Expanding surgical access in Africa through improved health insurance schemes: A review.

Surgical access remains a pressing public health concern in African nations, with a substantial portion of the population facing challenges in obtaining safe, timely, and affordable surgical care. This paper delves into the impact of health insurance schemes on surgical accessibility in Africa, exploring the barriers, challenges, and future directions. It highlights how high out-of-pocket costs, reliance on traditional healing practices, and inadequate surgical infrastructure hinder surgical utilization. Financing mechanisms often need to be more effective, and health insurance programs face resistance within the informal sector. Additionally, coverage of the poor remains a fundamental challenge, with geographical and accessibility barriers compounding the issue. Government policies, often marked by inconsistency and insufficient allocation of resources, create further obstacles. However, strategic purchasing and fund integration offer avenues for improving the efficiency of health insurance programs. The paper concludes by offering policy recommendations, emphasizing the importance of inclusive policies, streamlined financing mechanisms, coverage expansion, and enhanced strategic purchasing to bridge the surgical access gap in Africa. Decoupling entitlement from the payment of contributions, broadening the scope of coverage for outpatient medicines and related expenses, and enhancing safeguards against overall costs and charges, especially for individuals with lower incomes. Ultimately, by addressing these challenges and harnessing the potential of health insurance schemes, the continent can move closer to achieving universal surgical care and improving the well-being of its people.

Financial incentives for integrated care: A scoping review and lessons for evidence-based design.

BACKGROUND: In response to the increasing prevalence of people with chronic conditions, healthcare systems restructure to integrate care across providers. However, many systems fail to achieve the desired outcomes. One likely explanation is lack of financial incentives for integrating care. OBJECTIVES: We aim to identify financial incentives used to promote integrated care across different types of providers for patients with common chronic conditions and assess the evidence on (cost-)effectiveness and the facilitators/barriers to their implementation. METHODS: This scoping review identifies studies published before December 2021, and includes 33 studies from the United States and the Netherlands. RESULTS: We identify four types of financial incentives: shared savings, bundled payments, pay for performance, and pay for coordination. Substantial heterogeneity in the (cost-)effectiveness of these incentives exists. Key implementation barriers are a lack of infrastructure (e.g., electronic medical records, communication channels, and clinical guidelines). To facilitate integration, financial incentives should be easy to communicate and implement, and require additional financial support, IT support, training, and guidelines. CONCLUSIONS: All four types of financial incentives may promote integrated care but not in all contexts. Shared savings appears to be the most promising incentive type for promoting (cost-)effective care integration with the largest number of favourable studies allowing causal interpretations. The limited evidence pool makes it hard to draw firm conclusions that are transferable across contexts.

Administrative law as a determinant of public health.

Administrative law comprises the rules, values, and processes by which government and regulatory decision-making is subject to administrative monitoring, review, and accountability. It impacts public health in two ways: through the design, powers, and processes of institutions that enforce administrative law; and through the substantive rules of administrative law. Yet despite its fundamental regulation of the way in which public health decisions are made, insufficient research has been conducted on administrative law as a determinant of public health. Administrative law and public health operate as siloed academic disciplines with very little cross-disciplinary collaboration, engagement, or understanding. This results in major, untapped research opportunities exploring how administrative law could contribute to an optimized model of planetary health in both higher income and lower-middle income countries. Put simply, a holistic, global view of the determinants of public health must take due account of the accountability rules and controls that regulate how public health, and other, decisions are made. This commentary is a call to action to better understand how administrative law mechanisms, such as judicial review, administrative tribunals, ombudsmen, information commissioners, public auditors, and human rights monitors, can be designed or redesigned to better promote sustainable public health outcomes.

