Tag Archives: LMICs

Worm Wars Continued

We have discussed results of deworming before and argued that it is important to treat at cluster level because of rapid re-infection from reservoirs in soil. A recent important meta-analysis compares deworming targeted at children versus a community-wide intervention.[1] It finds that community-wide approaches are more effective than treatment targeted at children for roundworms (Ascaris) and hookworms (Ancylostoma), but not whipworms (Trichuris). This finding is consistent with the much greater efficiency of the medicine in the former two worm types. The relative effect was greater in roundworms (odds ratio >16) than the more dangerous hookworms (OR >4), consistent with the shorter life-span of hookworm eggs than of roundworm eggs. These are important findings, but there is a worry that resistance may emerge with mass treatment. It would be interesting to see whether any studies have been done in slum populations specifically.

— Richard Lilford, CLAHRC WM Director


  1. Clarke NE, Clements ACA, Doi SA, et al. Differential effect of mass deworming and targeted deworming for soil-transmitted helminth control in children: a systematic review and meta-analysis. Lancet. 2017; 389: 287-97.

Between Policy and Practice – the Importance of Health Service Research in Low- and Middle-Income Countries

There is a large and growing literature on disease and its causes in low- and middle-income countries (LMICs) – not only infectious disease, but also non-communicable diseases. Endless studies are published on disease incidence and prevalence, for example. There is also a substantial literature on policy / health systems,[1] much captured in the Health Systems Evidence database.[2] This deals with topics such as general taxation vs. contributory insurance, financial incentives for providers, and use of private providers to extend coverage.

However, how to provide health services given general policy and a certain profile of disease is less well studied. Issues such as skill mix (e.g. who should do what), distribution of services (e.g. hospital vs. clinic vs. home) and coverage (e.g. how many nurses or clinics are needed per head of population) are less well studied. For example, there have been calls for Africa to increase the capacity of Community Health Workers (CHW) to one million, but no-one knows the optimal mix of CHWs to nurses to medical officers to doctors, for example. Likewise, the mix of outreach services (e.g. CHWs), clinics, pharmacies, private facilities, and traditional healers that can best serve populations is very unclear according to a recent Lancet commission.[3] The situation in slums is positively chaotic. One could sit in an arm chair and propose a service configuration for slum environments of 10,000 people that looks like this:


The role of CHWs could be narrow (vaccination, child malnutrition), intermediate (vaccination, child malnutrition, sexual and reproductive health), or broad (all of the above, plus hypertension, obesity prevention, adherence to treatment, detection of depression, etc.). HIV and TB screening and treatment maintenance could be separate or included in the above, and so on.

Note that decisions about workforce and how and where the workforce is deployed have to be made irrespective of how care is financed, or whether financial or other incentives are used – decisions are still needed about who is to be incentivised to do what. And people do not appear overnight, so training (and the associated costs) must be included in cost and economic models. Of course, the range of possibilities according to per capita wealth in a country is large, but we do not know what good looks like in countries of approximately equal wealth. Here is the rub – it is much easier to study a diseases and its determinants than to study health services. Yet another study to link pollution to illness is easy to write as an applicant and understand as a reviewer. But talk about skill mix and eyes glaze over. Yet there is little point in measuring disease ever more precisely if there is no service to do anything about it.

— Richard Lilford, CLAHRC WM Director


  1. Mills A. Health Care Systems in Low- and Middle-Income Countries. New Engl J Med. 2014; 370: 552-7.
  2. McMaster University. Health systems evidence. Hamilton, Canada: McMaster University. 2017.
  3. McPake B, & Hanson K. Managing the public–private mix to achieve universal health coverage. Lancet. 2016; 388: 622-30.

