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Background In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services. Methods We used data from Indian Human Development Surveys done in 2004–2005 and in 2011–2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility. Results Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8–22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI − 1.6–11.1), 26% increase in SBA (95% CI 20–31.1), and 28% increase (95% CI 22.4–32.8) in facility births. Conclusions Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services.We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness.We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points).We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors.This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ).

We explore the impacts of Malawi's national unconditional cash transfer program targeting ultra-poor households on youth mental health. Experimental findings show that the program significantly improved mental health outcomes. Among girls in particular, the program reduces indications of depression by about 15 percentage points. We investigate the contribution of different possible pathways to the overall program impact, including education, health, consumption, caregiver's stress levels and life satisfaction, perceived social support, and participation in hard and unpleasant work. The pathways explain from 46 to 65 percent of the program impact, advancing our understanding of how economic interventions can affect mental health of youth in resource-poor settings. The findings underline that unconditional cash grants, which are used on an increasingly large scale as part of national social protection systems in Sub-Saharan Africa, have the potential to improve youth mental wellbeing and thus may help break the vicious cycle of poverty and poor mental health.

Background This study explored the role of health facility availability as it relates to maternal and newborn PNC use in rural Malawi. Methods Malawi Demographic and Health Survey (MDHS) 2015–16 data, MDHS 2015–16 household cluster GPS data, Malawi Service Provision Assessment (MSPA) 2013–14 data and MSPA 2013–14 facility GPS data were used. Household clusters were spatially linked with facilities using buffers. Descriptive analyses were performed and generalized estimating equations (GEE) were used to determine the effects of having different types of facilities at varying distances from household clusters on receipt of maternal and newborn PNC in rural Malawi. Results In rural Malawi, around 96% of women had facilities providing PNC within 10 km of where they live. Among women who have clinic-level facilities within 5 km of where they live, around 25% had clinic-level facilities that provide PNC. For rural women who gave birth in the past 5 years preceding the survey, only about 3% received maternal PNC within 24 h and about 16% received maternal PNC within the first week. As for newborn PNC, 3% of newborns had PNC within 24 h and about 26% had newborn PNC within the first week. PNC mostly took place at facilities (94% for women and 95% for newborns). For women who delivered at home, having a health center providing PNC within 5 km was positively associated with maternal and newborn PNC. For women who delivered at facilities, having a health center providing PNC within 5 km was positively associated with maternal PNC and having a health center providing PNC between 5 km and 10 km was positively associated with both maternal and newborn PNC. Regardless of the place of delivery and distance band, having a clinic-level facility providing PNC did not have significant positive effects on maternal and newborn PNC. Conclusions Providers should be trained to perform quality PNC at all facilities. It would also be important to address concerns related to health workers. Lastly, it would be key to increase community awareness about the importance of seeking timely PNC and about the utility of lower-level facilities for receiving preventative PNC.

Bangladesh is undergoing a rapid urbanization process. About one-third of the population of major cities in the country live in slums, which are areas that exhibit pronounced concentrations of factors that negatively affect health and nutrition. People living in slums face greater challenge to improve their health than other parts of the country, which fuels the growing intra-urban health inequities. Two rounds of the Bangladesh Urban Health Survey (UHS), conducted in 2013 and 2006, were designed to examine the reproductive health status and service utilization between slum and non-slum residents. We applied an adaptation of the difference-in-differences (DID) model to pooled data from the 2006 and 2013 UHS rounds to examine changes over time in intra-urban differences between slums and non-slums in key health outcomes and service utilization and to identify the factors associated with the reduction in intra-urban gaps. In terms of change in intra-urban differentials during 2006–2013, DID regression analysis estimated that the gap between slums and non-slums for skilled birth attendant (SBA) during delivery significantly decreased. DID regression analysis also estimated that the gap between slums and non-slums for use of modern contraceptives among currently married women also narrowed significantly, and the gap reversed in favor of slums. However, the DID estimates indicate a small but not statistically significant reduction in the gap between slums and non-slums for child nutritional status. Results from extended DID regression model indicate that availability of community health workers in urban areas appears to have played a significant role in reducing the gap in SBA. The urban population in Bangladesh is expected to grow rapidly in the coming decades. Wide disparities between urban slums and non-slums can potentially push country performance off track during the post-2015 era, unless the specific health needs of the expanding slum communities are addressed. To our knowledge, this is the first systematic explanation and quantification of the role of various factors for improving intra-urban health equity in Bangladesh using nationally representative data. The findings provide a strong rationale for continuing and expanding community-based reproductive health services in urban areas by the NGOs with a focus on slum populations.