RéSUMé: Le droit administratif comprend les règles, les valeurs et les processus qui assujettissent la prise de décisions gouvernementales et réglementaires à la responsabilité, aux examens et aux suivis administratifs. Il influence la santé publique de deux façons : par la conception, les pouvoirs et les processus des institutions qui appliquent le droit administratif, et par les règles de fond du droit administratif. Pourtant, bien qu'il régisse fondamentalement la façon dont les décisions de santé publique se prennent, il n'y a pas suffisamment d'études sur le droit administratif en tant que déterminant de la santé publique. Le droit administratif et la santé publique sont exercés en tant que disciplines universitaires cloisonnées, avec très peu de collaboration, de participation ou de compréhension entre elles. Il y a donc d'immenses possibilités de recherche inexplorées pour savoir comment le droit administratif pourrait contribuer à un modèle de santé planétaire optimisé, dans les pays à revenu élevé comme dans les pays à revenu intermédiaire ou faible. En clair, une perspective holistique et mondiale des déterminants de la santé publique doit tenir compte des règles et des contrôles de responsabilité qui régissent la prise des décisions de santé publique, entre autres. Notre commentaire est un appel à mieux comprendre comment les mécanismes du droit administratif, comme le contrôle judiciaire, les tribunaux administratifs, les protecteurs du citoyen, les commissaires à l'information, les auditeurs du secteur public et les observateurs ayant pour fonction de veiller au respect des droits de la personne, peuvent être conçus ou redéfinis pour favoriser des effets durables sur le plan de la santé publique.

Is household shock a boon or bane to the utilisation of preventive healthcare for children? Evidence from Uganda.

This paper investigates how poor households in low-income countries trade off time investment in their children's preventive healthcare vis-à-vis labour force participation during household-level health shocks. By using the reported illness or death of any household member as the indicator for an adverse health shock, I examine its effect on the intake of Vitamin A Supplementation (VAS) by children. Using four waves of the Uganda National Panel Survey, I find that children between 12-24 months are significantly more likely to get VAS when the household is under a health shock. I argue that this effect works through an economies of scale mechanism, by which the household adult(s) utilise the released time from the labour force during the shock to access remedial care from the healthcare facility and simultaneously obtain VAS for their children during the same visit. This arguably results from the high opportunity cost of time-constrained households, which is exacerbated by a mediocre service delivery side. To distinguish the unique mechanism of the health shock in this context, the effect and channels of an income shock are also explored. By proxying a negative income shock with the household-reported incidence of flood or drought, the study cautiously hints that VAS adoption may increase among the relatively wealthy who experience a dominating substitution effect of the income shock.

Who returned home? The COVID-19 pandemic and young adults' residential transitions.

The COVID-19 pandemic is thought to have led to an increase in the percentage of young adults living with their parents, but the relative contributions made by moves into and out of the parental home to this increase are unknown. Also unknown is whether changes in the likelihood of home leaving and returning were concentrated among privileged or disadvantaged youth. This study used data from the Panel Study of Income Dynamics Transition into Adulthood Supplement (2013-2021) and estimated logistic regression models to examine changes in the levels and correlates of moving into (n = 1872) and out of (n = 1852) the parental home before and after the onset of the COVID-19 pandemic in the U.S. Results show that relative to pre-pandemic trends, during the COVID-19 pandemic young adults were more likely to move back to the parental home and less likely to leave it. The increase in the likelihood of returning home was concentrated among young, white college students from advantaged families. The decline in leaving home was most pronounced among white and employed young adults.

A multi-dimensional assessment of financial hardship of cancer patients using existing health system data.

BACKGROUND: Existing financial hardship screening does not capture the multifaceted and dynamic nature of the problem. The use of existing health system data is a promising way to enable scalable and sustainable financial hardship screening. METHODS: We used existing data from 303 adult patients with cancer at the University of Virginia Comprehensive Cancer Center (2016-2018). All received distress screening and had a valid financial assistance screening based solely on household size-adjusted income. We constructed a composite index that integrates multiple existing health system data (Epic, distress screening, and cancer registry) to assess comprehensive financial hardship (e.g., material conditions, psychological responses, and coping behaviors). We examined differences of at-risk patients identified by our composite index and by existing single-dimension criterion. Dynamics of financial hardship over time, by age, and cancer type, were examined by fractional probit models. RESULTS: At-risk patients identified by the composite index were generally younger, better educated, and had a higher annual household income, though they had lower health insurance coverage. Identified periods to intervene for most patients are before formal diagnosis, 2 years, and 6 years after diagnosis. Within 2 years of diagnosis and more than 4 years after diagnosis appear critical for subgroups of patients who may suffer from financial hardship disparities. CONCLUSION: Existing health system data provides opportunities to systematically measure and track financial hardship in a systematic, scalable and sustainable way. We find that the dimensions of financial hardship can exhibit different patterns over time and across patient subgroups, which can guide targeted interventions. The scalability of the algorithm is limited by existing data availability.