The ‘Robin Hood’ Hypothesis in 33 African Countries

Across low- and middle-income countries (LMICs), over 50% of total health care spending is derived from out-of-pocket expenses. Some of these are formal recognised tariffs in public health systems. However, a proportion are irregular or informal payments (bribes/kick-backs). It is hypothesised that these informal payments are used to subsidise the poor at the expense of the rich after the fashion of Robin Hood in English folklore. Enter results from a series of publically available repeated surveys called ‘Afrobarometer‘. Here public attitudes and experiences relating to democracy and governance are surveyed in 18 African counties. Nationally representative samples of over 25,000 individuals are selected randomly across participating countries. Afrobarometer provides the data for an important study [1] of the extent to which informal payments were elicited across people of different income levels (according to the Lived Poverty Index). Far from confirming the Robin Hood hypothesis, the authors find a higher occurrence of bribe paying among the poorest people across the countries studied – elasticity is negative in that the richer the person, the lower the probability that they will have paid a bribe on attending a health care facility. These results are similar to those obtained in a previous study in Hungary. There is some evidence that the problem is worse in cities where service providers are less likely to have known or have community affiliations with patients. This finding reminds me of the Bible scripture – “For whosoever hath, to him shall be given… but whosoever hath not, from him shall be taken away...” (Matthew 13:12).

— Richard Lilford, CLAHRC WM Director


  1. Kankeu HT, Ventelou B. Socioeconomic inequalities in informal payments for health care: An assessment of the ‘Robin Hood’ hypothesis in 33 African countries. Soc Sci Med. 2016; 151: 173-86.

Let the Second Sanitary Revolution Begin

Despite the gains in recent years, far too many children still die before their fifth birthday. Childhood mortality in low income countries is 76 per thousand live births compared with 7 per thousand in high income countries.[1] Now that pneumococcal vaccine is in a widespread use we may expect diarrhoea to take over from pneumonia as the number one killer of children. Certainly in slums – soon to be home to over 1 billion people – diarrhoea is the greatest threat not just to life, but also to child health. Diarrhoea predisposes to chronic enteropathy, especially in malnourished children, which in turn predisposes to stunting and perhaps reduced cognitive development.[2]

But it does not have to be this way. The first ‘sanitary revolution’ in the second half of the 19th century in Europe and North America yielded massive gains in child survival.[3] Less than 4% of all development assistance has been allocated to urban water and sanitation improvement over the last few decades, according to Prof David Satterthwaite. Moreover, it is not as though Europe and America were awash with money; the per capita GDP of Britain in the 1860s ($703.1)[4] was roughly equivalent to that of Rwanda today ($697.3).[5] This suggests that a lack of political will is also to blame for poor sewage and water installations in modern day slums. And the pitiful state of sanitation in modern slums has been thoroughly documented.[6] Hardly surprisingly, improving sanitation is the number one priority for people who live in slums.[7] Water and sanitation is not a middle-class concern foisted on slum dwellers; it is a critically important issue that results in millions of child deaths and that local people want tackled.

There are of course barriers to tackling this problem relating to relative powerlessness of people in slums, poor local governance, immature financial markets, and so on. But there is another problem that is created entirely by a certain type of armchair academic – this is the pernicious idea that nothing can be done pending improvements in local and national governance. Such people argue that it is first necessary to improve security of tenure, functioning financial markets, and so on. An extension of this argument, for which empirical support is absent, is that water and sanitation is not enough; it must be part of an improvement in the whole slum ‘nexus’ to include solid waste disposal, street drainage, home improvement, etc. We cannot wait for extractive elites to disappear, the judiciary to be made independent, or every slum holder to achieve title before acting; Paris famously installed a functioning sewage system during the dictatorship of Napoleon the third following his coup d’état. Fortunately water and sanitation was prioritised at a recent WHO Technical Working Group on “Addressing Urban Health Equity Through Slum Upgrading” attended by the CLAHRC WM Director.

So, let the water and sanitation revolution begin. Let it be driven by political and social zeal but do not let it be undisciplined, and let us never forget that water and sanitation is a socio-technical innovation – it needs to be supported (ideally initiated) by local people themselves. Ensuring proper use and maintenance of sanitary facilities requires alignment of supply and demand.

A number of international organisation promote water and sanitation in low- and middle-income countries, for example the UN-HABITATs Water and Sanitation Trust Fund. But good intentions are not enough when it comes to sanitation – even where sanitation and water have been improved, the benefits on health are often nugatory.[8] [9] This is because the installations are inadequate, and/or because facilities are underused or poorly maintained. It is thus crucially important that interventions meet local needs, that they can be maintained, and that their effects in reducing exposure to infection and improving health are evaluated. Installation of improved water and sanitation utilities needs to be accompanied by research into how to make this socio-technical intervention work well and also summative evaluation of the effects on health and well-being.

