Kevin Croke

• Harvard University

Introduction Risk stratification of pregnancies informs clinical care globally. Yet recent research has cast doubt on the ability of currently used population‐level risk measures to accurately predict poor outcomes at the individual level. We examine the assumption that existing forms of risk stratification can successfully identify women likely to...

Background Diarrhea and growth faltering in early childhood reduce survival and impair neurodevelopment. We assessed whether a national program combining (i) funds for latrine and water upgrades; (ii) institutional strengthening; and (iii) behavior change campaigns reduced diarrhea and stunting, and strengthened local institutions. Methods and Fin...

Exposure to misinformation can affect citizens’ beliefs, political preferences, and compliance with government policies. However, little is known about how to durably reduce susceptibility to misinformation, particularly in the Global South. We evaluate an intervention in South Africa that encouraged individuals to consume biweekly fact-checks—as t...

A health systems reform known as Service Delivery Redesign for Maternal and Newborn Health seeks to make high-quality delivery care universal in Kakamega County, in western Kenya, by strengthening hospital-level care and making hospital deliveries the default option for pregnant women. Using a large prospective survey of new mothers in Kakamega Cou...

The WHO recommends mass drug administration (MDA) for intestinal worm infections in areas with over 20% infection prevalence. Recent Cochrane meta-analyses endorse treatment of infected individuals but recommend against MDA. We conducted a theory-agnostic random-effects meta-analysis of the effect of multiple-dose MDA and a cost-effectiveness analy...

Background Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and chil...

Kevin Croke and colleagues consider how demand for quality health systems can be made a political and public priority to drive change in low and middle income countries

Primary health care (PHC) is central to attainment of the Sustainable Development Goals, yet comparable cross-country data on key aspects of primary care have not been widely available. This study analysed data from the People's Voice Survey, which was conducted in 2022 and 2023 in 14 countries. We documented usual source of care across countries a...

Population confidence is essential to a well functioning health system. Using data from the People's Voice Survey—a novel population survey conducted in 15 low-income, middle-income, and high-income countries—we report health system confidence among the general population and analyse its associated factors. Across the 15 countries, fewer than half...

Over the past decade, Nigeria has seen major attempts to strengthen primary health care, through the Saving One Million Lives initiative (SOML), and to move towards universal health care, through the National Health Act. Both initiatives were successfully adopted, but faced political and institutional challenges to implementation and sustainability...

Background A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya. Women's voice, agency, and autonomy are critical aspects of gender equality and women's empowerment since women’s ability to make decisions alone or in consultation wit...

Todd Lewis and co-authors discuss development and use of the People's Voice Survey for health system assessment.

Global access to deworming treatment is one of the public health success stories of low-income countries in the twenty-first century. Parasitic worm infections are among the most ubiquitous chronic infections of humans, and early success with mass treatment programmes for these infections was the key catalyst for the neglected tropical disease (NTD...

Background: Despite substantial progress in improving maternal and newborn health, India continues to experience high rates of newborn mortality and stillbirths. One reason may be that many births happen in health facilities that lack advanced services-such as Caesarean section, blood transfusion, or newborn intensive care. Stratification based on...

In 2018, India’s Prime Minister announced a new health insurance program, Pradhan Mantri Jan Arogya Yojana (PMJAY), aiming to cover over 500 million people. This paper seeks to document and explain the emergence of PMJAY on India’s political and policy agendas. We analyze media, election manifestos, legislative debates, and health budgets to compar...

The paper, The Politics of Health Policy Agenda Setting in India: The Case of the PMJAY Program, is an extension of Nobel Laureates Amartya Sen & Jean Dreze's (2013) landmark work on the politics of health. Using innovative data sources available to practitioners (electoral manifestos, legislative debates, media coverage, and health budgets), we ex...

Abstract Background Low-and middle-income countries account for over 80% of fall-related fatalities globally. However there is little emphasis on the issue and limited high quality data to understand the burden, and to inform preventive and management strategies. We characterise the burden of fall injuries in Malawi and Tanzania. Methods This multi...

Nannini et al (2021) analyze barriers to national health insurance reforms in Uganda using a political economy approach primarily rooted in stakeholder analysis. This approach is valuable,not only for its clear description of the interest-based politics at play, but also for its extension of stakeholder analysis to include consideration of the role...

Racial identity and political partisanship have emerged as two important social correlates of hesitancy towards COVID-19 vaccines in the United States. To examine the relationship of these factors with respondents’ intention to vaccinate before the vaccine was available (November/December, 2020), we employed a multi-method approach: a survey experi...

Background Trauma is among the leading causes of morbidity and mortality among pediatric and adolescent populations worldwide, with over ninety percent of childhood injuries occurring in low-income and middle-income countries. Lack of region-specific data on pediatric injuries is among the major challenges limiting the ability of health systems to...