Making the cut on caesarean section: a logistic regression analysis on factors favouring caesarean sections without medical indication in comparison to spontaneous vaginal birth.

BACKGROUND: In the absence of medical necessity, opting for caesarean sections exposes mothers and neonates to increased risks of enduring long-term health problems and mortality. This ultimately results in greater economic burden when compared to the outcomes of spontaneous vaginal births. In Switzerland around 33% of all births are by caesarean section. However, the rate of caesarean sections without medical indication is still unknown. Therefore, we devise an identification strategy to differentiate caesarean sections without medical indication using routine data. In addition, we aim to categorize the influencing factors for women who undergo spontaneous vaginal births as opposed to those with caesarean sections without medical indication. METHOD: We use Swiss Federal Statistics data including 98.3% of all women giving birth from 2014 to 2018. To determine non-medically indicated caesarean sections in our dataset, we base our identification strategy on diagnosis-related groups, diagnosis codes, and procedure classifications. Subsequently, we compare characteristics of women who give birth by non-medically CS and external factors such as the density of practicing midwives to women with spontaneous vaginal birth. Logistic regression analysis measures the effect of factors, such as age, insurance class, income, or density of practicing midwives on non-medically indicated caesarean sections. RESULTS: Around 8% of all Swiss caesarean sections have no medical indication. The regression analysis shows that higher age, supplemental insurance, higher income, and living in urban areas are associated with non-medically indicated caesarean sections, whereas a higher density of midwives decreases the likelihood of caesarean sections without medical indication. CONCLUSIONS: By identifying non-medically indicated caesarean sections using routine data, it becomes feasible to gain insights into the characteristics of impacted mothers as well as the external factors involved. Illustrating these results, our recommendation is to revise the incentive policies directed towards healthcare professionals. Among others, future research may investigate the potential of midwife-assisted pregnancy programs on strengthening spontaneous vaginal births in absence of medical complications.

An analysis of the foremost issues with artisanal and small-scale gold mining from Ghana's perspective.

Ghana has abundant mineral reserves in many of its regions, and gold mining remains one of the country's main sources of revenue. Given Ghana's current position in the global gold market, this review provides insight into the ASGM sector to give an understanding of the pertinent issues in the sector and its role in the socio-economic development of the country. This review assesses the effects of ASGM operations in economic, social, health, and environmental contexts to raise awareness of issues related to ASGM. It evaluates the measures taken to lessen the consequences of ASGM and maintain the sector's long-term viability. This review considers the foremost issues, including continued Hg use in ASGM, recent use of cyanide in ASGM, pollution of water bodies, and toxic metal contamination. It takes into account sustainable measures and remedial techniques that Ghana has implemented to alleviate the negative effects and support best mining practices. The primary factors influencing people to participate in ASGM are the need for quick sources of income, the scarcity of jobs in rural areas, the economic hardship, the need to supplement earnings from other activities like trading, and the comparatively meager profits from agricultural activities. Findings indicated that to gain more traction in addressing the challenges in the ASGM sector, the involvement of the community and direct stakeholders is essential to promoting responsible mining and environmentally sustainable practices. This review will increase awareness and pressure on decision-makers, researchers, and ASGM communities about the relevance of environmental conservation and sustainability.

Income Disparity and Healthcare Utilization: Lessons from Indonesia's National Health Insurance Claim Data.

