Research
My main research interests are in the fields of health and health care, development, international, and institutional economics.
Published Papers:
A Child-Centered Health Dialogue for the prevention of obesity in Child Health Services in Sweden – a randomized controlled trial including an economic evaluation
Obesity Science & Practice, forthcoming
joint with Mariette Derwig, Iréne Tiberg, Jonas Björk, and Inger Kristensson Hallström
Abstract:
Background: Prevention of child obesity is an international public health priority and believed to be effective when started in early childhood. Caregivers often ask for an early and structured response from health professionals when their child is identified with overweight, yet cost-effective interventions for children aged 2–6 years and their caregivers in Child Health Services are lacking.
Objectives: To evaluate the effects and cost-effectiveness of a child-centered health dialogue in the Child Health Services in Sweden on 4-year-old children with normal weight and overweight.
Methods: Thirty-seven Child Health Centers were randomly assigned to deliver intervention or usual care. The primary outcome was zBMI-change.
Results: A total of 4598 children with normal weight (zBMI: 0.1 [SD=0.6] and 490 children with overweight (zBMI: 1.6 [SD=0.3]) (mean age: 4.1 years [SD=0.1]; 49% females) were included. At follow-up, at a mean age of 5.1 years [SD=0.1], there was no intervention effect on zBMI-change for children with normal weight. Children with overweight in the control group increased zBMI by 0.01± 0.50, while children in the intervention group decreased zBMI by 0.08±0.52. The intervention effect on zBMI-change for children with overweight was –0.11, with a 95% confidence interval of –0.24 to 0.01 (p=0.07). The estimated additional costs of the Child-Centered Health Dialogue for children with overweight were 167 euros per child with overweight and the incremental cost-effectiveness ratio was 183 euros per 0.1 zBMI unit prevented.
Conclusions: This low-intensive multicomponent child-centered intervention for the primary prevention of child obesity did not show statistical significant effects on zBMI, but is suggested to be cost-effective with the potential to be implemented universally in the Child Health Services. Future studies should investigate the impact of socio-economic factors in universally implemented obesity prevention programs.
Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries
BMJ Global Health, 2020, 5.
joint with Laura Di Gorgio, David K. Evans, Magnus Lindelow, Son Nam Nguyen, Jakob Svensson, and Waly Wane
Abstract:
Objective: Assess the quality of healthcare across African countries based on health providers’ clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage.
Methods: With nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme.
Results: Across all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers’ absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively.
Conclusion: Our findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers’ absenteeism would only modestly increase the average care readiness that meets minimum quality standards.
Health-Care Quality and Information Failure: Evidence from Nigeria
Health Economics, 2018, 27, p. e90-e93
joint with David K. Evans
Abstract:
Low‐quality health services are a problem across low‐ and middle‐income countries. Information failure may contribute, as patients may have insufficient knowledge to discern the quality of health services. That decreases the likelihood that patients will sort into higher quality facilities, increasing demand for better health services. This paper presents results from a health survey in Nigeria to investigate whether patients can evaluate health service quality effectively. Specifically, this paper demonstrates that although more than 90% of patients agree with any positive statement about the quality of their local health services, satisfaction is significantly associated with the diagnostic ability of health workers at the facility. Satisfaction is not associated with more superficial characteristics such as infrastructure quality or prescriptions of medicines. This suggests that patients may have sufficient information to discern some of the most important elements of quality, but that alternative measures are crucial for gauging the overall quality of care.
Globalization, Democracy, and Child Health in Developing Countries
Social Science & Medicine, 2015, 136-137, p. 52-63
joint with Carl Hampus Lyttkens and Therese Nilsson
Abstract:
Good health is crucial for human and economic development. In particular poor health in childhood is of utmost concern since it causes irreversible damage and has implications later in life. Recent research suggests globalization is a strong force affecting adult and child health outcomes. Yet, there is much unexplained variation with respect to the globalization effect on child health, in particular in low- and middle-income countries. One factor that could explain such variation across countries is the quality of democracy. Using panel data for 70 developing countries between 1970 and 2009 this paper disentangles the relationship between globalization, democracy, and child health. Specifically the paper examines how globalization and a country's democratic status and historical experience with democracy, respectively, affect infant mortality. In line with previous research, results suggest that globalization reduces infant mortality and that the level of democracy in a country generally improves child health outcomes. Additionally, democracy matters for the size of the globalization effect on child health. If for example Côte d’Ivoire had been a democracy in the 2000-2009 period, this effect would translate into1200 fewer infant deaths in an average year compared to the situation without democracy. We also find that nutrition is the most important mediator in the relationship. To conclude, globalization and democracy together associate with better child health in developing countries.
