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International Health

Health Systems Program

Keyword: health economics

Dr. Krishna D. Rao, assistant professor, joined the Health Systems Program in 2014, bringing expertise in health systems and health economics. He received his master’s degree at Cornell University in agriculture and resource economics and his PhD in health systems from the Program.

Prior to joining the Health Systems Program, Dr. Rao worked with the Public Health Foundation of India (PHFI), where he conducted research on health systems and taught health economics. Before coming to PHFI, Dr. Rao worked in Afghanistan as part of the Johns Hopkins team supporting their Ministry of Public Health (MoH) to evaluate models of community financing of health services. Dr. Rao started his career in public health at the World Bank, working on the delivery of child nutrition and health services in India. In 2016, Dr. Rao was selected as a practitioner resident fellow to the Rockefeller Foundation Bellagio Center Residency Program.

Dr. Rao’s research focuses on three major areas – human resources for health, health financing and evaluation. He is particularly concerned with issues around strengthening primary care and nutrition services, measuring quality of care, and reducing financial hardship faced by households due to health care payments. He teaches courses in health financing in low- and middle-income countries, and the role of health in economic development. Dr. Rao also co-leads the Program’s health systems seminars.

Dr. Rao is involved with a variety of research projects. One of Dr. Rao’s key projects includes evaluation of a large-scale mentoring program for nurses at primary health centers in the state of Bihar, India. The mentoring program is funded by the Gates Foundation and provides nurses with the knowledge and skills to improve their obstetric skills. This evaluation is being conducted in partnership with the Johns Hopkins School of Nursing.

Dr. Rao is also currently working on designing a conditional cash-transfer program for improving nutrition in young children in India. The study uses a discrete choice experiment to understand the preferences of mothers for program conditionalities and cash transfer amounts. Other key projects include mentoring researchers from eight different countries to help them improve their research skills, conducting a cost-effectiveness analysis of a nutrition program in Malawi, and a previous health financing project in Kyrgyzstan that examined how health financing issues affect delivery of services.

Going forward, Dr. Rao is interested in studying conditional and unconditional cash transfer programs, aging and what implications that has for health systems and the financing of health care, and how the management and institutional structures of health services affect health worker performance and quality of care. Read more about Dr. Rao’s work in his faculty profile

Changing ingrained attitudes, perceptions and cultural norms that lead to harmful behavior can be one of the trickiest challenges in public health. There are varying disciplines that attempt to examine why social and behavioral change can be so difficult to accomplish. One of those fields, Health Economics, examines how to design incentives to motivate people to take care of themselves. Dr. Antonio Trujillo, co-director of Health Systems Program’s Master of Health Science (MHS) in Health Economics academic program, spearheads a study in Peru that attempts to understand why people with diabetes fail to take care of themselves over and over again.

In collaboration with the Center of Excellence in Chronic Diseases (CRONICAS) in Peru, Dr. Trujillo’s study looks at the role group incentives play in promoting healthier behavior, specifically, how we can use the combination of cooperation and group monetary rewards to encourage people with diabetes to take care of themselves. Past studies have examined the use of individual monetary incentives to accomplish certain outcomes when trying to change behavior; however, individual cash rewards have increasingly been found to work short-term but not in the long run. In addition to a lack of long-term success for consistent healthy behavior, they are often infeasible and unaffordable to scale-up to larger projects and studies, and frequently face rejection from the general public who are opposed to paying individuals to take care of themselves.

This Health Systems Program project examines the viability of a mixed-incentive study that combines both group motivation and monetary reward. Using a teamwork approach, there are two participants: one patient implements the suggested lifestyle changes while their partner, designated as a “motivator,” encourages them to stick to the new regimen. If the person implementing the suggested changes makes the goal, then they both get rewarded. The aim of the design is to foster cooperation and synergies between participants. The use of social networks and personal connections establishes a more meaningful tie to the healthier routine.

Challenges to introducing behavior change over the long haul still persist and a big part of Dr. Trujillo’s work is understanding these challenges and how best to mitigate them. One such challenge touches upon one of the basic fundamentals of public health - people in many areas of the world lack the information and knowledge, access to primary care and insurance, and do not have the income to support a steady upkeep of their health. These obstacles persist across all geographic areas, and failures to take care of diabetes are similar in both the U.S. and Peru. Dr. Trujillo and the Health Systems Program wish to see gains happen across all different types of behaviors, starting with designing better programs to address chronic disease; however, in order to achieve that, it’s necessary to help people develop a habit of taking care of themselves – all around the world.