BACKGROUND: Indonesia's National Health Insurance Program, known as Jaminan Kesehatan Nasional (JKN), has a variety of membership pathways for those wishing to gain access. Claim data from JKN offers a cost-effective way of observing who is accessing healthcare services and what types of services are being used. This study is a novel attempt to measure disparities amongst JKN users in their engagement with services, providing an opportunity to reflect on patterns of use. METHODS: Using claims data collected from JKN users between 2015-2016, we used the Ordinary Least Square estimation model to compare health services utilization among subsidized and non-subsidized users. We focused primarily on the individual use of the hospital for outpatient and inpatient treatment. RESULTS: Analysis reveals that subsidized users access primary healthcare services more frequently than non-subsidized users. Conversely, non-subsidized users access secondary and tertiary health care services more frequently than other users. Subsidized users who utilize secondary and tertiary health care tend to suffer more severe health illnesses than non-subsidized members. CONCLUSIONS: This study concludes that income disparity affects healthcare utilization. Non-subsidized members are more likely than subsidized members to access secondary and tertiary health care services. Our study offers evidence of the potential underutilization of secondary and tertiary healthcare (STHC) by subsidized members, which could lead to inefficiency since subsidized members seeking STHC treatment had severe health conditions, thus needing to be treated longer and requiring higher healthcare expenditures.

Perceived income inadequacy is associated with Epstein-Barr Virus latency and mental health outcomes in informal caregivers who are also employed in the healthcare industry.

Finances are a prevalent source of stress. In a sample of 799 nursing home workers measured multiple times over 18 months, we found that higher perceived income inadequacy, the perception that one's expenses exceeds one's incomes, was associated with poorer self-reported mental health indicators and Epstein-Barr Virus antibody titers (a marker of cell-mediated immune function). Perceived income inadequacy predicted outcomes over and above the role of other socioeconomic status variables (objective household income and education). Mental health variables were not related to Epstein-Barr Virus antibody titers. Additionally, we found an interaction between perceived income inadequacy and informal caregiver status on our mental health outcomes; informal caregivers with higher perceived income inadequacy had poorer mental health than non-caregivers with the same perceived income inadequacy. Our findings may add nuance to the reserve capacity model, which states that those at lower socioeconomic levels are at higher risk of adverse health outcomes partly because they have fewer resources to address demands and strain. Perceived income inadequacy may significantly predict mental and physical well-being beyond other socioeconomic status variables, especially among lower-income employees. Caregiving stress and perceived income inadequacy may have synergistic effects on mental health.

The Head, the Heart, and the Community: Piloting a Brief Home-Based Mindfulness Intervention for Couples With Low Income.

Although mindfulness is documented to reduce both individual and relationship stress and has the flexibility to be taught anywhere (e.g., at home, clinic setting, etc.), research examining mindfulness interventions among individuals with low income and economic marginalization (LIEM; APA, 2019), or persons whose economic position negatively impacts their health or well-being due to factors such as access to healthcare, is limited. To address this gap, the author and colleagues used Community Based Participatory Research methods to develop a brief, couple-based, mindfulness intervention tailored for communities with LIEM (see Lenger et al., 2022). The present study tested this newly developed brief, couple-based, mindfulness intervention's effectiveness in improving individual and relationship health through 1- and 2-months post-intervention. The intervention was piloted on a sample of 39 couples with an overrepresentation of couples with LIEM. To improve access to care, couples could participate in their home or a variety of local clinics. Thirty-nine couples received the intervention and completed assessments on mindfulness, depression, anxiety, stress, relationship satisfaction, and communication at baseline, 1-month, and 2-months post-intervention. Results revealed that mindfulness, depression, and relationship satisfaction improved from baseline to 1-month post-intervention. Mindfulness improved at a greater rate for couples with LIEM relative to couples with higher incomes. From baseline to 2-months post-intervention, depression and stress significantly improved at similar rates for couples with higher income and couples with LIEM. Thus, this study indicates that mindfulness can be taught in a brief, two-session format, and can have favorable outcomes on individual and relationship functioning.

