William Jack

Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial

BACKGROUND Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. METHODS WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients were randomised (1:1) by simple randomisation with a random number generating program to a mobile phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h. Randomisation, laboratory assays, and analyses were done by investigators masked to treatment allocation; however, study participants and clinic staff were not masked to treatment. Primary outcomes were self-reported ART adherence (>95% of prescribed doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma HIV-1 viral RNA load suppression (<400 copies per mL) at 12 months. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00830622. FINDINGS Between May, 2007, and October, 2008, we randomly assigned 538 participants to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk [RR] for non-adherence 0·81, 95% CI 0·69-0·94; p=0·006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0·84, 95% CI 0·71-0·99; p=0·04). The number needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI 5·0-29·5) and the NNT to achieve viral load suppression was 11 (5·8-227·3). INTERPRETATION Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcome in resource-limited settings. FUNDING US Presidents Emergency Plan for AIDS Relief.

Health Investments and Economic Growth: Macroeconomic Evidence and Microeconomic Foundations

This paper reviews the correlations and potential links between health and economic growth and summarizes the evidence on the role of government in improving health status. At the macroeconomic level, the evidence of an impact of health on growth remains ambiguous due both to difficulties in measuring health, and to the methodological challenges of identifying causal links. The evidence on the micro linkages from health investments to productivity and income are robust. Progress in life expectancy over the past two centuries has been spectacular, fueled by: improved agriculture that has increased food quantity; knowledge of disease transmission, and effective public health interventions that have controlled communicable diseases such as malaria, yellow fever, and hookworm; and, most recently and importantly, investments in very young children that pay off in healthier and more productive adults. Whether public investments in medical care affect health hinges on the quality of health institutions. In much of the developing world, factors such as chronic absenteeism among public providers, poor budget execution, ineffective management, and virtually no accountability weaken public efforts. Institutional issues are central in efforts to enhance public health investments, which in turn have a direct impact on the populations welfare and, perhaps over the long term, improvements in national income.

The long-run poverty and gender impacts of mobile money

Substituting minutes for money In developing countries, bank branches and fixed-line telecommunications are scarce, whereas mobile phones are plentiful. These factors have led to the use of mobile money, whereby money can be deposited to an account linked to a phone, transferred to other users, and converted back into cash. Suri and Jack show that increased access to mobile money has increased long-term consumption in Kenya and reduced the number of households in extreme poverty. Science, this issue p. 1288 Mobile phone–based digital financial services have improved economic well-being in Kenya, particularly in female-lead households. Mobile money, a service that allows monetary value to be stored on a mobile phone and sent to other users via text messages, has been adopted by the vast majority of Kenyan households. We estimate that access to the Kenyan mobile money system M-PESA increased per capita consumption levels and lifted 194,000 households, or 2% of Kenyan households, out of poverty. The impacts, which are more pronounced for female-headed households, appear to be driven by changes in financial behavior—in particular, increased financial resilience and saving—and labor market outcomes, such as occupational choice, especially for women, who moved out of agriculture and into business. Mobile money has therefore increased the efficiency of the allocation of consumption over time while allowing a more efficient allocation of labor, resulting in a meaningful reduction of poverty in Kenya.

Documenting the birth of a financial economy

The birth and explosive growth of mobile money in Kenya has provided economists with an opportunity to study the evolution and impact of a new financial system. Mobile money is an innovation that allows individuals to store, send, and receive money on their mobile phone via text message. This system has opened up basic financial services to many who were previously excluded, and has had real and measurable impacts on the ability of households to protect themselves against health risks. Using a unique survey instrument covering nearly 2,300 households over 2008–2010, we first document the lightning-fast adoption of mobile money in Kenya, which was faster than most documented modern technologies in the United States. We then present evidence on how this innovation allows households to respond better to unexpected adverse health events. We find that in the face of these events, users of mobile money are better able to tap into remittances to finance additional health care costs without having to forego necessary expenditures on education, food, and other consumption needs.

Health insurance reform in four Latin American countries : theory and practice

The author examines public economics rationales for public intervention in health insurance markets, draws on the literature of organizational design to examine alternative intervention strategies, and considers health insurance reforms in four Latin American countries -- Argentina, Brazil, Chile, and Colombia -- in light of the theoretical literature. Equity has been the main reason for large-scale public intervention in the health insurance sector, despite the well-known failures of insurance and health care markets associated with imperfect information. Recent reforms have sought less to make private markets more efficient than to make public provision more efficient, sometimes by altering the focus and function of existing institutions (such as the obras sociales in Argentina) or by encouraging the growth of new ones (such as Chiles ISAPREs). Generally, these four Latin American countries have reformed the ways insurance and care are organized and delivered, have tried to extend formal coverage to previously marginalized groups, and have tried to finance this extension fairly. Colombia instituted an implicit two-tiered voucher scheme financed through a proportional wage tax. Chiles financing mechanism is similar but the distribution of benefits is less progressive, so the net effect is less redistributive. Argentinas remodeled obras system went halfway: the financing base is similar and there is some implicit redistribution from richer to poorer obras, but the quality of insurance increases with income. On the face of it, Brazils health insurance system is less redistributive than those of the other three countries, as no tax is earmarked for financing health insurance. But taxes paid by higher-income taxpayers are not reduced when they choose private insurance, highlighting the problem of examining the health sector independent of the general tax and transfer system.

Equilibrium in competitive insurance markets with ex ante adverse selection and ex post moral hazard

Existence of pure strategy equilibria is studied in insurance markets that exhibit both ex ante adverse selection of the Rothschild-Stiglitz-Wilson type, and ex post hidden information moral hazard. It is found that ex post moral hazard has two offsetting effects on the existence of equilibrium, and that in general it is difficult to say whether an equilibrium is more or less likely to exist.

Controlling selection incentives when health insurance contracts are endogenous

The paper examines the nature of health insurance contracts when insurance companies are forced to pool high and low risk individuals. Insureres have an incentive to design contracts so as to attract only better brisks, and equilibrium contracts are generally characterised by less coevrage and lower cost-reducing effort on the part of the insurer than in the absence of these incentives. Public transfers positively related to claims tend to increase coverage but reduce effort, si the optimal transfer rate may be positive or negative.

The public economics of tuberculosis control

This paper identifies specific sources of the failure of private markets to allocate TB control resources efficiently. These market failures, as well as the concentration of the disease amongst the poor, suggest a number of roles for public intervention. Government intervention should aim to either increase, add to, or substitute for private supply, depending on the type of market failure and the institutional capacity of the public sector.

Designing incentives for rural health care providers in developing countries

Abstract In many developing country settings, and particularly in rural areas, the implementation of anything more than very rudimentary contracts for medical care providers, including public employees, is virtually impossible. In this paper, we examine the kinds of policy levers that governments might conceivably have available to induce physicians to serve in rural areas. Using simple models of screening and spatial competition, we investigate how the government can sort between physicians with low and high opportunity costs of relocation, and how the quality of existing providers (e.g., traditional healers) might affect the governments training policies.

Public spending on health care: how are different criteria related? a second opinion

A natural response to difficult questions is to increase the number of objectives one pursues in the hope that each of them separately will be easy to satisfy. This note critically evaluates this strategy as employed in a recent paper in this journal [Musgrove, Health Policy 1999;47:207-223], especially its evaluation of the role of cost-effectiveness in priority setting in the health sector. It is suggested that cost-effectiveness measures provide information of limited use, and that the tools of applied welfare economics are sufficient to guide the policy choices addressed in the paper. Students of health economics and health policy makers would do well to be exposed to these tools.