Margaret E Kruk
Biographic Data
| ID | 1446407 |
|---|---|
| NAME | Margaret E Kruk |
| GIVEN NAMES | Margaret E |
| FAMILY NAME | Kruk |
| SIGNATURE | KRUK M E |
| AFFILIATIONS | Harvard Global Health Institute |
| ORCID | 0000-0002-9549-8432 |
| VERIFIED | Yes |
| TOTAL WORKS | 74 |
| TOTAL CITATIONS | 136 |
| AUTHOR COUNT | 74 |
| EDITOR COUNT | 0 |
| FIRST PUBLICATION YEAR | 1991 |
| LATEST PUBLICATION YEAR | 2026 |
| H-INDEX | 7 |
The relationship between prolonged travel and mortality among women with complicated deliveries in rural Kenya
Background: In many low- and middle-income settings, deliveries often take place in primary health facilities that are not equipped to address life-threatening complications. Emergency referral systems seek to rapidly transport women and newborns facing complications but inevitably introduce delays. Estimating the mortality impact of these delays is challenging due to potential selection bias. As an alternative approach, we examine the relationsh…
Health insurance in Nigeria
The recent Lancet Commission on Nigeria’s health system highlighted high out of pocket expenditures on health and underfunding of the public health sector as major obstacles to Nigeria’s achievement of the Sustainable Development Goals. Nigeria has sought to address these gaps by extending health insurance coverage. This paper measures health insurance coverage and access to care in Nigeria in 2023, using the first round of the People’s Voice Sur…
“If they were telling us to go, we will go”
INTRODUCTION: Few studies have explored the extent to which mother-newborn dyads have access to high-quality postnatal care (PNC) in low-income and middle-income countries. This study aims to measure effective (quality-adjusted) PNC coverage for newborns both before discharge and after discharge from the delivery facility, and for mothers before discharge, and to examine factors influencing access to high-quality PNC. METHODS: We conducted an exp…
The relationship between trust and compliance in the Italian NHS
BACKGROUND: Public health systems are assessed not only for outcomes but also for their ability to sustain legitimacy and trust. Trust supports long-term cooperation, while mandates can secure immediate adherence but risk eroding trust and weakening future willingness to comply. Italy illustrates this paradox, combining strong outcomes and extensive COVID-19 mandates with comparatively low public confidence. OBJECTIVE: To examine how trust, compl…
Quality of first antenatal care visits and perinatal outcomes
Antenatal care (ANC) is crucial for maternal and newborn health. Although ANC coverage has improved globally, ANC quality remains suboptimal. This study assessed the quality of first ANC visits and their association with perinatal outcomes. We used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy in Ethiopia, Kenya, South Africa, and India. Perinatal outcomes of interest includ…
The non-communicable disease e-Cohort for hypertension in Latin America
Non-communicable diseases like hypertension cause substantial morbidity and mortality in low- and middle-income countries, where limited access to high-quality care contributes to millions of preventable deaths annually. Traditional assessments of health system performance often rely on structural indicators and cross-sectional, overlooking patient experiences and care processes. In Latin America, amid rising cardiovascular disease, longitudinal …
To vaccinate or not to vaccinate? Experiences of Covid-19 vaccine uptake among people living with non-communicable diseases in Ghana
Following the development of a vaccine for COVID-19, the expectation was instantaneous widespread distribution and uptake to halt further spread, severe illness and deaths from the virus. However, studies show very low uptake, especially in resource-poor settings, and little is documented about the drivers of vaccine uptake in populations classified as high-risk. In this study, we explored access and uptake of COVID-19 vaccines among people livin…
Regional determinants of quality of care for sick children
Background: The limited impact of increased access to care on improvements in health outcomes during the Millennium Development Goal era has been attributed, in part, to inadequate quality of care. We identified regional factors associated with health service quality for sick child care in low-income countries and examined whether provider factors interact with regional factors to affect the quality of care. Methods: We conducted cross-sectional …
The maternal and newborn health eCohort to track longitudinal care quality
The MNH eCohort was developed to fill gaps in maternal and newborn health (MNH) care quality measurement. In this paper, we describe the survey development process, recruitment strategy, data collection procedures, survey content and plans for analysis of the data generated by the study. We also compare the survey content to that of existing multi-country tools on MNH care quality. The eCohort is a longitudinal mixed-mode (in-person and phone) su…