Background: Large-scale multisite trauma registries with broad geographic coverage in low-income countries are rare. This lack of systematic trauma data impedes effective policy responses. Methods: All patients presenting with trauma at 10 hospitals in Malawi from September 2018 to March 2020 were enrolled in a prospective registry. Using data f...

Civil conflict began in Ethiopia in November 2020 and has reportedly caused major disruptions in access to health services, food, and related critical services, in addition to the direct impacts of the conflict on health and well-being. However, the population-level impacts of the conflict have not yet been systematically quantified. We analyze hig...

Background Maternal and neonatal mortality remain elevated in low and middle income countries, and progress is slower than needed to achieve the Sustainable Development Goals. Existing strategies appear to be insufficient. One proposed alternative strategy, Service Delivery Redesign for Maternal and Neonatal Health (SDR), centers on strengthening h...

Objective The government of the Democratic Republic of Congo (DRC) responded to COVID‐19 with policy measures, such as business and school closures and distribution of vaccines, which rely on citizen compliance. In other settings, prior experience with effective government programmes has increased compliance with public health measures. We study th...

Industrialisation and structural change entails shifting workers from low-skill to high-skill occupations. In emerging economies, multiple constraints may impede sectoral switches among workers, including skill and spatial mismatches, and social norms related to gender in the workplace. This study uses a job training experiment across five cities i...

Payment digitisation efforts in the health sector in low/middle-income countries have accelerated due to the COVID-19 pandemic. ► Research on impacts of worker payment digitisation on health systems is lacking. ► Our conceptual model details how payment digitisation could improve health systems. ► Wage digitisation has the potential to improve heal...

Global access to deworming is one of the public health success stories of the twenty-first century and was the key catalyst for creating the neglected tropical disease (NTD) agenda. Human worm infections appear to have been with us since the domestication of household animals, some 10,500 years ago, and putative treatments are known from the earlie...

Background. Road traffic injuries (RTIs) pose a severe public health crisis in Sub-Saharan Africa (SSA) and specifically in Tanzania, where the mortality due to RTIs is nearly double the global rate. There is a paucity of RTI data in Tanzania to inform evidence-based interventions to reduce the incidence and improve care outcomes. A trauma registry...

Background Trauma is among the leading causes of morbidity and mortality among paediatric and adolescent populations worldwide, with over ninety percent of childhood injuries occurring in low-income and middle-income countries. Lack of region-specific data on paediatric injuries is among the major challenges limiting ability to implement interventi...

Context: The United States is the only high-income country that relies on employer-sponsored health coverage to insure a majority of its population, and millions of Americans lost employer-sponsored health insurance during the COVID-19-induced economic downturn. We examine public opinion toward universal health coverage policies in this context....

Introduction Inadequate water and sanitation is a central challenge in global health. Since 2008, the Democratic Republic of Congo government has implemented a national programme, Healthy Villages and Schools ( Villages et Ecoles Assainis (VEA), with support from UNICEF, financed by UK’s Foreign, Commonwealth and Development Office. Methods A clus...

Health system reforms across high- and middle-income countries often involve changes to public hospital governance. Corporatization is one such reform, in which public sector hospitals are granted greater functional independence while remaining publicly owned. In theory, this can improve public hospital efficiency, while retaining a public service...

Ethiopia’s expansion of primary health care over the past 15 years has been hailed as a model in sub-Saharan Africa. A leader closely associated with the programme, Tedros Adhanom Gebreyesus, is now Director-General of the World Health Organization, and the global movement for expansion of primary health care often cites Ethiopia as a model. Starti...

Background Access to health facilities in many low-income and middle-income countries remains low, with a strong association between individuals’ distance to facilities and health outcomes. Yet plausibly causal estimates of the effects of facility construction programmes are rare. Starting in 2004, more than 2800 government health facilities were b...

Background Trauma is a rapidly growing component of the burden of disease in developing countries; yet systematic data collection about trauma in such contexts is relatively rare. Methods This paper describes the implementation of a trauma registry in 10 government‐run hospitals in Malawi, with a focus on implementation logistics, stakeholder enga...

There is growing evidence that political economy factors are central to whether or not proposed health financing reforms are adopted, but there is little consensus about which political and institutional factors determine the fate of reform proposals. One set of scholars see the relative strength of interest groups in favour of and opposed to refor...

Do improvements in health service delivery affect trust in political leaders in Africa? Citizens expect their government to provide social services. Intuitively, improvements in service delivery should lead to higher levels of trust in and support for political leaders. However, in contexts where inadequate services are the norm, and where politica...

Background Up to 1.45 billion people currently suffer from soil transmitted helminth infection, with the largest burden occurring in Africa and Asia. Safe and cost effective deworming treatment exists, but there is a debate about mass distribution of this treatment in high prevalence settings. While the World Health Organization recommends mass adm...

