David H Peters

Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States

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Publications (88)371.92 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Despite progress in improving health outcomes in Afghanistan by contracting public health services through non-governmental organizations (NGOs), inequity in access persists between the poor and non-poor. This study examined the distributive effect of different contracting types on primary health services provision between the poor and non-poor in rural Afghanistan. Contracts to NGOs were made to deliver a common set of primary care services in each province, with the funding agencies determining contract terms. The contracting approaches could be classified into three contracting out types (CO-1, CO-2 and CO-3) and a contracting-in (CI) approach based on the contract terms, design and implementation. Exit interviews of patients attending randomly sampled primary health facilities were collected through systematic sampling across 28 provinces at two time points. The outcome, the odds that a client attending a health facility is poor, was modelled using logistic regression with a robust variance estimator, and the effect of contracting was estimated using the difference-in-difference approach combined with stratified analyses. The sample covered 5960 interviews from 306 health facilities in 2005 and 2008. The adjusted odds of a poor client attending a health facility over time increased significantly for facilities under CO-1 and CO-2, with odds ratio of 2.82 (1.49, 5.36) P-value 0.001 and 2.00 (1.33, 3.02) P-value 0.001, respectively. The odds ratios for those under CO-3 and CI were not statistically significantly different over time. When compared with the non-contracting facilities, the adjusted ratio of odds ratios of poor status among clients was significantly higher for only those under CO-1, ratio of 2.50 (1.32, 4.74) P-value 0.005. CO-1 arrangement which allows contractors to decide on how funds are allocated within a fixed lump sum with non-negotiable deliverables, and actively managed through an independent government agency, is effective in improving equity of health services provision. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.
    Health policy and planning. 12/2014;
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    ABSTRACT: Bangladesh has a serious shortage of qualified health workforce. The limited numbers of trained service providers are based in urban areas, which limits access to quality healthcare for the rural population. mHealth provides a new opportunity to ensure access to quality services to the population. A recent review suggested that there are 19 mHealth initiatives in the country. This paper reports findings on people's knowledge, perception, use, cost and compliance with advice received from mHealth services from a study carried out during 2012-13 in Chakaria, a rural sub-district in Bangladesh.
    PLoS ONE 11/2014; 9(11):e111413. · 3.53 Impact Factor
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    ABSTRACT: Many full-time Ugandan government health providers take on additional jobs - a phenomenon called dual practice. We describe the complex patterns that characterize the evolution of dual practice in Uganda, and the local management practices that emerged in response, in five government facilities. An in-depth understanding of dual practice can contribute to policy discussions on improving public sector performance.
    Health research policy and systems / BioMed Central. 08/2014; 12(1):41.
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    Globalization and Health 06/2014; 10(1):51. · 1.49 Impact Factor
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    Gerald Bloom, Spencer Henson, David H Peters
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    ABSTRACT: The rapid evolution and spread of health markets across low and middle-income countries (LMICs) has contributed to a significant increase in the availability of health-related goods and services around the world. The support institutions needed to regulate these markets have lagged behind, with regulatory systems that are weak and under-resourced. This paper explores the key issues associated with regulation of health markets in LMICs, and the different goals of regulation, namely quality and safety of care, value for money, social agreement over fair access and financing, and accountability. Licensing, price controls, and other traditional approaches to the regulation of markets for health products and services have played an important role, but they have been of questionable effectiveness in ensuring safety and efficacy at the point of the user in LMICs. The paper proposes a health market systems conceptual framework, using the value chain for the production, distribution and retail of health goods and services, to examine regulation of health markets in the LMIC context. We conclude by exploring the changing context going forwards, laying out implications for future heath market regulation. We argue that the case for new approaches to the regulation of markets for health products and services in LMICs is compelling. Although traditional "command and control" approaches will have a place in the toolkit of regulators, a broader bundle of approaches is needed that is adapted to the national and market-level context of particular LMICs. The implication is that it is not possible to apply standard or single interventions across countries, as approaches proven to work well in one context will not necessarily work well elsewhere.
    Globalization and Health 06/2014; 10(1):53. · 1.49 Impact Factor
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    ABSTRACT: This paper presents a system dynamics computer simulation model to illustrate unintended consequences of apparently rational allocations to curative and preventive services.
    Health research policy and systems / BioMed Central. 06/2014; 12(1):28.
