Depression, violence and socioeconomic outcomes among refugees in East Africa: evidence from a multicountry representative survey.

BACKGROUND: Existing research on refugee mental health is heavily skewed towards refugees in high-income countries, even though most refugees (83%) are hosted in low-income and middle-income countries. This problem is further compounded by the unrepresentativeness of samples, small sample sizes and low response rates. OBJECTIVE: To present representative findings on the prevalence and correlates of depression among different refugee subgroups in East Africa. METHODS: We conducted a multicountry representative survey of refugee and host populations in urban and camp contexts in Kenya, Uganda and Ethiopia (n=15 915). We compared the prevalence of depression between refugee and host populations and relied on regression analysis to explore the association between violence, depression and socioeconomic outcomes. FINDINGS: We found a high prevalence of elevated depressive symptoms (31%, 95% CI 28% to 35%) and functional impairment (62%, 95% CI 58% to 66%) among the refugee population, which was significantly higher than that found in the host population (10% for depressive symptoms, 95% CI 8% to 13% and 25% for functional impairment, 95% CI 22% to 28%) (p<0·001). Further, we observed a dose-response relationship between exposure to violence and mental illness. Lastly, high depressive symptoms and functional impairment were associated with worse socioeconomic outcomes. CONCLUSION: Our results highlight that refugees in East-Africa-particularly those exposed to violence and extended exile periods-are disproportionately affected by depression, which may also hinder their socioeconomic integration. CLINICAL IMPLICATIONS: Given the high prevalence of depression among refugees in East Africa, our results underline the need for scalable interventions that can promote refugees' well-being.

Lives and livelihoods: Estimates of the global mortality and poverty effects of the Covid-19 pandemic.

We evaluate the global welfare consequences of increases in mortality and poverty generated by the Covid-19 pandemic. Increases in mortality are measured in terms of the number of years of life lost (LY) to the pandemic. Additional years spent in poverty (PY) are conservatively estimated using growth estimates for 2020 and two different scenarios for its distributional characteristics. Using years of life as a welfare metric yields a single parameter that captures the underlying trade-off between lives and livelihoods: how many PYs have the same welfare cost as one LY. Taking an agnostic view of this parameter, we compare estimates of LYs and PYs across countries for different scenarios. Three main findings arise. First, we estimate that, as of early June 2020, the pandemic (and the observed private and policy responses) had generated at least 68 million additional poverty years and 4.3 million years of life lost across 150 countries. The ratio of PYs to LYs is very large in most countries, suggesting that the poverty consequences of the crisis are of paramount importance. Second, this ratio declines systematically with GDP per capita: poverty accounts for a much greater share of the welfare costs in poorer countries. Finally, a comparison of these baseline results with mortality estimates in a counterfactual "herd immunity" scenario suggests that welfare losses would be greater in the latter in most countries.

Allocation of development assistance for health: is the predominance of national income justified?

Gross national income (GNI) per capita is widely regarded as a key determinant of health outcomes. Major donors heavily rely on GNI per capita to allocate development assistance for health (DAH). This article questions this paradigm by analysing the determinants of health outcomes using cross-sectional data from 99 countries in 2012. We use disability-adjusted life years (Group I) per capita as our main indicator for health outcomes. We consider four primary variables: GNI per capita, institutional capacity, individual poverty and the epidemiological surroundings. Our empirical strategy has two innovations. First, we construct a health poverty line of 10.89 international-$ per day, which measures the minimum level of income an individual needs to have access to basic healthcare. Second, we take the contagious nature of communicable diseases into account, by estimating the extent to which the population health in neighbouring countries (the epidemiological surroundings) affects health outcomes. We apply a spatial two-stage least-squares model to mitigate the risks of reverse causality. Our model captures 92% of the variation in health outcomes. We emphasize four findings. First, GNI per capita is not a significant predictor of health outcomes once other factors are controlled for. Second, the poverty gap below the 10.89 health poverty line is a good measure of universal access to healthcare, as it explains 19% of deviation in health outcomes. Third, the epidemiological surroundings in which countries are embedded capture as much as 47% of deviation in health outcomes. Finally, institutional capacity explains 10% of deviation in health outcomes. Our empirical findings suggest that allocation frameworks for DAH should not only take into account national income, which remains an important indicator of countries' financial capacity, but also individual poverty, governance and epidemiological surroundings to increase impact on health outcomes.

What goes wrong with the allocation of domestic and international resources for HIV?