Care seeking during pregnancy
A health systems reform known as Service Delivery Redesign (SDR) for maternal and newborn health seeks to make high-quality delivery care universal in Kakamega County, in western Kenya, by strengthening hospital-level care and making hospital deliveries the default option for pregnant women. Using a large prospective survey of new mothers in Kakamega County, we examine several key assumptions that underpin the SDR policy’s theory of change. We an…
Multisectoral resilience for the next global health emergency
Health system adaptions to improve care for people living with non-communicable diseases during Covid-19 in low-middle income countries
Over the past three decades, the burden of non-communicable diseases (NCDs) increased significantly in low-and middle-income countries (LMICs), with 2019 reports showing that more than 80% of deaths in LMICs were caused by NCDs. Some studies have projected that NCDs are set to overtake communicable/infectious diseases as the main public health threats in LMICs after [...]
Covid-19 and resilience of healthcare systems in ten countries
Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) coun…
Overcoming disruptions in essential health services during the Covid-19 pandemic in Mexico
Associations between women’s empowerment, care seeking, and quality of malaria care for children
Background: Fever and malaria are highly prevalent among children under five across sub-Saharan Africa, but utilization and quality of care for febrile illness remain insufficient. Many studies examine socioeconomic and demographic determinants of care seeking; however, few assess how women's empowerment influences care seeking and quality. We examine associations of women's empowerment with: a) care utilization for children with fever and malari…
Service delivery reform for maternal and newborn health in Kakamega County, Kenya
This protocol describes a hybrid effectiveness/implementation evaluation study with an adaptive design. The impact evaluation ("effectiveness") study focuses on maternal and newborn health outcomes, and will be accompanied by an implementation evaluation focused on program reach, adoption, and fidelity
Best and worst performing health facilities
Primary care services are on average of low quality in Nepal. However, there is marked variation in performance of basic clinical and managerial functions between primary health care centers. The determinants of variation in primary care performance in low- and middle-income countries have been understudied relative to the prominence of primary care in national health plans. We used the positive deviance approach to identify best and worst perfor…
Disruption in essential health services in Mexico during Covid-19
INTRODUCTION: The COVID-19 pandemic has disrupted health systems around the world. The objectives of this study are to estimate the overall effect of the pandemic on essential health service use and outcomes in Mexico, describe observed and predicted trends in services over 24 months, and to estimate the number of visits lost through December 2020. METHODS: We used health information system data for January 2019 to December 2020 from the Mexican …
If we build it, will they come? Results of a quasi-experimental study assessing the impact of maternity waiting homes on facility-based childbirth and maternity care in Zambia
INTRODUCTION: Maternity waiting homes (MWHs) aim to increase access to maternity and emergency obstetric care by allowing women to stay near a health centre before delivery. An improved MWH model was developed with community input and included infrastructure, policies and linkages to health centres. We hypothesised this MWH model would increase health facility delivery among remote-living women in Zambia. METHODS: We conducted a quasi-experimenta…
The Lancet NCDI Poverty Commission
Temporal trends in coverage, quality and equity of maternal and child health services in Rwanda, 2000–2015
INTRODUCTION: Achieving the maternal and child health (MCH)-related Sustainable Development Goals (SDG) will require equitable and effective (quality-adjusted) coverage of recommended health interventions in low- and middle-income countries. We assessed effective coverage and equity of MCH services in Rwanda in the Millennium Development Goal (MDG) era to help guide policy decisions to improve equitable health gains in the SDG era and beyond. MET…
The role of health system context in the design and implementation of performance-based financing
Low quality of care is a significant problem for health systems in low-income and middle-income countries (LMICs). Policymakers are increasingly interested in using performance-based financing (PBF), a system-wide provider payment reform, conditioned on both quantity and quality of performance, to improve quality of care. The health system context influences both the design and the implementation of these programmes and thus their effectiveness. …