— Richard Lilford, CLAHRC WM Director


  1. World Health Organization. Under-five mortality. WHO, 2016.
  2. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in the first 5 years for children in developing countries. Lancet 2007; 369: 60–70.
  3. Szreter S. The Population Health Approach in Historical Perspective. Am J Public Health. 2003; 93(3): 421-31.
  4. Broadberry S, Campbell B, Klein A, Overton M, van Leeuwen B. British economic growth and the business cycle, 1700-1870. 2011. Working Paper.
  5. The World Bank. GDP per capita (current US$). 2016.
  6. Ezah A, Oyebode O, Satterthwaite D, et al. The history, geography, and sociology of slums and the health problems of people who live in slums. Lancet. 2016. [ePub].
  7. Parikh P, Parikh H, McRobie A. The role of infrastructure in improving human settlements. Urban Design Planning, 2012; 166; 101-18.
  8. Wolf J, Prüss-Ustün A, Cumming O, et al. Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression. Trop Med Int Health. 2014; 19(8): 928-42.
  9. Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM, Jr. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis. 2005; 5(1): 42-52.

Golden Rice Controversy

Genetically modified rice – called ‘golden rice’ – can increase yields and, since it produces beta-carotene, can prevent the sequelae of vitamin A deficiency that is common in those with a predominantly rice-based diet. For an interesting article on the controversy over use of this GM crop in Bangladesh, and its potential costs-benefit, please read Uttam Deb’s article from the Copenhagen Consensus Center.[1]

— Richard Lilford, CLAHRC WM Director


  1. Deb U. Returns to Golden Rice Research in Bangladesh: An Ex-ante Analysis. Bangladesh Priorities, Copenhagen Consensus Center, 2016.


A Proper Large-Scale Quality Improvement Study in a Middle-Income Country

The vast majority of studies testing an intervention to improve quality/safety of care are conducted in high-income countries. However, a cluster RCT of 118 Brazilian ICUs (6,761 patients) has recently been reported.[1] The intervention was compound (multi-component), involving goal setting, clinician prompting, and multi-disciplinary ward rounds. Although mortality and other patient outcomes were not improved, clinical processes (e.g. use of appropriate settings on the ventilator and avoidance of heavy sedation) did improve. The nub of my argument is that clinical outcomes are insensitive indicators of improved practice, and we should be content with showing improved adherence to proven care standards – the argument is laid out numerically elsewhere.[2] The safety and quality movement is doomed so long as we insist on showing improvements in patient level outcomes.

— Richard Lilford, CLAHRC WM Director


  1. Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet). Effect of a Quality Improvement Intervention with Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients. JAMA. 2016;315(14):1480-90.
  2. Lamont T, Barber N, de Pury J, et al. New approaches to evaluating complex health and care systems. BMJ. 2016; 352: i154.

Cluster Trial of Home Visits for Newborn Children in Sub-Saharan Africa

Forty percent of childhood deaths in low- and middle-income countries (LMICs) take place within the first month after birth. Trials conducted in Asia have shown that an intervention whereby home-visits are made over this crucial period of life is effective. Would it work in Africa? To find out, Betty Kirkwood and colleagues randomised 197 clusters in Ghana to intervention and control.[1] Mothers in the intervention clusters were to receive two home visits in pregnancy and three in the first week after birth. Coverage was good and the proportion of mothers who adopted health promoting behaviours increased. These behaviours included use of anti-mosquito bed-nets, timely transfer to a facility when appropriate, breastfeeding, ‘kangaroo’ care, delayed bathing of the baby, and hand-washing. Reductions in neonatal mortality observed in this trial alone were not significant, but a significant 12% reduction in mortality was estimated when the data were combined with those from the Asian trials in a meta-analysis. The CLAHRC WM Director could not find out whether the study was rural or urban. Trials of women’s groups [2] provide positive results in rural areas but not slums. It would be interesting to examine the effect of place of residence further since half of all African people will soon be urban, and more than half of those people will live in slums.

— Richard Lilford, CLAHRC WM Director


  1. Kirkwood BR, Manu A, ten Asbroek AHA, et al. Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial. Lancet. 2013; 381(9884): 2184-92.
  2. Prost A, Colbourn T, Seward N, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in resource-limited settings: systematic review and meta-analysis. Lancet. 2013; 381(9879): 1736-46.