The Core of the Nordic Health Care System is Not Empty
Nordic Journal of Health Economics, 4, 1, p. 7-27
joint with Carl Hampus Lyttkens, Terkel Christiansen, Unto Häkkinen, Oddvar Kaarbøe, and Matthew Sutton
Abstract:
The Nordic countries are well-known for their welfare states. A very important feature of the welfare state is that it aims at easy and equal access to adequate health care for the entire population. For many years, the Nordic systems were automatically viewed as very similar, and they were placed in the same group when the OECD classified health care systems around the world. However, close inspection soon reveals that there are important differences between the health care systems of Denmark, Finland, Iceland, Norway and Sweden. Consequently, it is perhaps no surprise that the Nordic countries fell into three different categories when the OECD revised its classification a few years ago. In this paper, we revisit this issue and argue that the most important similarity across the Nordic countries is the institutional context in which the health care sector is embedded. Nordic health care exists in a high-trust, high-taxation setting of small open economies. With this background, we find a set of important similarities in the manner in which health care is organized and financed in the Nordic countries. To evaluate the performance of the Nordic health care system, we compare a few health quality indicators in the Nordic countries with those of five non-Nordic similarly small open European economies with the same level of income. Overall, the Nordic countries seem to be performing relatively well. Whether they will continue to do so will depend to a large extent on whether the welfare state will continue to reform itself as it has in the past.
Working Papers and Ongoing Work:
Does Debt Relief Improve Child Health? Evidence from Cross-Country Micro Data
World Bank Policy Research Working Paper 7872
Abstract:
This paper analyzes the effects of a multilateral debt relief program on child health. The International Monetary Fund and the World Bank launched the Heavily Indebted Poor Countries Initiative in the late 1990s to reduce the debt burdens of poor countries, and explicitly linked the initia-tive to the aim of poverty reduction and social targets. As a result, debt-servicing costs have gone down by an average 1.8 percentage points of gross domestic product in Heavily Indebted Poor Countries. However, the social effects of debt relief are not well known. The paper employs micro data on infant mortality from 56 country-specific Demo-graphic and Health Surveys to investigate the effects of the Heavily Indebted Poor Countries Initiative on child health. The retrospective fertility structure of the data allows for analysis using the within-mother variation in the probability of survival of babies before and after different stages of the initiative. The results suggest that after a debt-ridden country enters the program, which is conditional on reform and pro-development policies, and receives interim debt relief, the probability of infant mortality goes down by about 0.5 percentage point. This translates into about 3,000 fewer infant deaths in an average Heavily Indebted Poor Country. The findings are particularly strong for infants born to poor mothers and mothers living in rural areas, and are driven by access to vaccines early in life and during pregnancy. There are no child health effects from graduating from the program and receiving full debt relief.
Sick of you? A register-based study of partners’ health-related benefits and divorce among older working-age men and women in Sweden
joint with Therese Nilsson and Maria Stanfors
Partners’ uptake of health related benefits: Evidence from Sweden
joint with Therese Nilsson and Maria Stanfors
Building bridges: The effect of major international infrastructure development on trade
joint with Maria Persson and Christian Soegaard
Rethinking the human resource "crisis" in Africa’s health systems: Evidence from 10 countries
joint with colleagues at the World Bank and Center for Global Development
Parents’ eHealth literacy and socioeconomic status in pediatric care in Sweden
joint with Olof Kristjansdottir, Pernilla Stenström, Charlotte Castor, and Inger Kristensson Hallström
eHealth as an aid for facilitating and supporting self-management in families with long-term childhood illness; development, evaluation and implementation in clinical practice – A research programme
joint with Åsa B. Tornberg, Charlotte Castor, Helena E. Hansson, Robert Holmberg, Degu Jerene, Björn A. Johnsson, Gudrun Kristjansdottir, Olof Kristjansdottir, Boris Magnusson, Annica Sjöström-Strand, Pernilla Stenström, and Inger Kristensson Hallström