Ukraine is among the top 20 highest drug-resistant tuberculosis burden countries in the world. Driving the high drug-resistant tuberculosis rates is an unchecked treatment default rate. This evaluation measures the effect of social support provided to tuberculosis patients at risk of defaulting on treatment during outpatient treatment. Five tuberculosis patient cohorts, served in three oblasts from 2011 and 2012, were constructed from medical records to compare risk factors for default, receipt of social services, and treatment outcome. Regression analyses were used to identify risk factors predictive of treatment default and to estimate the impact of the social support program on treatment default, controlling for risk, disease status, and demographics. In 2012, tuberculosis patients receiving social support in Ukraine reduced their probability of defaulting on continuation treatment by 10 percentage points compared to high-risk patients who did not receive social support in 2012 or 2011. Treatment success rates for the high-risk patients receiving social support were comparable to the low-risk cohorts and significantly improved over the high-risk comparison cohorts. Further research is recommended to quantify the costs and benefits for scaling-up social support services, evaluate social support program fidelity, identify which populations respond best to select services, and what barriers might still exist to achieve better adherence. With that information, tailoring programs to most effectively reach and serve clients in a patient-centered approach may reap substantial rewards for Ukraine.

There is increasing interest in the ability of cash transfers to facilitate safe transitions to adulthood in low‐income settings; however, evidence from scaled‐up government programming demonstrating this potential is scarce. Using two experimental evaluations of unconditional cash transfers targeted to ultra‐poor and labor‐constrained households over approximately three years in Malawi and Zambia, we examine whether cash transfers delayed early marriage and pregnancy among youth aged 14 to 21 years at baseline. Although we find strong impacts on poverty and schooling, two main pathways hypothesized in the literature, we find limited impacts on safe transition outcomes for both males and females. In addition, despite hypotheses that social norms may constrain potential impacts of cash transfer programs, we show suggestive evidence that pre‐program variation in social norms across communities does not significantly affect program impact. We conclude with policy implications and suggestions for future research.

Maternal health services continue to favour the wealthiest in lower and middle income countries. Debate about the potential of performance-based financing (PBF) to address these disparities continues. As PBF is adopted by countries, it is critical to understand the equity effects for maternal services. The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population. In Rwanda, PBF was designed to increase health service use, which was universally low. Paired districts were randomly assigned to intervention and control for PBF implementation. Using Rwanda's Demographic Health Survey data from 2005 (pre-intervention) and 2007-8 (post-intervention), a cluster-level panel dataset of 7899 women 15-49 years of age from intervention (4477) and control districts (3422) was created. The impact of PBF on reported use of facility deliveries, antenatal care (ANC) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects. Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women. The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts (P = 0.014), while no significant effects were noted for ANC visits or modern contraceptive use. Service use increased for intervention and control populations and across all wealth quintiles from 2005 to 2007, with no evidence that PBF was a pro-poor or a pro-rich strategy. Insurance remained a positive predictor of service use. This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services, such as facility deliveries, may improve service use overall. However, if the equity gap is extreme, then a PBF programme without equity targets will do little to alleviate disparities.

Using the National Mexican Health and Aging Study panel dataset, the authors estimate the effect of having informal care on the probability of dying and on the change in elderly health over a two-year period. Three measures of functional health were used: self-reported health, activities of daily living, and instrumental activities of daily living. We develop an empirical strategy that relies on the panel structure of the dataset to sort out the possible correlation between unobservable characteristics that affect both elderly health and an individual's decision to provide informal care. Our findings suggest that informal care provided by daughters reduces the probability of dying. In addition, informal care provided by daughters reduces the probability of having a decline in activities of daily living and instrumental activities of daily living, while it has no effect on the observed changes in self-reported health status. The protective effect of informal care provided by sons is not statistically significant for any health outcomes. A discussion of the policy options to increase elderly health and to improve the role of caregivers is included.

