Health Financing and Delivery in Low- and Middle-Income Countries in the SDG Era

Abstract

This dissertation explores questions related to financing and delivery of health services under the Sustainable Development Goals (SDGs) and is comprised of three standalone papers. In Paper 1, using the case of Armenia, I explore the health and financial impact of higher cigarette prices (achieved through higher excise taxes) using extended cost-effectiveness analysis (ECEA) methods. Specifically, I model the potential impact of tobacco tax hikes on measures of health, individual and government expenditures, and financial risk protection. In addition, I use qualitative methods to examine the agenda setting of tobacco taxation. The ECEA results suggest large health and health-related financial benefits of tobacco tax increases, with the health benefits concentrated among the poor. The findings from qualitative interviews with key stakeholders indicate that fiscal constraints faced by the government and influence of external pressure created a window of opportunity for tobacco taxes to be placed on the policy agenda. In Paper 2, I investigate the impact of measles supplementary immunization activities (SIAs) on utilization of selected maternal and child health (MCH) services in low- and middle-income countries (LMICs). This is the first quantitative multi-country study to examine this relationship. Based on the findings, measles SIAs do not appear to significantly influence the utilization of MCH services at health facilities, except for care seeking related to a child’s cough for which I do find a substantial reduction in utilization during the period of SIA implementation. In Paper 3, I examine the efficiency of primary health care facilities in four sub-Saharan African countries and the degree to which the incorporation of technical quality changes facility estimates of technical efficiency. This is one of the first studies to incorporate measures of technical quality in efficiency analysis in LMICs. While the country average efficiency scores using quality-adjusted output are similar to the unadjusted efficiency scores, I observe significant changes in individual facility efficiency scores. This suggests that quality is particularly important if the goal of efficiency analysis is to identify best and worst performers rather than to simply measure average efficiency among a set of facilities.