Jan-Walter De Neve

Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment

Background An estimated 2·3 Million individuals are newly infected with HIV each year. Existing cross-sectional and longitudinal studies have found conflicting evidence on the association between education and HIV risk, and no randomized experiment to date has identified a causal effect of education on HIV incidence. Methods A 1996 policy reform changed the grade structure of secondary school in Botswana and increased educational attainment. We use this reform as a ‘natural experiment’ to identify the causal effect of schooling on HIV infection. Data on HIV biomarkers and demographics were obtained from the 2004 and 2008 Botswana AIDS Impact Surveys, nationally-representative household surveys (N = 7018). The association between years of schooling and HIV status was described using multivariate OLS regression models. Using exposure to the policy reform as an instrumental variable, we estimated the causal effect of years of schooling on the cumulative probability that an individual contracted HIV up to his or her age at the time of the survey. The cost-effectiveness of secondary schooling as an HIV prevention intervention was assessed in comparison to other established interventions. Findings Each additional year of secondary schooling induced by the policy change led to an absolute reduction in the cumulative risk of HIV infection of 8·1% points (p = 0·008), relative to a baseline prevalence of 25·6%. Effects were particularly large among women (11·6% points, p = 0·046). Results were robust to a wide array of sensitivity analyses. Secondary school was cost-effective as an HIV prevention intervention by standard metrics. Interpretation Additional years of secondary schooling had a large protective effect against HIV risk, particularly for women, in Botswana. Increasing progression through secondary school may be a cost-effective HIV prevention measure in HIV-endemic settings, in addition to yielding other societal benefits. Funding Takemi Program in International Health at the Harvard School of Public Health, Belgian American Educational Foundation, and Fernand Lazard Foundation.

Barriers and Delays in Tuberculosis Diagnosis and Treatment Services: Does Gender Matter?

Background. Tuberculosis (TB) remains a global public health problem with known gender-related disparities. We reviewed the quantitative evidence for gender-related differences in accessing TB services from symptom onset to treatment initiation. Methods. Following a systematic review process, we: searched 12 electronic databases; included quantitative studies assessing gender differences in accessing TB diagnostic and treatment services; abstracted data; and assessed study validity. We defined barriers and delays at the individual and provider/system levels using a conceptual framework of the TB care continuum and examined gender-related differences. Results. Among 13,448 articles, 137 were included: many assessed individual-level barriers (52%) and delays (42%), 76% surveyed persons presenting for care with diagnosed or suspected TB, 24% surveyed community members, and two-thirds were from African and Asian regions. Many studies reported no gender differences. Among studies reporting disparities, women faced greater barriers (financial: 64% versus 36%; physical: 100% versus 0%; stigma: 85% versus 15%; health literacy: 67% versus 33%; and provider-/system-level: 100% versus 0%) and longer delays (presentation to diagnosis: 45% versus 0%) than men. Conclusions. Many studies found no quantitative gender-related differences in barriers and delays limiting access to TB services. When differences were identified, women experienced greater barriers and longer delays than men.

Spillovers between siblings and from offspring to parents are understudied: A review and future directions for research

BACKGROUND While a large literature has highlighted the protective effects of human capital on an individuals health and to some extent their offsprings health, little evidence is available on the positive spillover benefits of human capital for other family members. We conducted a scoping review of the evidence and identify future directions for research. METHODS We systematically searched the public health and economics literature on spillover effects from human capital, as indicated by educational attainment, to the health and/or survival of family members. We assessed (i) downward spillover effects (from parents and/or grandparents to offspring), (ii) horizontal spillover effects (from partners, spouses, and/or siblings), and (iii) upward spillover effects (from offspring to their parents and/or grandparents). We assessed the frequency of studies, their study designs, findings, and identified priority areas to inform future research on spillover effects of human capital. FINDINGS A total of 567 studies met our selection criteria. 286 studies assessed downward spillovers, 22 studies assessed horizontal spillovers, and five studies assessed upward spillovers. Studies on horizontal and upward spillovers found universally positive associations between additional education and better health in family members. The majority of studies used cross-sectional and longitudinal study designs as opposed to (quasi-)experimental designs. Further research is needed on horizontal and upward spillovers and research in low-resource settings, in addition to understanding what level of education matters the most, as well as mechanisms. CONCLUSIONS Although positive spillovers of human capital between siblings and from offspring to parents are likely, they have been understudied. Estimates of the returns to human capital that exclude these benefits may be too low.