Main robustness checks. (PDF)

Analysis of non-response by treatment status and additional covariates. (PDF)

Additional details about the Uwezo sample. (PDF)

Relationship between education and migration in 2009-2010 Uganda National Panel Survey. (PDF)

School attendance and enrolment by treatment interactions. (PDF)

Primary outcome regressions using survey weights. (PDF)

Treatment effects by survey rounds, 2010-2015. (PDF)

Primary outcome regressions using imputed test scores and inverse probability weights to adjust for non-response. (PDF)

Background Neglected tropical diseases (NTDs) account for a large disease burden in sub-Saharan Africa. While the general cost-effectiveness of NTD interventions to improve health outcomes has been assessed, few studies have also accounted for the financial and education gains of investing in NTD control. Methods We built on extended cost-effectiv...

Subnational analysis: Cost-effectiveness of neglected tropical disease control by different district prevalence categories in Madagascar. (DOCX)

Benefit-cost analysis of NTD control in Madagascar using an alternative benefit scenario: Assuming all infections occur within the same individuals (100% overlap). (DOCX)

Distribution of outpatient visits at primary care centers (“Centres de Santé de Base”) by region in Madagascar (2015). (DOCX)

Additional background information and context. (DOCX)

Base-case values and uncertainty ranges used in the probabilistic sensitivity analysis. (DOCX)

Benefit-cost analysis of neglected tropical disease (NTD) control in Madagascar. Each NTD intervention was modelled independently with its own programmatic cost. (DOCX)

Cure rates of selected drugs for control of NTDs. (DOCX)

Estimated unit cost of drugs (per tablet) for neglected tropical diseases in Madagascar (2012). (DOCX)

Prevalence of soil-transmitted helminthiases by district in Madagascar (2016). (DOCX)

Univariate sensitivity analysis: Drugs used for preventive chemotherapy for neglected tropical diseases in Madagascar are not donated for free by pharmaceutical companies. (DOCX)

For more than 100 years, countries have used mass drug administration as a public health response to soil-transmitted helminth infection. The series of analyses published as Disease Control Priorities is the World Bank's vehicle for exploring the cost-effectiveness and value for money of public health interventions. The first edition was published...

The realisation of human potential for development requires age-specific investment throughout the 8000 days of childhood and adolescence. Focus on the first 1000 days is an essential but insufficient investment. Intervention is also required in three later phases: the middle childhood growth and consolidation phase (5-9 years), when infection and...

Background: Sickle Cell Trait (SCT) has been shown to be protective against malaria. A growing literature suggests that malaria exposure can reduce educational attainment. This study assessed the relationship and interactions between malaria, SCT and educational attainment in north-eastern Tanzania. Methods: Seven hundred sixty seven children we...

Studies have found links between organizational structure and performance of public organizations. Considering the wide variation in uptake of malaria interventions and outcomes across Nigeria, this exploratory study examined how differences in administrative location (a dimension of organizational structure), the effectiveness of administrative pr...

A large literature examining advanced and consolidating democracies suggests that ed-ucation increases political participation. However, in electoral authoritarian regimes, educated voters may instead deliberately disengage. If education increases critical capacities, political awareness, and support for democracy, educated citizens may believe tha...

A large literature examining advanced and consolidating democracies suggests that education increases political participation However, in electoral authoritarian regimes, educated voters may instead deliberately disengage. If education increases critical capacities, political awareness, and support for democracy, educated citizens may believe that...

Political systems dominated by a single party are common in the developing world, including in countries that hold regular elections. Yet we lack knowledge about the strategies by which these regimes maintain political dominance. This article presents evidence from Tanzania, a paradigmatic dominant party regime, to demonstrate how party institution...

Abstract—Motivated by a common interest in political economy analysis in global health and a belief that this field has been neglected in global health policy debates, we convened at the Rockefeller Foundation's Bellagio Center for a workshop on the Political Economy of Global Health in May of 2014. Given our shared experiences working as academic...

This article identifies political economy factors that help explain dramatic differences in the pace of child mortality reduction between Tanzania and Uganda from 1995 to 2007. The existing literature largely explains divergence in basic health outcomes with reference to economic variables such as GDP per capita. However, these factors cannot expla...

As mobile phone ownership rates have risen in Africa, there is increased interest in using mobile telephony as a data collection platform. This paper draws on two pilot projects that use mobile phone interviews for data collection in Tanzania and South Sudan. The experience was largely a success. High frequency panel data have been collected on a w...

How do single party regimes maintain long-lasting, enduring political dominance in developing countries, even when elections are reasonably free and civil liberties respected? This paper presents evidence from a series of survey experiments and quasi-experiments to develop a theory of the Tanzanian case. First, we present evidence that shows that t...