producers in sub-Saharan Africa are often unable integrate into markets and access high-value opportunities by effectively participating in global chains for high-value fresh produce. Using data from a survey of large avocado farmers in Kenya, this study examines the determinants and impacts of smallholder-producer participation in avocado export markets on labor inputs, farm yields, sales prices, and incomes, using a switching regression framework to control for selection effects. We found that farmers who participate in export markets differ significantly from nonparticipating farmers: They are older, have somewhat larger farms, have received more training, and own more avocado trees of the Hass variety, the type favored in export markets. Living near a well-functioning avocado farmers’ group is also positively associated with participation in export markets. Participation in avocado export markets will have positive impacts on incomes, revenues, prices, and labor inputs. However, there is an offsetting effect in terms of higher prices and lower volumes, reflecting the stricter quality requirements of export markets. Applying a decomposition analysis, we found that not only differences in endowment sizes, but also differences in returns from endowments in export versus domestic markets, are key to understanding differences in yields, revenues, sales prices, and labor inputs. This suggests that policymakers should not only focus on resource accumulation for farmers, but also pay attention to the inclusiveness of export market participation for smallholder farmers.

Background: Access to and utilisation of quality maternal and child healthcare services is generally recognized as the best way to reduce maternal and child mortality.Objectives: We evaluated whether the introduction of a voluntary family health insurance programme, combined with quality improvement of healthcare facilities [The Community Health Plan (TCHP)], and the introduction of free access to delivery services in all public facilities [Free Maternity Services programme (FMS)] increased antenatal care utilisation and use of facility deliveries among pregnant women in rural Kenya.Methods: TCHP was introduced in 2011, whilst the FMS programme was launched in 2013. To measure the impact of TCHP, percentage points (PP) changes in antenatal care utilisation and facility deliveries from the pre-TCHP to the post-TCHP period between the TCHP programme area and a control area were compared in multivariable difference-in-differences analysis. To measure the impact of the FMS programme, PP changes in antenatal care utilisation and facility deliveries from the pre-FMS to the post-FMS period in the pooled TCHP programme and control areas was assessed in multivariable logistic regression analysis. Data was collected through household surveys in 2011 and 2104. Households (n=549) were randomly selected from the member lists of 2 dairy companies, and all full-term pregnancies in the 3.5 years preceding the baseline and follow-up survey among women aged 15-49 at the time of pregnancy were eligible for this study (n=295).Results: Because only 4.1% of eligible women were insured through TCHP during pregnancy, any increase in utilisation attributable to the TCHP programme could only have come about as a result of the quality improvements in TCHP facilities. Antenatal care utilisation significantly increased after TCHP was introduced (14.4 PP; 95% CI: 4.5–24.3; P=0.004), whereas no effect was observed of the programme on facility deliveries (8.8 PP; 95% CI: -14.1 to +31.7; P=0.450). Facility deliveries significantly increased after the introduction of the FMS programme (27.9 PP; 95% CI: 11.8–44.1; P=0.001), but antenatal care utilisation did not change significantly (4.0 PP; 95% CI: -0.6 to +8.5; P=0.088).Conclusion: Access to the FMS programme increased facility deliveries substantially and may contribute to improved maternal and new-born health and survival if the quality of delivery services is sustained or further improved. Despite low up-take, TCHP had a positive effect on antenatal care utilisation among uninsured women by improving the quality of existing healthcare facilities. An alignment of the two programmes could potentially lead to optimal results.Funding: The study was funded by the Health Insurance Fund (http://www.hifund.org/), through a grant from the Dutch Ministry of Foreign Affairs.Keywords: Free Maternity Services programme, maternal and child healthcare utilisation rural, Kenya, a dairy farmer population-based study.

This paper documents that children in rural Indonesia participate in a great variety of early childhood education pathways. Three key factors predict early education pathways: household wealth, mother’s education, and the quality of available services. We also find that children who enrolled in playgroup programs at age 3–4 followed by kindergarten programs at age 5–6 scored significantly higher on primary school tests than those enrolled only in playgroup programs or only in kindergarten programs. This suggests that the sequence of these pathways is important for future learning. We also provide illustrative estimates of the cost-effectiveness of different pathways. Refereed/Peer-reviewed