Can complex programs be sustained? A mixed methods sustainability evaluation of a national infant and young child feeding program in Bangladesh and Vietnam
The inclusion of multiple activities in A&T and efforts to integrate the program into existing institutions were seen as crucial to its success but also made it difficult to sustain, particularly given unstable financial support and human resource constraints. Future complex programs should carefully plan for institutionalization in advance of the program by cultivating champions across the health system, and designing unique and complementary ro…
Quality of clinical assessment and child mortality
This analysis describes specific gaps in the quality of health care in Central Africa and assesses the association between quality of clinical care and mortality at age 2–59 months. Regionally representative facility and household surveys for the Democratic Republic of the Congo, Cameroon and Central African Republic were collected between 2012 and 2016. These data are novel in linking facilities with households in their catchment area. Complianc…
Community engagement for health system resilience
The importance of community engagement (CE) for health system resilience is established in theoretical and empirical literature. The practical dimensions of how to operationalize theory and implement its principles have been less explored, especially within low-resource crisis settings. It is therefore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critica…
Rebuilding health systems to improve health and promote statebuilding in post-conflict countries
Bypassing primary care facilities for childbirth
In an effort to reduce maternal mortality, developing countries have been investing in village-level primary care facilities to bring skilled delivery services closer to women. We explored the extent to which women in rural western Tanzania bypass their nearest primary care facilities to deliver at more distant health facilities, using a population-representative survey of households (N = 1204). Using a standardized instrument, we asked women who…
Women's Preferences for Place of Delivery in Rural Tanzania
Objectives. We fielded a population-based discrete choice experiment (DCE) in rural western Tanzania, where only one third of women deliver children in a health facility, to evaluate health-system factors that influence women's delivery decisions. Methods. Women were shown choice cards that described 2 hypothetical health centers by means of 6 attributes (distance, cost, type of provider, attitude of provider, drugs and equipment, free transport)…
Disrespectful and abusive treatment during facility delivery in Tanzania
Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. We measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania. Using a struc…
The persistent problem of malaria
Community engagement for health system resilience
The importance of community engagement (CE) for health system resilience is established in theoretical and empirical literature. The practical dimensions of how to operationalize theory and implement its principles have been less explored, especially within low-resource crisis settings. It is therefore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critica…
Beyond the crisis
Resilience was widely identified as a critical attribute for strong health systems following the 2014-15 West Africa Ebola epidemic. In Liberia, Sierra Leone and Guinea, struggles to control the disease and suspension of the operation of many health services demonstrated that health systems must plan for resilience long before a crisis. However, the operational elements of resilience and ways that a crisis experience can shape resilience are not …
Local adaptations to a global health initiative
Global health initiatives (GHIs) are implemented across a variety of geographies and cultures. Those targeting maternal health often prioritise increasing facility delivery rates. Pressure on local implementers to meet GHI goals may lead to unintended programme features that could negatively impact women. This study investigates penalties for home births imposed by traditional leaders on women during the implementation of Saving Mothers, Giving L…
Eye of the beholder? Observation versus self-report in the measurement of disrespect and abuse during facility-based childbirth
Human rights has been a vital tool in the global movement to reduce maternal mortality and to expose the disrespect and abuse that women experience during childbirth in facilities around the world. Yet to truly transform the relationship between women and providers, human rights-based approaches (HRBAs) will need to go beyond articulation, dissemination and even legal enforcement of formal norms of respectful maternity care. HRBAs must also devel…
Women's preferences for obstetric care in rural Ethiopia
BACKGROUND: Delivery attended by skilled professionals is essential to reducing maternal mortality. Although the facility delivery rate in Ethiopia's rural areas is extremely low, little is known about which health system characteristics most influence women's preferences for delivery services. In this study, women's preferences for attributes of health facilities for delivery in rural Ethiopia were investigated. METHODS: A population-based discr…