A rapid review of initiatives to address financial strain and wellbeing in high-income contexts.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has exacerbated financial strain among populations worldwide. This is concerning, given the link between financial strain and health. There is little evidence to guide action in this area, particularly from a public health perspective. To address this gap, we examined initiatives to address financial wellbeing and financial strain in high-income contexts. METHODS: We used rapid review methodology and applied an equity-focused lens in our analysis. We searched six databases (MEDLINE, PsycINFO, Web of Science, ProQuest, Informit, and Google Advanced) for peer-reviewed, academic and practice-based literature evaluating initiatives to address financial strain and wellbeing in high-income contexts published between 2015-2020. We conducted a relevancy and quality appraisal of included academic sources. We used EPPI-reviewer software to extract equity-related, descriptive data, and author-reported outcomes. RESULTS: We conducted primary screening on a total of 4779 titles/abstracts (academic n = 4385, practice-based n = 394); of these, we reviewed 182 full text articles (academic n = 87, practice-based n = 95) to assess their relevancy and fit with our research question. A total of 107 sources were excluded based on our selection criteria and relevance to the research question (Figure 1), leaving 75 sources that were extracted for this review (academic n = 39, practice-based n = 36). These sources focused on initiatives predominantly based in Australia, the US, and Canada, with a smaller number from the UK and Europe. Most sources primarily targeted financial literacy and personal/family finances, followed by employment, housing, and education. CONCLUSIONS: We found that holistic initiatives (i.e., complex, wrap-around) that ensured people's basic needs were met (for example, before building financial skills) were aligned with positive and equitable financial wellbeing and financial strain outcomes, as reported in the reviewed studies. We noted significant gaps in the literature related to equity, such as the impact of initiatives on socially excluded populations (e.g., Indigenous peoples, racialised peoples, and rural dwellers). More research using a public health lens is required to guide equitable and sustainable action in this area.

Growing Up Can Be Hard to Do: Reimagining 1 Structurally Supportive Pediatric-to-Adult Transitions of Care from a Rights-Based Perspective.

Extended life expectancies and shifting dynamics in chronic disease have changed the landscape of public health interventions worldwide, with an increasing emphasis on chronic care. As a result, transition from pediatric to adult care for medically complex adolescents and young adults is a growing area of intervention. Transition medicine is a nascent field whose current emphasis is on middle- and high-income countries, and thus far its methods and discourse have reflected those origins. Through several case-based examples, this paper aims to highlight the possibilities of an analytic approach grounded in structural competency for transforming transition medicine through a human rights-based framework, with an emphasis on imagining a more global framework for transition medicine. Our cases highlight the disparities between patients navigating pediatric to adult-based care, illuminating social stigma, stratification between public and private insurances, engagement in risk-taking behaviors, family conflict, and challenges with transition readiness. To reimagine transition medicine so that it is based on human rights, we must prioritize structural solutions that embrace multisectoral integration and holistic mental health support rather than oppress and marginalize these critical systemic adaptations. We aim to reconfigure this scaffolding to center structures that integrate holistic well-being and imagine alternate realities to healing. Our work contributes to the literature bringing structural competency to new spaces of clinical practice, contextualizing new frontiers for the exploration of chronic diseases across diverse clinical contexts worldwide.

Analysis of Inequalities and Inequities in Maternal Mortality in Chocó, Colombia.

We used a mixed design study to analyze the inequalities and inequities in Maternal Mortality (MM) for Chocó (Colombia) between 2010-2018. The quantitative component consisted of an analytical ecological design, where proportions, ratios, measures of central tendency and rates ratios, rate difference, Gini and concentration indices were calculated to measure inequalities. The qualitative component had a phenomenological and interpretive approach. One hundred thirty-one women died in Choco between 2010-2018. The Maternal Mortality Ratio was 224/100.000 live births. The Gini coefficient was 0.35, indicating inequality in the distribution of the number of MM with respect to live births. The health service offers have been concentrated in the private sector in urban areas (77%). The exercise of midwifery has played an important role in maternal and perinatal care processes, especially in territories where the State has been absent. Nevertheless, it occurs in complex circumstances such as the armed conflict, lack of transportation routes, and income deficits, affecting the timelines and care quality for these vulnerable groups. MM in Chocó has been a consequence of deficiencies in the health system and weaknesses in its infrastructure (absence of a high level of maternal-perinatal care). This is in addition to the territory's geographical characteristics, which increase vulnerability and health risks for women and their newborns. In Colombia, as well as in other countries, many maternal and newborn deaths are preventable because their causes are due to social injustices.