Watching NoCounter interact with “Aunty” Martha (not their real names) in Mahwaqe, South Africa, and learning about NoCounter’s roles as Martha’s health advocate, personal trainer and medication manager was anything but dismal. So as a dismal scientist, I was fascinated by how Community Health Workers (CHWs) seem to contradict one of our most famous founders, Adam Smith. To help explain one of the concepts for which he would become famous, “the invisible hand”, Smith wrote: “I have never known much good done by those who affected to trade for the public good”.[1]

To consider whether NoCounter and other CHWs are an exception to this statement, there are three questions that need to be considered:

Is the CHW doing good?
Almost all of the available research evidence suggests that CHWs are effective in enhancing the health of their communities,[2] and since the World Health Organization also see CHWs as playing a pivotal role in helping countries achieve health-related Millennium Development Goals,[3] it is most likely that CHWs are “doing good”. In Mahwaqe, we saw how NoCounter helped Martha do the chair yoga exercises that now mean she can walk and explained her medications, which helped Martha understand the importance of adherence.

Is the CHW trading?
NoCounter is giving up her time (working around 50% FTE) and in return, receives a stipend from an NGO of around R800 (~£36) per month and as such, is trading. However, as a maid in South Africa, she could earn around R1,200 (~£54) per month for the same hours, so NoCounter does not seem to be receiving the full monetary value of her time. If approximate role equivalence can be assumed, compared to a CHW in the US, NoCounter’s time is undervalued by a factor of around 8.5: a US CHW working for an hour could buy 3.3 McDonald’s Big Macs; NoCounter could buy 0.4.[4] [5] NoCounter is also using her skills and experience to provide care, but economics would describe these as “non-rivalrous” and thus not directly tradable.

Is the CHW doing so for the public good or her own self-interest?
Adam Smith might be confused by NoCounter, because her aim doesn’t seem to be wealth maximisation. However, a “utility maximising” economist would argue that NoCounter is making up for not being paid the full monetary value of her time by obtaining utility either from substitutes for money or from directly helping her community.[6] Even if NoCounter obtains utility from the latter, her motivation would still be to do public good. With regards to money substitutes, CHWs may also receive non-monetary incentives such as community respect, housing and access to health care and/or be motivated in their roles via the support of their families.[6] [7] Furthermore, the CHW role is particularly desirable in areas where residents have a high marginal rate of substitution for leisure over consumption, since CHWs do not have to commute to their place of work. Finally, a by-product of NoCounter’s work as a CHW from which she benefits directly is that she lives in a healthier community: by encouraging vaccination of new-borns, for example, she is lowering her own risk of TB.

On this last question, the relative importance of the different reasons why CHWs undertake their role for a wage lower than they appear to be worth, we cannot be certain about the answer. Research in this area is critical given the push to eliminate the under-supply of CHWs.[8] There are also additional pre-conditions – the organisational structure required to implement a successful CHW programme [9] – that also must be met before the demand for CHWs can be realised (made “effective”) in practice. Nevertheless, it is critical to determine whether all of the additional CHWs required to meet demand would also offer their labour at a low relative price. This was assumed in a costing exercise of a CHW roll-out programme,[10] but which prima facie contradicts basic economic theory of demand and supply.

Fortunately for me, economics provides one approach to studying the interaction between monetary and non-monetary incentives with respect to the supply of labour, for example using discrete choice experiments, where CHWs would be asked to make a choice between a series of pairs of packages of stipend/salary, level of health produced, and non-monetary incentives (see [11] for an example). Such experiments would need to be repeated in (and possibly also within) different countries, since the relative value of “doing good” by volunteering may well differ according to a country’s stage in economic development. Such work would help to provide evidence regarding the sustainability of CHWs as a cadre of health care providers. Here, we hypothesise a U-shaped curve if propensity to volunteer is plotted against GDP per capita

