Publications by Author: Emmanuela Gakidou

2009
Public Policy for the Poor? A Randomised Assessment of the Mexican Universal Health Insurance Programme
Gary King, Emmanuela Gakidou, Kosuke Imai, Jason Lakin, Ryan T Moore, Clayton Nall, Nirmala Ravishankar, Manett Vargas, Martha María Téllez-Rojo, Juan Eugenio Hernández Ávila, Mauricio Hernández Ávila, and Héctor Hernández Llamas. 2009. “Public Policy for the Poor? A Randomised Assessment of the Mexican Universal Health Insurance Programme.” The Lancet, 373, Pp. 1447-1454.Abstract

Background: We assessed aspects of Seguro Popular, a programme aimed to deliver health insurance, regular and preventive medical care, medicines, and health facilities to 50 million uninsured Mexicans. Methods: We randomly assigned treatment within 74 matched pairs of health clusters–-i.e., health facility catchment areas–-representing 118,569 households in seven Mexican states, and measured outcomes in a 2005 baseline survey (August 2005, to September 2005) and follow-up survey 10 months later (July 2006, to August 2006) in 50 pairs (n=32 515). The treatment consisted of encouragement to enrol in a health-insurance programme and upgraded medical facilities. Participant states also received funds to improve health facilities and to provide medications for services in treated clusters. We estimated intention to treat and complier average causal effects non-parametrically. Findings: Intention-to-treat estimates indicated a 23% reduction from baseline in catastrophic expenditures (1·9% points and 95% CI 0·14-3·66). The effect in poor households was 3·0% points (0·46-5·54) and in experimental compliers was 6·5% points (1·65-11·28), 30% and 59% reductions, respectively. The intention-to-treat effect on health spending in poor households was 426 pesos (39-812), and the complier average causal effect was 915 pesos (147-1684). Contrary to expectations and previous observational research, we found no effects on medication spending, health outcomes, or utilisation. Interpretation: Programme resources reached the poor. However, the programme did not show some other effects, possibly due to the short duration of treatment (10 months). Although Seguro Popular seems to be successful at this early stage, further experiments and follow-up studies, with longer assessment periods, are needed to ascertain the long-term effects of the programme.

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Replication Data for: Public Policy for the Poor? A Randomised Assessment of the Mexican Universal Health Insurance Programme
Gary King, Emmanuela Gakidou, Kosuke Imai, Jason Lakin, Ryan T Moore, Clayton Nall, Nirmala Ravishankar, Manett Vargas, Martha María Téllez-Rojo, Juan Eugenio Hernández Ávila, Mauricio Hernández Ávila, and Héctor Hernández Llamas. 2009. “Replication Data for: Public Policy for the Poor? A Randomised Assessment of the Mexican Universal Health Insurance Programme”. Publisher's Version
2007
A "Politically Robust" Experimental Design for Public Policy Evaluation, with Application to the Mexican Universal Health Insurance Program
Gary King, Emmanuela Gakidou, Nirmala Ravishankar, Ryan T Moore, Jason Lakin, Manett Vargas, Martha María Téllez-Rojo, Juan Eugenio Hernández Ávila, Mauricio Hernández Ávila, and Héctor Hernández Llamas. 2007. “A "Politically Robust" Experimental Design for Public Policy Evaluation, with Application to the Mexican Universal Health Insurance Program.” Journal of Policy Analysis and Management, 26, Pp. 479-506.Abstract

We develop an approach to conducting large scale randomized public policy experiments intended to be more robust to the political interventions that have ruined some or all parts of many similar previous efforts. Our proposed design is insulated from selection bias in some circumstances even if we lose observations and our inferences can still be unbiased even if politics disrupts any two of the three steps in our analytical procedures and and other empirical checks are available to validate the overall design. We illustrate with a design and empirical validation of an evaluation of the Mexican Seguro Popular de Salud (Universal Health Insurance) program we are conducting. Seguro Popular, which is intended to grow to provide medical care, drugs, preventative services, and financial health protection to the 50 million Mexicans without health insurance, is one of the largest health reforms of any country in the last two decades. The evaluation is also large scale, constituting one of the largest policy experiments to date and what may be the largest randomized health policy experiment ever.

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2006
Death by Survey: Estimating Adult Mortality without Selection Bias from Sibling Survival Data
Emmanuela Gakidou and Gary King. 2006. “Death by Survey: Estimating Adult Mortality without Selection Bias from Sibling Survival Data.” Demography, 43, Pp. 569–585.Abstract
The widely used methods for estimating adult mortality rates from sample survey responses about the survival of siblings, parents, spouses, and others depend crucially on an assumption that we demonstrate does not hold in real data. We show that when this assumption is violated – so that the mortality rate varies with sibship size – mortality estimates can be massively biased. By using insights from work on the statistical analysis of selection bias, survey weighting, and extrapolation problems, we propose a new and relatively simple method of recovering the mortality rate with both greatly reduced potential for bias and increased clarity about the source of necessary assumptions.
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2003
Determinants of Inequality in Child Survival: Results from 39 Countries
Emmanuela Gakidou and Gary King. 2003. “Determinants of Inequality in Child Survival: Results from 39 Countries.” In Health Systems Performance Assessment: Debates, Methods and Empiricism, edited by Christopher J.L. Murray and David B. Evans, Pp. 497-502. Geneva: World Health Organization.Abstract

Few would disagree that health policies and programmes ought to be based on valid, timely and relevant information, focused on those aspects of health development that are in greatest need of improvement. For example, vaccination programmes rely heavily on information on cases and deaths to document needs and to monitor progress on childhood illness and mortality. The same strong information basis is necessary for policies on health inequality. The reduction of health inequality is widely accepted as a key goal for societies, but any policy needs reliable research on the extent and causes of health inequality. Given that child deaths still constitute 19% of all deaths globally and 24% of all deaths in developing countries (1), reducing inequalities in child survival is a good beginning.total = between + within

The between-group component of total health inequality has been studied extensively by numerous scholars. They have expertly analysed the causes of differences in health status and mortality across population subgroups, defined by income, education, race/ethnicity, country, region, social class, and other group identifiers (2–9).

 

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2002
Emmanuela Gakidou and Gary King. 2002. “Measuring Total Health Inequality: Adding Individual Variation to Group-Level Differences.” BioMed Central: International Journal for Equity in Health, 1.Abstract
Background: Studies have revealed large variations in average health status across social, economic, and other groups. No study exists on the distribution of the risk of ill-health across individuals, either within groups or across all people in a society, and as such a crucial piece of total health inequality has been overlooked. Some of the reason for this neglect has been that the risk of death, which forms the basis for most measures, is impossible to observe directly and difficult to estimate. Methods: We develop a measure of total health inequality – encompassing all inequalities among people in a society, including variation between and within groups – by adapting a beta-binomial regression model. We apply it to children under age two in 50 low- and middle-income countries. Our method has been adopted by the World Health Organization and is being implemented in surveys around the world and preliminary estimates have appeared in the World Health Report (2000). Results: Countries with similar average child mortality differ considerably in total health inequality. Liberia and Mozambique have the largest inequalities in child survival, while Colombia, the Philippines and Kazakhstan have the lowest levels among the countries measured. Conclusions: Total health inequality estimates should be routinely reported alongside average levels of health in populations and groups, as they reveal important policy-related information not otherwise knowable. This approach enables meaningful comparisons of inequality across countries and future analyses of the determinants of inequality.
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