This study explores the prevalence and correlates of past-year physical violence against women in slum and nonslum areas of urban Bangladesh. The authors use multivariate logistic regression to analyze data from the 2006 Urban Health Survey, a population-based survey of 9,122 currently married women aged between 15 and 49 who were selected using a multistage cluster sampling design. The prevalence of reported past-year physical spousal violence is 31%. Prevalence of past-year physical spousal violence is higher in slums (35%) than in nonslums (20%). Slapping/arm-twisting and pushing/shaking/ throwing something at the women are the most commonly reported acts of physical abuse. Multivariate analysis shows that the risk of physical spousal abuse is lower among older women, women with post—primary education, and those belonging to rich households and women whose husbands considered their opinion in decision making. Women are at higher risk of abuse if they had many children, believe that married woman should work if the husband is not making enough money, and approve wife-beating norms. This study serves to confirm the commonness of physical spousal abuse in urban Bangladesh, demonstrating the seriousness of this multifaceted phenomenon as a social and public health issue. The present findings suggest the need for comprehensive prevention and intervention strategies that capitalize on the interplay of individual and sociocultural factors that cause physical spousal violence. Our study adds to a growing literature documenting domestic violence against women in urban areas of developing south Asian nations.

The past three decades have witnessed remarkable progress in many lower income nations toward reducing fertility rates in order to stabilize population size. However in some instances this trend appears to be losing momentum perhaps as we reach what might be the limits to the effectiveness of more narrowly focused population policies that target usage of modern contraception methods. This has led to suggestions that in some societies continued progress toward stable populations will require the pursuit of more comprehensive initiatives that address broadly the human resource circumstances of mothers and their children. The purpose of this paper is to evaluate the impact of an essential health services program in Bangladesh motivated by these considerations. Researchers and policymakers have generally taken the view that parents in lower-income societies likely wish to have fewer children but are effectively constrained from doing so by a lack of effective modern family planning options. Traditional focused family planning policies (i.e. those more narrowly geared toward the promotion of modern family planning method adoption) motivated by this outlook in all likelihood played an important role in lowering the total fertility rate in many lower-income nations in recent decades. In Bangladesh this manifested itself particularly in programs designed to promote contraceptive use through doorstep delivery. However by the 1990s total fertility appeared to have leveled off at around 3.3. The apparent limits to the focused doorstep delivery approach also brought its comparative costliness into higher relief. (excerpt)

Background Performance-based financing (PBF) strategies are promoted as a supply-side, results-based financing mechanism to improve primary health care. This study estimated the effects of Rwanda’s PBF program on less-incentivized child health services and examined the differential program impact by household poverty. Methods Districts were allocated to intervention and comparison for PBF implementation in Rwanda. Using Demographic Health Survey data from 2005 to 2007–08, a community-level panel dataset of 5781 children less than 5 years of age from intervention and comparison districts was created. The impacts of PBF on reported childhood illness, facility care-seeking, and treatment received were estimated using a difference-in-differences model with community fixed effects. An interaction term between poverty and the program was estimated to identify the differential effect of PBF among children from poorer families. Results There was no measurable difference in estimated probability of reporting illness with diarrhea, fever or acute respiratory infections between the intervention and comparison groups. Seeking care at a facility for these illnesses increased over time, however no differential effect by PBF was seen. The estimated effect of PBF on receipt of treatment for poor children is 45 percentage points higher (p = 0.047) compared to the non-poor children seeking care for diarrhea or fever. Conclusions PBF, a supply-side incentive program, improved the quality of treatment received by poor children conditional on patients seeking care, but it did not impact the propensity to seek care. These findings provide additional evidence that PBF incentivizes the critical role staff play in assuring quality services, but does little to influence consumer demand for these services. Efforts to improve child health need to address both supply and demand, with additional attention to barriers due to poverty if equity in service use is a concern. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1033-7) contains supplementary material, which is available to authorized users.

Accurate knowledge of the characteristics of the health labour force that can affect health care production is of critical importance to health planners and policymakers. This study uses health facility survey data to examine characteristics of the primary health care labour force in Nicaragua, Tanzania and Bangladesh. The characteristics examined are those that are likely to affect service provision, including urban/rural distribution, demographic characteristics, and experience and in-service training, for three types of providers (physicians, nurses and auxiliary nurses). The profiles suggest a pattern of urban/rural imbalances in Nicaragua and Tanzania. The Bangladesh facility survey did not include hospitals, thereby making concrete conclusions on the supply and distribution of providers difficult to make. Multivariate logistic regressions are used to assess the relationship between the urban/rural placement of providers by health need, population demand and facility characteristics. Health need, as measured by child mortality rates, does not have a significant association with the placement of providers in either country, unlike population size and annual growth rates. The mean number of years providers have worked at a facility is significantly associated with a decreased likelihood of rural placement for the three types of providers in Nicaragua. The mean age and percentage of female providers at each facility has a negative association with the placement of rural providers in Tanzania. The use of health facility data to profile the health care labour force is also discussed.