Offspring schooling associated with increased parental survival in rural KwaZulu-Natal, South Africa.

Background Investing in offsprings human capital has been suggested as an effective strategy for parents to improve their living conditions at older ages. A few studies have assessed the role of childrens schooling in parental survival in high-income countries, but none have considered lower-resource settings with limited public wealth transfers and high adult mortality. Methods We followed 17,789 parents between January 2003 and August 2015 in a large population-based open cohort in rural KwaZulu-Natal, South Africa. We used Cox proportional hazards models to investigate the association between offsprings schooling and time to parental death. We assessed the association separately by parental sex and for four cause of death groups. Results A one year increase in offsprings schooling attainment was associated with a 5% decline in the hazard of maternal death (adjusted Hazard Ratio [aHR]: 0.95, 95%CI: 0.94–0.97) and a 6% decline in the hazard of paternal death (aHR: 0.94, 95%CI: 0.92–0.96), adjusting for a wide range of demographic and socio-economic variables of the parent and their children. Among mothers, the association was strongest for communicable, maternal, perinatal and nutritional conditions (aHR: 0.87, 95%CI: 0.82–0.92) and AIDS and tuberculosis (aHR: 0.92, 95%CI: 0.89–0.96), and weakest for injuries. Among fathers, the association was strongest for injuries (aHR: 0.87, 95%CI: 0.79–0.95) and AIDS and tuberculosis (aHR: 0.92, 95%CI: 0.89–0.96), and weakest for non-communicable diseases. Conclusion Higher levels of schooling in offspring are associated with increased parental survival in rural South Africa, particularly for mothers at risk of communicable disease mortality and fathers at risk of injury mortality. Offsprings human capital may be an important factor for health disparities, particularly in lower-resource settings.

Causal Effect of Parental Schooling on Early Childhood Undernutrition: Quasi-Experimental Evidence From Zimbabwe

An estimated 3.1 million children die each year because of undernutrition. Although cross-sectional and longitudinal studies have found a protective association between greater parental education and undernutrition in their children, no randomized trial has identified a causal effect, to our knowledge. Using the 1980 education reform in Zimbabwe as a natural experiment, we estimated the causal effect of additional parental schooling on the probability of anthropometric failure in their children under 5 years of age (ages 3 through 59 months). Analyzing data on 8,243 children from the 1988, 1999, 2005-2006, and 2010-2011 Demographic and Health Surveys, we found no effect of parental schooling on early childhood undernutrition at the national level in Zimbabwe. Among households in the urban and high-wealth-index subsamples, each additional year of maternal schooling led to absolute reductions in the probability of a childs being wasted of 5.2 percentage points (95% confidence interval (CI): -9.3, -1.2) and 3.6 percentage points (95% CI: -6.9, -0.4), respectively. In the subsample of children between the ages of 3 and 23 months, each additional year of paternal schooling increased the probability of a childs being stunted by 9.6 percentage points (95% CI: 1.4, 17.9). Secondary schooling alone may not be enough to improve early childhood nutrition in low-resource settings.

Improving the performance of community health workers in Swaziland: findings from a qualitative study

BackgroundThe performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.MethodsThe CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance.ResultsAcross the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: (i) increased monetary compensation of CHWs, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance.ConclusionsWhile this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.

Harmonizing community-based health worker programs for HIV: a narrative review and analytic framework

BackgroundMany countries have created community-based health worker (CHW) programs for HIV. In most of these countries, several national and non-governmental initiatives have been implemented raising questions of how well these different approaches address the health problems and use health resources in a compatible way. While these questions have led to a general policy initiative to promote harmonization across programs, there is a need for countries to develop a more coherent and organized approach to CHW programs and to generate evidence about the most efficient and effective strategies to ensure their optimal, sustained performance.MethodsWe conducted a narrative review of the existing published and gray literature on the harmonization of CHW programs. We searched for and noted evidence on definitions, models, and/or frameworks of harmonization; theoretical arguments or hypotheses about the effects of CHW program fragmentation; and empirical evidence. Based on this evidence, we defined harmonization, introduced three priority areas for harmonization, and identified a conceptual framework for analyzing harmonization of CHW programs that can be used to support their expanding role in HIV service delivery. We identified and described the major issues and relationships surrounding the harmonization of CHW programs, including key characteristics, facilitators, and barriers for each of the priority areas of harmonization, and used our analytic framework to map overarching findings. We apply this approach of CHW programs supporting HIV services across four countries in Southern Africa in a separate article.ResultsThere is a large number and immense diversity of CHW programs for HIV. This includes integration of HIV components into countries’ existing national programs along with the development of multiple, stand-alone CHW programs. We defined (i) coordination among stakeholders, (ii) integration into the broader health system, and (iii) assurance of a CHW program’s sustainability to be priority areas of harmonization. While harmonization is likely a complex political process, with in many cases incremental steps toward improvement, a wide range of facilitators are available to decision-makers. These can be categorized using an analytic framework assessing the (i) health issue, (ii) intervention itself, (iii) stakeholders, (iv) health system, and (v) broad context.ConclusionsThere is a need to address fragmentation of CHW programs to advance and sustain CHW roles and responsibilities for HIV. This study provides a narrative review and analytic framework to understand the process by which harmonization of CHW programs might be achieved and to test the assumption that harmonization is needed to improve CHW performance.