Weak regulations threaten the safety of consumers from harmful weight-loss supplements globally: results from a pilot global policy scan.

OBJECTIVE: To pilot a global policy scan assessing how governments worldwide regulate weight-loss supplements (WLS). DESIGN: Experts on WLS policies from thirty countries that varied by World Bank income classification, with five from each of the six WHO regions, completed an online survey on WLS regulation in their country. The survey covered six domains: legal frameworks; pre-market requirements; claims, labelling, and advertisements; product availability; adverse events reporting; and monitoring and enforcement. Percentages were calculated for presence or absence of a type of regulation. SETTING: Experts were recruited through websites of regulatory bodies and professional LinkedIn networks and scientific article searches on Google Scholar. PARTICIPANTS: Thirty experts, one from each country (i.e. researchers, regulators, other experts in food and drug regulation). RESULTS: WLS regulations varied widely across countries, and a number of gaps were identified. One country (Nigeria) has a minimum legal age to purchase WLS. Thirteen countries reported independently evaluating the safety of a new WLS product sample. Two countries have limitations on where WLS can be sold. In eleven countries, reports on adverse events related to WLS are publicly available. In eighteen countries, safety of new WLS is to be established through scientific criteria. Penalties for WLS non-compliance with pre-market regulations exist in twelve countries and labelling requirements in sixteen countries. CONCLUSIONS: Results of this pilot study document wide variability in national WLS regulations globally, exposing many gaps in important components of consumer protection regulatory frameworks for WLS, which likely put consumer health at risk.

Assessment of integrated patterns of human-animal-environment health: a holistic and stratified analysis.

BACKGROUND: Data-driven research is a very important component of One Health. As the core part of the global One Health index (GOHI), the global One Health Intrinsic Drivers index (IDI) is a framework for evaluating the baseline conditions of human-animal-environment health. This study aims to assess the global performance in terms of GOH-IDI, compare it across different World Bank regions, and analyze the relationships between GOH-IDI and national economic levels. METHODS: The raw data among 146 countries were collected from authoritative databases and official reports in November 2021. Descriptive statistical analysis, data visualization and manipulation, Shapiro normality test and ridge maps were used to evaluate and identify the spatial and classificatory distribution of GOH-IDI. This paper uses the World Bank regional classification and the World Bank income groups to analyse the relationship between GOH-IDI and regional economic levels, and completes the case studies of representative countries. RESULTS: The performance of One Health Intrinsic Driver in 146 countries was evaluated. The mean (standard deviation, SD) score of GOH-IDI is 54.05 (4.95). The values (mean SD) of different regions are North America (60.44, 2.36), Europe and Central Asia (57.73, 3.29), Middle East and North Africa (57.02, 2.56), East Asia and Pacific (53.87, 5.22), Latin America and the Caribbean (53.75, 2.20), South Asia (52.45, 2.61) and sub-Saharan Africa (48.27, 2.48). Gross national income per capita was moderately correlated with GOH-IDI (R2 = 0.651, Deviance explained = 66.6%, P < 0.005). Low income countries have the best performance in some secondary indicators, including Non-communicable Diseases and Mental Health and Health risks. Five indicators are not statistically different at each economic level, including Animal Epidemic Disease, Animal Biodiversity, Air Quality and Climate Change, Land Resources and Environmental Biodiversity. CONCLUSIONS: The GOH-IDI is a crucial tool to evaluate the situation of One Health. There are inter-regional differences in GOH-IDI significantly at the worldwide level. The best performing region for GOH-IDI was North America and the worst was sub-Saharan Africa. There is a positive correlation between the GOH-IDI and country economic status, with high-income countries performing well in most indicators. GOH-IDI facilitates researchers' understanding of the multidimensional situation in each country and invests more attention in scientific questions that need to be addressed urgently.

Why were some countries more successful than others in curbing early COVID-19 mortality impact? A cross-country configurational analysis.