Access to emergency and surgical care in sub-Saharan Africa
BACKGROUND: The effort to increase access to emergency and surgical care in low-income countries has received global attention. While most of the literature on this issue focuses on workforce challenges, it is critical to recognize infrastructure gaps that hinder the ability of health systems to make emergency and surgical care a reality. METHODS: This study reviews key barriers to the provision of emergency and surgical care in sub-Saharan Afric…
Best and worst performing health facilities
Primary care services are on average of low quality in Nepal. However, there is marked variation in performance of basic clinical and managerial functions between primary health care centers. The determinants of variation in primary care performance in low- and middle-income countries have been understudied relative to the prominence of primary care in national health plans. We used the positive deviance approach to identify best and worst perfor…
Factors influencing modes of transport and travel time for obstetric care
Transportation is an important barrier to accessing obstetric care for many pregnant and postpartum women in low-resource settings, particularly in rural areas. However, little is known about how pregnant women travel to health facilities in these settings. We conducted 1633 exit surveys with women who had a recent facility delivery and 48 focus group discussions with women who had either a home or a facility birth in the past year in eight distr…
Equity of Skilled Birth Attendant Utilization in Developing Countries
Objectives. Developing countries with higher health care spending have greater overall utilization of maternal health services than do countries with lower spending. However, the rich tend to disproportionately use these services. We assessed whether redistributive government policies in the context of higher levels of health spending were associated with more-equitable use of skilled birth attendants (doctors, nurses, or midwives) between rich a…
Where women go to deliver
Growing evidence from a number of countries in Asia and Africa documents a large shift towards facility deliveries in the past decade. These increases have not led to the improvements in health outcomes that were predicted by health policy researchers in the past. In light of this unexpected evidence, we have assessed data from multiple sources, including nationally representative data from 43 countries in Asia and Africa, to understand the size …
Redesigning Primary Care to Tackle the Global Epidemic of Noncommunicable Disease
Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared f…
Parity and institutional delivery in rural Tanzania
OBJECTIVES: We assess the extent to which the use of healthcare facilities for childbirth varies by parity, conditional on socio-economic, psychological and health characteristics. We also assess differences in the determinants of institutionalized delivery for first-time mothers and multiparous, and explore village-level variations in observed relationships. METHODS: Survey data from a three-stage cross-sectional cluster sample of 1205 women fro…
The Role of Health Systems and Policies in Promoting Safe Delivery in Low- and Middle-Income Countries
We aimed to measure the contribution of national factors, particularly health system characteristics, to the individual likelihood of professionally attended delivery (“safe delivery”) for women in low- and middle-income countries. Using Demographic and Health Survey data for 165 774 women in 31 countries, we estimated multilevel logistic regression models to measure the contribution of national economic and health system characteristics to likel…
Equity and the child health Millennium Development Goal
BACKGROUND: There are substantial disparities in mortality between rich and poor children in developing countries. As a result, there is a call for explicitly pro-poor health programming in efforts to reach the child health Millennium Development Goals. AIM: To estimate the contribution made by pro-poor health policy to reduction in wealth disparities in under-5 mortality. METHODS: An ecological, cross-sectional analysis was performed using Demog…
Persistent Psychopathology in the Wake of Civil War
Objectives. We assessed the geographical distribution of posttraumatic stress disorder (PTSD) in postconflict Nimba County, Liberia, nearly 2 decades after the end of primary conflict in the area, and we related this pattern to the history of conflict. Methods. We administered individual surveys to a population-based sample of 1376 adults aged 19 years or older. In addition, we conducted a historical analysis of conflict in Nimba County, Liberia,…
Quality of clinical assessment and child mortality