Background In response to the high financial burden of health services facing tuberculosis (TB) patients in China, the China-Gates TB project, Phase II, has implemented a new financing and payment model as an important component of the overall project in three cities in eastern, central and western China. The model focuses on increasing the reimbursement rate for TB patients and reforming provider payment methods by replacing fee-for-service with a case-based payment approach. This study investigated changes in out-of-pocket (OOP) health expenditure and the financial burden on TB patients before and after the interventions, with a focus on potential differential impacts on patients from different income groups. Methods Three sample counties in each of the three prefectures: Zhenjiang, Yichang and Hanzhong were chosen as study sites. TB patients who started and completed treatment before, and during the intervention period, were randomly sampled and surveyed at the baseline in 2013 and final evaluation in 2015 respectively. OOP health expenditure and percentage of patients incurring catastrophic health expenditure (CHE) were calculated for different income groups. OLS regression and logit regression were conducted to explore the intervention’s impacts on patient OOP health expenditure and financial burden after adjusting for other covariates. Key-informant interviews and focus group discussions were conducted to understand the reasons for any observed changes. Results Data from 738 (baseline) and 735 (evaluation) patients were available for analysis. Patient mean OOP health expenditure increased from RMB 3576 to RMB 5791, and the percentage of patients incurring CHE also increased after intervention. The percentage increase in OOP health expenditure and the likelihood of incurring CHE were significantly lower for patients from the highest income group as compared to the lowest. Qualitative findings indicated that increased use of health services not covered by the standard package of the model was likely to have caused the increase in financial burden. Conclusions The implementation of the new financing and payment model did not protect patients, especially those from the lowest income group, from financial difficulty, due partly to their increased use of health service. More financial resources should be mobilized to increase financial protection, particularly for poor patients, while cost containment strategies need to be developed and effectively implemented to improve the effective coverage of essential healthcare in China. Electronic supplementary material The online version of this article (10.1186/s40249-019-0532-x) contains supplementary material, which is available to authorized users.

ObjectivesTo examine changes in the screening, diagnosis, treatment and management of drug-resistant tuberculosis (DRTB) patients, and investigate the impacts of DRTB-related policies on patients of different demographic and socioeconomic characteristics.DesignA retrospective cohort study using registry data, plus a survey on DRTB-related policies.SettingAll prefecture-level Centres for Disease Control in Zhejiang Province, China.Main outcome measuresAlongside the care cascade, we examined: (1) reported number of presumptive DRTB patients; (2) percentage of presumptive patients with drug susceptibility testing (DST) records; (3) percentage of DRTB/rifampicin-resistant (RR) patients registered; (4) percentage of RR/multidrug-resistant TB (MDRTB) patients that received anti-DRTB treatment; and (5) percentage of RR/MDRTB patients cured/completed treatment among those treated. Multivariate logistic regressions were conducted to explore the impacts of DRTB policies after adjusting for other factors.ResultsThe number of reported presumptive DRTB patients and the percentage with DST records largely increased during 2015–2018, and the percentage of registered patients who received anti-DRTB treatment also increased from 59.0% to 86.5%. Patients under the policies of equipping GeneXpert plus expanded criteria for DST had a higher likelihood of being registered compared with no GeneXpert (adjusted OR (aOR)=2.57, 95% CI: 1.20 to 5.51), while for treatment initiation the association was only significant when further expanding the registration criteria (aOR=2.38, 95% CI: 1.19 to 4.79). Patients with registered residence inside Zhejiang were more likely to be registered (aOR=1.96, 95% CI: 1.52 to 2.52), treated (aOR=3.83, 95% CI: 2.78 to 5.28) and complete treatment (aOR=1.92, 95% CI: 1.03 to 3.59) compared with those outside.ConclusionThe policy changes on DST and registration have effectively improved DRTB case finding and care. Nevertheless, challenges remain in servicing vulnerable groups such as migrants and improving equity in the access to TB care. Future policies should provide comprehensive support for migrants to complete treatment at their current place of residence.

In the context of rapid urbanization, poorer residents in cities across low- and middle-income countries increasingly experience food and nutrition deficiencies. The United Nations has highlighted urban agriculture (UA) as a viable solution to food insecurity, by empowering the urban poor to produce their own fresh foods and make some profit from surplus production. Despite its potential role in reducing poverty and food insecurity, there appears to be little political will to support urban agriculture. This is seen in unclear political mandates that are sustained by information gaps on selection criteria for UA sites. The research reported here addresses this issue in the form of a decision-making support tool that assesses the suitability of cadastral units and informal plots for allotment gardens in urban and peri-urban areas. The tool was developed and tested for three rapidly expanding cities in Benin, a low-income country in West Africa, based on an ordered logit model that relates a set of 300 expert assessments on site suitability to georeferenced information on biophysical and socio-economic characteristics. Soil, land use, groundwater depth, vicinity to market and women’s safety were significant factors in the assessment. Scaled up across all cadastral units and informal sites, the tool generated detailed baseline maps on site suitability and availability of areas. Its capacity to support policymakers in selecting appropriate sites comes to the fore by reporting changes in site suitability under scenarios of improved soil fertility and enhanced safety for women.