Why was there considerable variation in initial COVID-19 mortality impact across countries? Through a configurational lens, this paper examines which configurations of five conditions-a delayed public-health response, past epidemic experience, proportion of elderly in population, population density, and national income per capita-influence early COVID-19 mortality impact measured by years of life lost (YLL). A fuzzy-set qualitative comparative analysis (fsQCA) of 80 countries identifies four distinctive pathways associated with high YLL rate and four other different pathways leading to low YLL rate. Results suggest that there is no singular "playbook"-a set of policies that countries can follow. Some countries failed differently, whereas others succeeded differently. Countries should take into account their situational contexts to adopt a holistic response strategy to combat any future public-health crisis. Regardless of the country's past epidemic experience and national income levels, a speedy public-health response always works well. For high-income countries with high population density or past epidemic experience, they need to take extra care to protect elderly populations who may otherwise overstretch healthcare capacity.

A comprehensive examination of discrimination and the impact on health in young adults.

Research has begun to clarify links between discrimination and health, but important gaps remain. A more complete understanding may arise from data on both frequency of discrimination as well as the various forms of discrimination. Using unique Panel Study of Income Dynamics (PSID) Transition to Adulthood Supplement (TAS) data on a representative sample of young adults from the 2017 and 2019 waves, we consider frequency and forms of discrimination separately and in tandem. Using generalized estimating equations panel models, we find that the association between discrimination and health is more pronounced when the frequency of, and the number of reasons for, discriminatory experiences are considered together. For example, relative to experiencing no discrimination, perceiving frequent discrimination and for three or more reasons results in nearly three times higher odds of poor/fair self-rated health and 1.25 points lower on the languishing/flourishing scale. The impact of perceived discrimination on health is likely underestimated if frequency and rationale are not considered as a holistic experience.

The value of donkeys to livelihood provision in northern Ghana.

Increased demand for the supply of donkey hides for use in the Traditional Chinese Medicine e'jiao, is leading to a re-appraisal of donkeys' contributions to livelihoods across the world. This research aimed to understand the utilitarian value donkeys provide to poor small holder farmers, especially women, in their efforts to make a living in two rural communities in northern Ghana. Uniquely, children and donkey butchers were interviewed for the first time about their donkeys. A qualitative thematic analysis was undertaken of data disaggregated by sex, age and donkey-ownership. The majority of protocols were repeated during a second visit, ensuring comparative data between one wet, and one dry season. Donkeys are more important in people's lives than had previously been recognised and are highly valued by their owners for their help in reducing drudgery and the multi-functional services they offer. Hiring out donkeys to generate income is a secondary role for people who own donkeys, especially women. However, for financial and cultural reasons the way donkeys are kept results in the loss of a certain percentage of the animals to the donkey meat market, as well as the global hides trade. Increasing demand for donkey meat, coupled with increasing demand for donkeys for farming, is leading to donkey price inflation and theft of donkeys. This is putting pressure on the donkey population of neighbouring Burkina Faso and pricing resource-poor non-donkey owners out of the market. E'jiao has put the spotlight on the value of dead donkeys for the first time, especially to governments and middlemen. This study shows that the value of live donkeys to poor farming households is substantial. It attempts to understand and document this value thoroughly, should the majority of donkeys in West Africa be rounded up and slaughtered for the value of their meat and skin instead.

Value addition and farmers: Evidence from coffee in Ethiopia.

Local value-addition in developing countries is often aimed at for upgrading of agricultural value chains, since it is assumed that doing so will make farmers better off. However, transmission of the added value through the value chain and constraints to adoption of value-adding activities by farmers are not well understood. We look at this issue in the case of coffee in Ethiopia-the country's most important export product-and value-addition in the coffee value-chain through 'washing' coffee, which is done in wet mills. Washed coffee is sold internationally with a significant premium compared to 'natural' coffee but the share of washed coffee in Ethiopia's coffee exports has stagnated. Relying on a unique primary large-scale dataset and a combination of qualitative and quantitative methods, we examine the reasons for this puzzle. The reasons seemingly are twofold. First, labor productivity in producing red cherries, which wet mills require, is lower than for natural coffee, reducing incentives for adoption, especially for those farmers with higher opportunity costs of labor. Second, only impatient, often smaller, farmers sell red cherries, as more patient farmers use the storable dried coffee cherries as a rewarding savings instrument, given the negative real deposit rates in formal savings institutions.