  • British journal of sports medicine 04/2014; 48(8):731-6. · 3.67 Impact Factor
  • Gerald Bloom, Spencer Henson, David Peters
    Globalization and Health 01/2014; 10(a):53. · 1.49 Impact Factor
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    ABSTRACT: High maternal and infant mortality continue to be major challenges to the attainment of the Millennium Development Goals for many low and middle-income countries. There is now evidence that voucher initiatives can increase access to maternal health services. However, a dearth of knowledge exists on the cost implications of voucher schemes. This paper estimates the incremental costs of a demand and supply side intervention aimed at increasing access to maternal health care services.
    Cost Effectiveness and Resource Allocation 01/2014; 12:14. · 0.87 Impact Factor
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    ABSTRACT: In Bangladesh, rapid advancements in coverage of many health interventions have coincided with impressive reductions in fertility and rates of maternal, infant, and childhood mortality. These advances, which have taken place despite such challenges as widespread poverty, political instability, and frequent natural disasters, warrant careful analysis of Bangladesh's approach to health-service delivery in the past four decades. With reference to success stories, we explore strategies in health-service delivery that have maximised reach and improved health outcomes. We identify three distinctive features that have enabled Bangladesh to improve health-service coverage and health outcomes: (1) experimentation with, and widespread application of, large-scale community-based approaches, especially investment in community health workers using a doorstep delivery approach; (2) experimentation with informal and contractual partnership arrangements that capitalise on the ability of non-governmental organisations to generate community trust, reach the most deprived populations, and address service gaps; and (3) rapid adoption of context-specific innovative technologies and policies that identify country-specific systems and mechanisms. Continued development of innovative, community-based strategies of health-service delivery, and adaptation of new technologies, are needed to address neglected and emerging health challenges, such as increasing access to skilled birth attendance, improvement of coverage of antenatal care and of nutritional status, the effects of climate change, and chronic disease. Past experience should guide future efforts to address rising public health concerns for Bangladesh and other underdeveloped countries.
    The Lancet 11/2013; · 39.21 Impact Factor
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    ABSTRACT: Implementation research is a growing but not well understood field of health research that can contribute to more effective public health and clinical policies and programmes. This article provides a broad definition of implementation research and outlines key principles for how to do it.
    BMJ Clinical Research 11/2013; · 14.09 Impact Factor
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    ABSTRACT: SUMMARY Background After the fall of the Taliban regime, most clinics in Afghanistan were charging fees to patients. The government invested in monitoring and evaluation systems for its newly rebuilt primary care system, but little was known about the effects of user fees. This study was undertaken to provide evidence on user fees' effects on quality and service utilization and to help inform development of health financing policy and strategy. MethodsA quasi-experimental health financing pilot study was implemented in 2005. Forty-seven facilities were randomized to implement a standardized user fee intervention, offer free services, or serve as controls, continuing current cost-sharing systems. Revenues were co-managed by staff and community leaders for facility improvement. Baseline and follow-up facility assessments, exit interviews, and household surveys, as well as routine data were used to evaluate user fee effects over 2 years. ResultsObserved and perceived quality improved at most facilities but did not differ by study group. Utilization increased in all groups, but the increase was 682 to 748 visits per month larger in facilities randomized to free services compared with those randomized to fees or controls (p < 0.01). Conclusion User fees demonstrated few beneficial effects and slowed the rate of increase of service utilization in Afghanistan. In 2008, the government abolished primary care fees, citing results of this study. Copyright © 2013 John Wiley & Sons, Ltd.
    International Journal of Health Planning and Management 10/2013; 28(4). · 0.97 Impact Factor
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    ABSTRACT: Producing services efficiently and equitably are important goals for health systems. Many countries pursue horizontal equity - providing people with the same illnesses equal access to health services - by locating facilities in remote areas. Staff are often paid incentives to work at such facilities. However, there is little evidence on how many fewer people are treated at remote facilities than facilities in more densely settled areas. This research explores if there is an association between the efficiency of health centers in Afghanistan and the remoteness of their location. Survey teams collected data on facility level inputs and outputs at a stratified random sample of 579 health centers in 2005. Quality of care was measured by observing staff interact with patients and determining if staff completed a set of normative patient care tasks. We used seemingly unrelated regression to determine if facilities in remote areas have fewer outpatient visits than other rural facilities. In this analysis, one equation compares the number of outpatient visits to facility inputs, while another compares quality of care to determinants of quality. The results indicate remote facilities have about 13% fewer outpatient visits than non-remote facilities, holding inputs constant. Our analysis suggests that facilities in remote areas are realizing horizontal equity since their clients are receiving comparable quality of care to those at non-remote facilities. However, we find the average labor cost for a visit at a remote facility is $1.44, but only $0.97 at other rural facilities, indicating that a visit in a remote facility would have to be 'worth' 1.49 times a visit at a rural facility for there to be no equity - efficiency trade-off. In determining where to build or staff health centers, this loss of efficiency may be offset by progress toward a social policy objective of providing services to disadvantaged rural populations.