This analysis describes specific gaps in the quality of health care in Central Africa and assesses the association between quality of clinical care and mortality at age 2–59 months. Regionally representative facility and household surveys for the Democratic Republic of the Congo, Cameroon and Central African Republic were collected between 2012 and 2016. These data are novel in linking facilities with households in their catchment area. Complianc…
Liberation Theology From a Marxian Perspective
Marx denounced religion in general, and the nineteenth century Christian Socialist movement in Europe in particular, as oppressive forces which can never authentically take the side of the poor in transforming an unjust society. I compare the development of the Christian social movement in Europe to the development of Liberation Theology in Central America to establish whether Marx's criticism of religion applies to the latter. I find Liberation …
Ending Africa's Poverty Trap
Africa’s development crisis is unique. Not only is Africa the poorest region in the world, but it was also the only major developing region with negative growth in income per capita during 1980–2000 (table 1). Some African countries grew during the 1990s, but for the most part this growth recovered ground lost during the 1980s. Moreover, Africa’s health condi-tions are by far the worst on the planet. The AIDS pandemic is wreaking havoc, as is the…
Source of Antenatal Care Influences Facility Delivery in Rural Tanzania
Equity of Skilled Birth Attendant Utilization in Developing Countries
Objectives. Developing countries with higher health care spending have greater overall utilization of maternal health services than do countries with lower spending. However, the rich tend to disproportionately use these services. We assessed whether redistributive government policies in the context of higher levels of health spending were associated with more-equitable use of skilled birth attendants (doctors, nurses, or midwives) between rich a…
The persistent problem of malaria
Bypassing primary care facilities for childbirth
In an effort to reduce maternal mortality, developing countries have been investing in village-level primary care facilities to bring skilled delivery services closer to women. We explored the extent to which women in rural western Tanzania bypass their nearest primary care facilities to deliver at more distant health facilities, using a population-representative survey of households (N = 1204). Using a standardized instrument, we asked women who…
Women's Preferences for Place of Delivery in Rural Tanzania
Objectives. We fielded a population-based discrete choice experiment (DCE) in rural western Tanzania, where only one third of women deliver children in a health facility, to evaluate health-system factors that influence women's delivery decisions. Methods. Women were shown choice cards that described 2 hypothetical health centers by means of 6 attributes (distance, cost, type of provider, attitude of provider, drugs and equipment, free transport)…
The contribution of primary care to health and health systems in low- and middle-income countries
Women's preferences for obstetric care in rural Ethiopia
BACKGROUND: Delivery attended by skilled professionals is essential to reducing maternal mortality. Although the facility delivery rate in Ethiopia's rural areas is extremely low, little is known about which health system characteristics most influence women's preferences for delivery services. In this study, women's preferences for attributes of health facilities for delivery in rural Ethiopia were investigated. METHODS: A population-based discr…
Persistent Psychopathology in the Wake of Civil War
Objectives. We assessed the geographical distribution of posttraumatic stress disorder (PTSD) in postconflict Nimba County, Liberia, nearly 2 decades after the end of primary conflict in the area, and we related this pattern to the history of conflict. Methods. We administered individual surveys to a population-based sample of 1376 adults aged 19 years or older. In addition, we conducted a historical analysis of conflict in Nimba County, Liberia,…
Rebuilding health systems to improve health and promote statebuilding in post-conflict countries
Equity and the child health Millennium Development Goal
BACKGROUND: There are substantial disparities in mortality between rich and poor children in developing countries. As a result, there is a call for explicitly pro-poor health programming in efforts to reach the child health Millennium Development Goals. AIM: To estimate the contribution made by pro-poor health policy to reduction in wealth disparities in under-5 mortality. METHODS: An ecological, cross-sectional analysis was performed using Demog…
Galea et al. Respond
We would like to thank Myers for her interest in our work. Two issues are raised; we would like to tackle each in turn. First, we are in complete agreement on the need for cross-cultural validation for any measure used to assess mental health. While definitive validation is particularly challenging in contexts like Liberia, where psychiatrists or psychologists who may provide “gold standard assessments” are essentially nonexistent, we conducted b…