Intra-European medical travel remains minor: a commentary in response to 'Hermesse J, Lewalle H, Palm W. Patient mobility within the European Union. Eur J of Public Health. 1997'.

Given the rapid integration of EU Member States and current debate on patient mobility in the EU, one would expect a significant amount of intra-European medical travel. The available data, however, reveals relatively low cross-border healthcare throughout EU history. In 2006, the Observatoire Social Européen in Brussels found that the overall numbers of medical travel in Europe remained ‘minor’. Medical travel seemed the result of specific circumstances such as waiting times or national bioethical legislations, and were endemic to certain areas and contexts such as tourist areas and border regions. Later, in 2008, the European Commission stated that cross-border healthcare was responsible for (only) 1% of public expenditure on healthcare involving an expenditure of US

Secondary education and HIV infection in Botswana

13.5 billion (Forbes, 2009). In Germany, a survey by one of the largest health insurances, ‘Techniker Krankenkasse’, with over 7 million insured, found that its members were actually quite mobile but only 2–5% of those needed healthcare, and whose costs represented <0.5% of their overall expenditure. According to ‘Zorgverzekeraars Nederland’, the sector organization representing the Dutch providers of healthcare, 1% of medical care for the Dutch takes place abroad ‘consciously’. Medical travel out off the Netherlands increased between 2001 and 2005 but has stagnated ever since. Mr Westerwoudt, spokesperson of Centraal Ziekenfonds (‘CZ’), third largest Dutch health insurance with over 3 million insured, was also quoted recently as saying ‘Medical travel is dead’ and ‘Financial crisis or not, we never really believed in it’. In addition, whatever medical travel still happens, happens in border areas. ‘CZ’ states that 90% of Dutch medical travellers go to border areas in Belgium (8000 people per year) and Germany (2000 people per year). According to ‘CZ’, these Commentaries 249

Children’s education and parental old age survival – Quasi-experimental evidence on the intergenerational effects of human capital investment

In a reanalysis of our results, Michelle Remme and colleagues (October, 2015) 2 found that “secondary schooling might [even] be as good an HIV investment as male circumcision”, not to mention more expensive biomedical options. As Remme and colleagues rightly point out, we had excluded from our costeff ectiveness calculations the myriad other benefi ts to secondary schooling beyond HIV. If the HIV community paid the costs of schooling net of those other benefits, secondary schooling would be extremely costeff ective. A crucial question is how to operationalise this insight. Remme and colleagues suggest a “cofi nancing” approach based on willingness to pay in the HIV sector: HIV budgets would contribute to educational funding up to the value of their next best investment (ie, male circumcision). Of course, the impact of cofi nancing will depend not just on the size of the subsidy, but also on the elasticity of supply in the education sector. There is urgent need for case studies to determine whether cofi nancing can be successfully implemented. In a Comment, Karen Ann Grepin and Prashant Bharadwaj wrote: “increasing access to education in low-income countries should be an important priority.” But at what level of schooling should such investments be made? Investments at different school levels may have vastly diff erent health eff ects due to several factors such as stages of cognitive development, risk exposures, and long-run habit formation. We found a large causal eff ect of upper secondary schooling on HIV infection, but no association with primary schooling. In a natural experiment in Zimbabwe, secondary schooling led to delayed sexual debut, delayed fertility, and reduced child mortality. There is mounting evidence of health returns at the secondary level. Whether these results can be integrated into policy (eg, through cofi nancing) will have real implications for global health.