    Social Science [?] Medicine 07/2013; 89C:25-31. · 2.73 Impact Factor
  • David H Peters, Gerald Bloom
    Nature 03/2013; 495(7439):47. · 38.60 Impact Factor
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    ABSTRACT: Abstract The growing burden of road traffic injuries, which kill over 1.2 million people yearly, falls mostly on low- and middle-income countries (LMICs). Despite this, evidence generation on the effectiveness of road safety interventions in LMIC settings remains scarce. This paper explores a scientific approach for evaluating road safety programmes in LMICs and introduces such a road safety multi-country initiative, the Road Safety in 10 Countries Project (RS-10). By building on existing evaluation frameworks, we develop a scientific approach for evaluating large-scale road safety programmes in LMIC settings. This also draws on '13 lessons' of large-scale programme evaluation: defining the evaluation scope; selecting study sites; maintaining objectivity; developing an impact model; utilising multiple data sources; using multiple analytic techniques; maximising external validity; ensuring an appropriate time frame; the importance of flexibility and a stepwise approach; continuous monitoring; providing feedback to implementers, policy-makers; promoting the uptake of evaluation results; and understanding evaluation costs. The use of relatively new approaches for evaluation of real-world programmes allows for the production of relevant knowledge. The RS-10 project affords an important opportunity to scientifically test these approaches for a real-world, large-scale road safety evaluation and generate new knowledge for the field of road safety.
    Global Public Health 02/2013; · 0.92 Impact Factor
  • BMJ (online) 01/2013; 347:f6753. · 17.22 Impact Factor
  • David H Peters, Ligia Paina, Finn Schleimann
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    ABSTRACT: Sector-wide approaches (SWAps) in health were developed in the early 1990s in response to widespread dissatisfaction with fragmented donor-sponsored projects and prescriptive adjustment lending. SWAps were intended to provide a more coherent way to articulate and manage government-led sectoral policies and expenditure frameworks and build local institutional capacity as well as offer a means to more effective relationships between governments and donor agencies. The global health landscape has changed dramatically since then. Although many countries have undertaken SWAps, the experience deviated considerably from the early vision, and many of the problems in national health systems persist. SWAps have contributed to the development of robust national health policies and transparent expenditure frameworks as well as strengthening institutional capacity, though the levels of success vary widely. Government stewardship of donors and local stakeholders as well as their political will to implement health strategies also vary highly. Although SWAps are geared towards consensus building policy changes at the national level, in the face of urgent global health concerns, notably the HIV epidemic, donors often by-passed SWAp arrangements through global health initiatives intended to address international priorities. Yet, a key to sustaining global health initiatives is how well they can be integrated into national health systems, a task requiring a return to SWAp principles. Despite shortcomings, SWAps have remained a popular approach for supporting alignment, harmonization and improved accountability between donors and country governments, increasing predictability of aid and reducing fragmentation. The future of SWAps will depend on stronger government oversight and innovative institutional arrangements to support health strategies that address the need for both targeted initiatives and stronger health systems to provide a wide range of public health and clinical services. For development assistance to be more effective, it will also depend on better discipline by donors to support national governments through transparent negotiation.
    Health Policy and Planning 12/2012; · 2.65 Impact Factor
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    ABSTRACT: For over a decade, investments have been made to revamp health infrastructure and service delivery to ensure access and quality for the rural poor in Afghanistan. Through contracting mechanisms the delivery of a basic package of health services has achieved significant improvements in coverage for reproductive and child health services. Employing multilevel probability sampling, 7057 households were selected in communities within the public health facility catchment areas in nine provinces, in 2010. Preferential careseeking for common pediatric conditions and average costs of payment were examined based on the wealth quintile of the respondents. Results: Commonly reported conditions were those targeted by IMCI: diarrhea (7%), fever (26%) and cough (30%), with significantly lower levels of careseeking for children in the poorest quintile, though a majority sought care from public facilities. Primary reasons for not seeking care were perceived seriousness of illness (35%), lack of transport (49%) and lack of finances (41%). Multivariate analysis controlling for age and literacy of the mother and child age, illustrated that the strongest predictors for careseeking were wealth (upper 4/5ths wealth quintile OR 1.9, p <0.001), gender (males OR 1.2, p <0.05) and type of illness (Diarrhea and Respiratory illness, OR 2.8, p <0.001, and other conditions OR 2.2, p<0.001). Preferential careseeking for male children and higher payments were evident. Reported distress financing was significantly higher in the poorest quintile for hospitalizations. Additional efforts to strengthen community IMCI services and other educational measures are warranted to ensure that the poor seek care and ensure gender equity.