Which Doctor
BACKGROUND: Liberia is rebuilding its health system after a lengthy civil war in which traditional health care was the only reliable source of care. OBJECTIVE: This study explored individual, village, and health system factors related to the utilization of health clinics versus informal providers (eg, healers, medicine sellers) in Liberia. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES: This was a cross-sectional population-representative survey of …
Globalisation and global health governance
Globalisation is a defining economic and social trend of the past several decades. Globalisation affects health directly and indirectly and creates economic and health disparities within and across countries. The political response to address these disparities, exemplified by the Millennium Development Goals, has put pressure on the global community to redress massive inequities in health and other determinants of human capability across countrie…
Equity of inpatient health care in rural Tanzania
The findings indicated that while current Tanzanian health financing policies may have improved access to health care for children under five, additional policies are needed to further close the equity gap, especially for obstetric inpatients
Access to emergency and surgical care in sub-Saharan Africa
BACKGROUND: The effort to increase access to emergency and surgical care in low-income countries has received global attention. While most of the literature on this issue focuses on workforce challenges, it is critical to recognize infrastructure gaps that hinder the ability of health systems to make emergency and surgical care a reality. METHODS: This study reviews key barriers to the provision of emergency and surgical care in sub-Saharan Afric…
Policy talk
Like many countries in sub-Saharan Africa, Ghana is faced with the simultaneous challenges of increasing its health workforce, retaining them in country and promoting a rational distribution of staff in remote or deprived areas of the country. Recent increases in both public-sector doctor and nurse salaries have contributed to a decline in international out-migration, but problems of geographic mal-distribution remain. As part of a research proje…
The Role of Health Systems and Policies in Promoting Safe Delivery in Low- and Middle-Income Countries
We aimed to measure the contribution of national factors, particularly health system characteristics, to the individual likelihood of professionally attended delivery (“safe delivery”) for women in low- and middle-income countries. Using Demographic and Health Survey data for 165 774 women in 31 countries, we estimated multilevel logistic regression models to measure the contribution of national economic and health system characteristics to likel…
Global health 2035
countries can be reduced by 2035 through inexpensive population-based and clinical interventions. Fiscal policies are an especially promising lever for reducing this burden.
Parity and institutional delivery in rural Tanzania
OBJECTIVES: We assess the extent to which the use of healthcare facilities for childbirth varies by parity, conditional on socio-economic, psychological and health characteristics. We also assess differences in the determinants of institutionalized delivery for first-time mothers and multiparous, and explore village-level variations in observed relationships. METHODS: Survey data from a three-stage cross-sectional cluster sample of 1205 women fro…
Defining disrespect and abuse of women in childbirth
PerspectivesIn the field of maternal and newborn health, there have been calls to prioritize the intra-partum period and promote facility delivery to meet maternal and newborn mortality reduction goals. This aim is based on a decade of epide-miological work identifying causes of death, systematically reviewing effective interventions, and modelling the impact of intervention coverage on mortality.
What is a resilient health system? Lessons from Ebola
Association Between Disrespect and Abuse During Childbirth and Women’s Confidence in Health Facilities in Tanzania
Can the health system deliver? Determinants of rural Liberians’ confidence in health care
BACKGROUND: Following a protracted civil war, Liberia is rebuilding its health system. One of the aims of reconstruction is to expand access to health care to a previously underserved rural population. OBJECTIVE: This study analysed the determinants of Liberians' confidence in their ability to obtain needed care for themselves or their children in case of serious illness. METHODS: A cross-sectional survey of 1435 adults in Nimba County, Liberia w…
Medicine (58 works) · Global Maternal and Child Health (56 works) · Environmental health (47 works) · Economic growth (39 works) · Population (35 works) · Nursing (34 works) · Health care (33 works) · Healthcare Systems and Reforms (28 works) · Business (26 works) · Political science (26 works)