This paper examines how domestic and international financing for HIV is, and ought to be, distributed. We build a theoretical framework that decomposes domestic and international financing for HIV into nonlinear functions of national income, HIV prevalence, and government effectiveness. We test this model, paying particular attention to nonlinearities and to problems of bad controls, multicollinearity, and reverse causality. Finally, we use the fitted values of quartile regressions to study how much countries could reasonably pay domestically and how much they should receive from donors. Worryingly, countries with higher financial means receive on average more aid per PLHIV than very poor ones, and countries with higher HIV prevalence receive on average less aid per people living with HIV. The normative analysis concludes that US$3.08 billion of fiscal space could be created in LIC and MIC. We identify the countries that could be allocated more aid.

Financing the HIV response in sub-Saharan Africa from domestic sources: Moving beyond a normative approach.

Despite optimism about the end of AIDS, the HIV response requires sustained financing into the future. Given flat-lining international aid, countries' willingness and ability to shoulder this responsibility will be central to access to HIV care. This paper examines the potential to expand public HIV financing, and the extent to which governments have been utilising these options. We develop and compare a normative and empirical approach. First, with data from the 14 most HIV-affected countries in sub-Saharan Africa, we estimate the potential increase in public HIV financing from economic growth, increased general revenue generation, greater health and HIV prioritisation, as well as from more unconventional and innovative sources, including borrowing, health-earmarked resources, efficiency gains, and complementary non-HIV investments. We then adopt a novel empirical approach to explore which options are most likely to translate into tangible public financing, based on cross-sectional econometric analyses of 92 low and middle-income country governments' most recent HIV expenditure between 2008 and 2012. If all fiscal sources were simultaneously leveraged in the next five years, public HIV spending in these 14 countries could increase from US$3.04 to US$10.84 billion per year. This could cover resource requirements in South Africa, Botswana, Namibia, Kenya, Nigeria, Ethiopia, and Swaziland, but not even half the requirements in the remaining countries. Our empirical results suggest that, in reality, even less fiscal space could be created (a reduction by over half) and only from more conventional sources. International financing may also crowd in public financing. Most HIV-affected lower-income countries in sub-Saharan Africa will not be able to generate sufficient public resources for HIV in the medium-term, even if they take very bold measures. Considerable international financing will be required for years to come. HIV funders will need to engage with broader health and development financing to improve government revenue-raising and efficiencies.

Natural resources and the spread of HIV/AIDS: Curse or blessing?

This paper answers two questions: "What impact have natural resources had on the spread of the HIV epidemic so far?" and "What role can natural resource rents play in order to finance the long-run response to HIV/AIDS?" Using a panel dataset covering 137 countries from 1990 until 2008, de Soysa and Gizelis (2013) provided evidence in Social Science & Medicine that oil-rich countries are more deeply affected by the HIV and TB epidemics. They concluded that government of resource-rich countries failed to implement effective public policies for dealing with the epidemics. In this paper, I show that their results are (1) not robust, (2) based on an inappropriate choice of dependent variable and (3) spurious because series are non-stationary. After correcting for these issues, I find no robust relationship between resource rents and the spread of HIV and TB. The paper concludes by emphasizing the potential of natural resources rents for financing the long-term liability brought about by the HIV/AIDS epidemic in sub-Saharan Africa.

Why are Testing Rates so Low in Sub-Saharan Africa? Misconceptions and Strategic Behaviors.

Voluntary testing and counseling (VTC) is a popular method for fighting the HIV/AIDS epidemic. The purpose of VTC is to reduce the incidence of the virus in a two-fold manner. First, testing provides access to health care and antiretroviral therapies that diminish the transmission rate of the virus. Second, counseling encourages safer behavior for not only individuals who test HIV-negative and wish to avoid HIV/AIDS infection but also altruistic individuals who test HIV-positive and wish to protect their partners from becoming infected by HIV. Surprisingly, DHS surveys that were conducted in sub-Saharan Africa provide empirical evidence that testing services are underutilized. Moreover, it is rare for both partners in a couple to be tested for HIV. This paper proposes a theoretical model that indicates how misperceptions about the HIV/AIDS virus may explain these puzzles. More specifically, this study demonstrates that individuals who are at risk of HIV infection may act strategically to avoid the cost of testing if they overestimate the risk of HIV transmission or believe that health care is not required if HIV is asymptomatic. The correction of false beliefs and the promotion of self-testing are expected to increase HIV testing rates.