    140st APHA Annual Meeting and Exposition 2012; 10/2012
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    ABSTRACT: OBJECTIVE: /st>To examine the relationship between workforce capacity and quality of pediatric care in outpatient clinics in Afghanistan. DESIGN: /st>Annual national performance assessments were conducted between 2005 and 2008 to determine quality of care through patient observations in >600 health facilities, selected by stratified random sampling each year. Other variables measured were health provider capacity, competency and adequacy of support systems. SETTING: /st>Primary care facilities in 29 provinces in Afghanistan. PARTICIPANTS: /st>Pediatric patients and their caretakers greater than 2400 were selected at random each year. MAIN OUTCOME MEASURES: /st>Index of observed quality of care for patient assessment and counseling based on WHO's Integrated Management of Childhood Illness (IMCI) clinical guidelines. RESULTS: /st>Quality of care improved for all IMCI indices between 2005 and 2008 (IMCI index increased from 43.1 to 56.1; P < 0.001) and was significantly associated with the availability of doctors, IMCI training and knowledge and factors such as provider job satisfaction, availability of clinical guidelines, frequency of supervision and the presence of community councils. There was also a progressive increase in the index summarizing staffing capacity during the study period. Basic health centers increased from 75.6 to 85.5% (P < 0.001), comprehensive health centers increased from 27.9 to 37.9% (P < 0.03) and district hospitals increased from 34.1 to 37.2% (P > 0.05). CONCLUSIONS: /st>Enhancing workforce capacity and competency and ensuring appropriate supervision and systems support mechanisms can contribute to improved quality of care. Although the results indicate sustained improvements over the study period, further research on the mixture of provider skills, competency and factors influencing provider motivation are essential to determine the optimal workforce capacity in Afghanistan.
    International Journal for Quality in Health Care 10/2012; · 1.79 Impact Factor
  • Yue Xiao, Kun Zhao, David M Bishai, David H Peters
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    ABSTRACT: In 2009 the government of China identified an essential drugs policy as one of five priority areas for health system reform. Since then, a national essential drugs policy has been defined, along with plans to implement it. As a large scale social intervention, the policy will have a significant impact on various local health actors. This paper uses the lens of complex adaptive systems to examine how the policy has been implemented in three rural Chinese counties. Using material gathered from interviews with key actors in county health bureaus and township health centers, we illustrate how a single policy can lead to multiple unanticipated outcomes. The complexity lens applied to the material gathered in interviews helps to identify relevant actors, their different relationships and policy responses and a new framework to better understand heterogeneous pathways and outcomes. Decision-makers and policy implementers are advised to embrace the complex and dynamic realities of policy implementation. This involves developing mechanisms to monitor different behaviors of key actors as well as the intended outcomes and unintended consequences of the policy.
    Social Science [?] Medicine 10/2012; · 2.73 Impact Factor

Publication Stats

1k Citations
371.92 Total Impact Points


  • 2003–2014
    • Johns Hopkins Bloomberg School of Public Health
      • Department of International Health
      Baltimore, Maryland, United States
  • 2013
    • International Centre for Diarrhoeal Disease Research, Bangladesh
      Mujib City, Dhaka, Bangladesh
  • 2002–2012
    • Johns Hopkins University
      • Department of International Health
      Baltimore, Maryland, United States
  • 2011
    • Institute of Development Studies
      Brighton, England, United Kingdom
    • University of Washington Seattle
      Seattle, Washington, United States
    • Makerere University
      • School of Public Health
      Kampala, Kampala District, Uganda
  • 2010–2011
    • University of Ibadan
      • College of Medicine
      Ibadan, Oyo State, Nigeria
  • 2009
    • Makerere University Business School
      Kampala, Central Region, Uganda
    • Universidade Federal de Pelotas
      São Francisco de Paula, Rio Grande do Sul, Brazil
  • 2008
    • University of British Columbia - Vancouver
      Vancouver, British Columbia, Canada