CONTEXT: Gender inequality is a long-recognized driver of the HIV epidemic. However few studies have investigated the association between gender-based power and HIV risk in India which has the world’s third largest HIV epidemic. METHODS: Population-based data collected in 2003 from 3385 couples residing in Uttar Pradesh and Uttarakhand North India were used to examine associations between gender-based power (wife’s autonomy and husband’s inequitable gender attitudes) and indicators of couples’ HIV risk (whether the husband had had premarital sex with someone other than his eventual spouse extramarital sex in the past year or STI symptoms in the past year). Structural equation modeling was used to create composite variables for the gender-based power measures and test their associations with HIV risk measures. RESULTS: Twenty-four percent of husbands had had premarital sex 7% had had extramarital sex in the past year and 6% had had STI symptoms in the past year. Structural equation models indicated that wives who reported higher levels of autonomy were less likely than other wives to have husbands who had had extramarital sex in the past year (direct association) or STI symptoms in the past year (indirect association). Moreover husbands who endorsed more inequitable gender attitudes were more likely than others to report having had premarital sex with someone other than their spouse which in turn was associated with having had extramarital sex and STI symptoms in the past year. CONCLUSIONS: If the associations identified in this study reflect a causal relationship between gender-based power and HIV risk behavior then HIV prevention programs that successfully address inequitable gender roles may reduce HIV risks in North India.

Maternal and newborn health (MNH) is a high priority for global health and is included among the Millennium Development Goals (MDGs). However, the slow decline in maternal and newborn mortality jeopardizes achievements of the targets of MDGs. According to UNICEF, 60 million women give birth outside of health facilities, and family planning needs are satisfied for only 50%. Further, skilled birth attendance and the use of antenatal care are most inequitably distributed in maternal and newborn health interventions in low- and middle-income countries. Conditional cash transfer (CCT) programmes have been shown to increase health service utilization among the poorest but little is written on the effects of such programmes on maternal and newborn health. We carried out a systematic review of studies on CCT that report maternal and newborn health outcomes, including studies from 8 countries. The CCT programmes have increased antenatal visits, skilled attendance at birth, delivery at a health facility, and tetanus toxoid vaccination for mothers and reduced the incidence of low birthweight. The programmes have not had a significant impact on fertility while the impact on maternal and newborn mortality has not been well-documented thus far. Given these positive effects, we make the case for further investment in CCT programmes for maternal and newborn health, noting gaps in knowledge and providing recommendations for better design and evaluation of such programmes. We recommend more rigorous impact evaluations that document impact pathways and take factors, such as cost-effectiveness, into account.

This paper identifies the main gender differences in health and socio-economic characteristics of the elderly in four Latin American cities. Using locally weighted regressions as well as a flexible model specification that treats age non-parametrically, we investigate whether these unadjusted gender gaps in health are due to gender differences in the distribution of age and other explanatory variables. Interestingly, for all cities, the analyses show a gender gap in health in favour of males at each age. The gaps are larger when one uses functional impairment in mobility and personal self-care as indicators of an individual's health instead of self-reported health. Furthermore, controlling for demographic characteristics, baseline health and the availability of family support do little to change the disadvantage for women in measured health outcomes. Controlling for socio-economic variables does, however, reduce most of the gender differences in health.

Using the SABE(1) data set, this paper describes the support that the elderly receive from family members, siblings, friends and the community where they live in four Latin American cities. It also reports the activities that the elderly do for their family members. In the four distinct cities included in the study, we find similar trends in terms of living arrangements, the role of caregivers and the type of activities that elderly people provide for their family members. Our findings indicate the elderly without any support tend to be in better health and socio-economic conditions than elderly persons with family or community support; this is likely because healthier individuals need less assistance. Surprisingly, most of the elderly without any help from family members do not receive support from the community either. Daughters inside the household are the most likely caregivers and receive most assistance from the elderly in return. The exchange of services and activities within the household reflects the higher gains that female caregivers receive from taking care of elderly relatives, or the lower wages and consequently their lower cost of providing care. Among the providers of money, sons and daughters share similar characteristics. A significant number of caregivers are in the productive years of their life. A discussion of the policy options to increase elderly health and to improve the role of caregivers is included.