BackgroundGlobally, the possession of medicines stored at home is increasing. However, little is known about the determinants of possessing medicines, their usage according to clinical purpose, which we term ‘correct drug match’, and the role of health insurance.MethodsThis study uses data from a 2013 survey evaluating a health insurance program in Kwara State, Nigeria, which upgraded health facilities and subsidized insurance premiums. The final dataset includes 1,090 households and 4,641 individuals. Multilevel mixed-effects logistic regressions were conducted at both the individual level and at the level of the medicines kept in respondents’ homes to understand the determinants of medicine possession and correct drug match, respectively, and to investigate the effect of health insurance on both.ResultsA total of 9,266 medicines were classified with 61.2% correct match according to self-reported use, 11.9% incorrect match and 26.9% indeterminate. Most medicines (73.0%) were obtained from patent proprietary medicine vendors (PPMVs). At 36.6%, analgesics were the most common medicine held at home, while anti-malarial use had the highest correct match at 96.1%. Antihistamines, vitamins and minerals, expectorants, and antibiotics were most likely to have an incorrect match at respectively 35.8%, 33.6%, 31.9%, and 26.6%. Medicines were less likely to have a correct match when found with the uneducated and obtained from public facilities. Enrolment in the insurance program increased correct matches for specific medicines, notably antihypertensives and antibiotics (odds ratio: 25.15 and 3.60, respectively).ConclusionSince PPMVs serve as both the most popular and better channel compared to the public sector to obtain medicines, we recommend that policymakers strengthen their focus on these vendors to educate communities on medicine types and their correct use. Health insurance programs that provide affordable access to improved-quality health facilities represent another important avenue for reducing the burden of incorrect drug use. This appears increasingly important in view of the global rise in antimicrobial resistance.

International audience; This research assesses how low-income households in rural Kenya coped with the immediate economic consequences of the COVID-19 pandemic. It uses granular financial data from weekly household interviews covering six weeks before the first case was detected in Kenya to five weeks after during which various containment measures were implemented. Based on household-level fixed-effects regressions, our results suggest that income from work decreased with almost one-third and income from gifts and remittances reduced by more than one-third after the start of the pandemic. Nevertheless, household expenditures on food remained at pre-COVID levels. We do not find evidence that households coped with reduced income through increased borrowing, selling assets or withdrawing savings. Instead, they gave out less gifts and remittances themselves, lent less money to others and postponed loan repayments. Moreover, they significantly reduced expenditures on schooling and transportation, in line with the school closures and travel restrictions. Thus, despite their affected livelihoods, households managed to keep food expenditures at par, but this came at the cost of reduced informal risk-sharing and social support between households.

There is a dearth of evidence on the socio-cultural aspects of climate change risk perception in developing countries. This study investigates the variation in farmers’ perception of the risks of climate change and variability by their socio-cultural characteristics. Data were collected from 810 randomly selected households in central Ethiopia using a structured questionnaire. Polling, a maximum likelihood prediction method of multivariate analysis that jointly evaluates the combined roles of different variables, allowing for non-parametric interactions, was used to analyse the data. The results show that households with a high risk perception have high accurate knowledge about climate change, experience of climatic events, value both societal and individual responsibilities to reduce the impact of climate change, and reside in the midland agro-ecological settings. On the other hand, a low descriptive norm, low social capital, lack of access to media, low level of education, and valuing autonomy characterize households with a low risk perception. The findings entail that communication strategies focusing on evidence-based knowledge about causes and consequences of and responses to climate change, past experience of climatic events, as well as fostering self-transcendence and openness-to-change values raise risk perception to engage farmers in adaptation actions.

This study has examined traditional coping systems, emerging adaptation strategies and barriers to the adoption of these strategies. Structured questionnaires on coping and adaptation strategies were conducted among Nyangatom households, expounded by focus group discussions and key informant interviews. Correlations between times series (1987–2016) on rainfall, temperature and the local perceptions on CC were examined. The time series analysis confirmed pastoralists' perception that the frequency of extreme drought has increased since 1987. The Nyangatom responded by temporal migration and herd diversification. Other responses include flood cultivation and enhancing alliance formation with other ethnic groups. Multi-nominal logistic regression analyses indicated that age of household head (−), livestock ownership (+), crop productivity (+), off-farm income (+) and access to climate information (+) proved to be key determinants with a statistically significant (negative or positive) effect on adoption. Other factors that hindered climate change adaption include intermittent conflicts with neighbouring ethnic groups and limited access to alternative livelihood options. Interventions to facilitate transition towards sustainable, adaptation-based communities need to incorporate deliberate, longer-term, risk-reducing strategies, including rangeland management, water harvesting and small scale-irrigation schemes. Improved education access, extension services, and a conducive pastoral policy environment will help to enhance the Nyangatom adaptive capacity.

The majority of smallholder farmers in Sub-Saharan Africa face myriad challenges to participating in agribusiness markets. However, how the spatially explicit factors interact to influence household decision choices at the local level is not well understood. This paper&rsquo, s objective is to identify, map, and analyze spatial dependency and heterogeneity in factors that impede poor smallholders from participating in agribusiness markets. Using the researcher-administered survey questionnaires, we collected geo-referenced data from 392 households in Western Kenya. We used three spatial geostatistics methods in Geographic Information System to analyze data&mdash, Global Moran&rsquo, s I, Cluster and Outliers Analysis, and geographically weighted regression. Results show that factors impeding smallholder farmers exhibited local spatial autocorrelation that was linked to the local context. We identified distinct local spatial clusters (hot spots and cold spots clusters) that were spatially and statistically significant. Results affirm that spatially explicit factors play a crucial role in influencing the farming decisions of smallholder households. The paper has demonstrated that geospatial analysis using geographically disaggregated data and methods could help in the identification of resource-poor households and neighborhoods. To improve poor smallholders&rsquo, participation in agribusiness, we recommend policymakers to design spatially targeted interventions that are embedded in the local context and informed by locally expressed needs.