— Celia Taylor, Senior Lecturer


  1. Smith A. An Inquiry into the Nature and Causes of the Wealth of Nations. London: Strahan and Cadell, 1776.
  2. Perry H, Zulliger R. How Effective are Community Health Workers? An Overview of Current Evidence with Recommendations for Strengthening Community Health Worker Programs to Accelerate Progress in Achieving the Health-related Millennium Development Goals. Baltimore, MD: John Hopkins Bloomberg School of Public Health, 2012.
  3. World Health Organization and Global Health Workforce Alliance. Global Consultation on Community Health Workers. Geneva, Switzerland: World Health Organization, 2010.
  4. Payscale Homepage. 2015.
  5. The Economist. The Big Mac Index. 2015.
  6. Greenspan JA, McMahon SA, Chebet JJ, Mpunga M, Urassa DP, Winch PJ. Sources of community health worker motivation: a qualitative study in Morogoro Region, Tanzania. Hum Resour Health. 2013; 11: 52.
  7. Dambisya YM. A review of non-financial incentives for health worker retention in east and southern Africa. In: EQUINET Discussion Paper Number 44 with ESCA-HC. Loewenson R (Editor). Harare, Zimbabwe: EQUINET, 2007.
  8. One Million Community Health Workers Campaign. One Million Community Health Workers Campaign. 2015.
  9. World Health Organization, Policy Brief. Community health workers: What do we know about them? Geneva, Switzerland: World Health Organization, 2007
  10. McCord GC, Liu A, Singh P. Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions. Bull World Health Organ. 2012; 91(4):244-53B.
  11. Kasteng F, Settumba S, Källander K, Vassall, A, inSCALE Study Group. Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa. Health Policy Plan. 2016: 31(2): 205-16.

Return on Investment from Vaccines

CLAHRC Africa has previously carried out health economic assessments in Low- and Middle-Income Countries (LMICs) concerned with devices,[1] [2] and is now doing so with respect to milk banking and breastfeeding in collaboration with the African Population and Health Research Centre (APHRC). We were therefore interested to read a Return on Investment analysis on vaccines in LMICs.[3] Ten vaccines were considered, singly and in combination. The costs of the programmes were obtained largely from Gavi, the Vaccine Alliance. The costs saved were calculated on the basis of costs of treating cases at home (including days off work for carers), costs of admission by hospital day, transport costs to care facilities, costs of care for disabilities, and lost production costs based on discounted per capita GDP for people who died or could not work. Herd immunity was not taken into account, neither were effects on demographic structures of countries, thereby under-estimating return. The return on investment ([monetised benefit – programme cost] / programme cost) was a whopping $16 per dollar expended. There are few other such studies in LMICs, but the return was even higher than deployment of Community Health Workers at $9 per dollar expended, but lower than improving road safety at $19 per dollar expended. The ratios were positive for all the ten vaccine studied, but the most favourable ratio was for measles, followed by yellow fever (a surprise to the CLAHRC WM Director) and Meningococcal meningitis.

— Richard Lilford, CLAHRC WM Director


  1. Burn SL, Chilton PJ, Gawande AA, Lilford RJ. Peri-operative pulse oximetry in low-income countries: a cost-effectiveness analysis. Bull World Health Organ. 2014; 92(12): 858-67.
  2. Lilford RJ, Burn SL, Diaconu KD, et al. An approach to prioritization of medical devices in low-income countries: an example based on the Republic of South Sudan. Cost Eff Resour Alloc. 2015; 13(1): 2.
  3. Ozawa S, Clark S, Portnoy A, et al. Return on Investment from Childhood Immunization in Low- and Middle-Income Countries, 2011-20. Health Aff. 2016; 35(2): 199-207.

Correlation between Schooling and Per Capita GDP Growth

Previous studies have found only a modest correlation between mean years of schooling and GDP growth in low- and medium-income countries (LMICs). But the educational content of a given number of school years varies enormously – on average, school leavers in Honduras are over an unconscionable six years behind their age-controlled peers in Singapore in Science and Maths competence. A recent paper from ‘Science’ [1] shows that it is school achievement that is important and in logistic regression accounts for over half of the variance between countries in growth rate, conditional on economic starting point, and the temporal relationships all but exclude reverse causality. Of course, it is possible that there is some other ingredient that causes both school and economic attainment in the high economic growth countries. The CLAHRC WM Director hypothesises that knowledge is not just knowledge – education has a deeper effect on the psyche leading to a more empathetic, altruistic person. As the old quote has it, “education is what is left after all the facts have been forgotten.” Is this hypothesis testable?

— Richard Lilford, CLAHRC WM Director


  1. Hanushek EA, & Woessmann L. Knowledge Capital, Growth, and the East Asian Miracle. Science. 2016; 51 (6271): 344-5.