Thesis advisor: Donald Cox / I investigate the effect of the medical brain drain on health in sub-Saharan Africa. Such information would be invaluable to policymakers; if doctors are likely to emigrate, there is little benefit in investing in their training. Previous work has mostly been limited to measuring correlations, which fail to illuminate causal pathways; countries with weakly structured healthcare systems may have both poor health and high physician emigration. I address the problem with an instrumental variable. For African countries with historic colonial ties to the United Kingdom or France, I used immigration policy changes in these European nations to instrument for the medical brain drain. Higher rates of medical brain drain cause decreased physician density, decreased rates of measles immunizations among children, and increased rates of HIV prevalence in sub-Saharan Africa. Therefore, I conclude that targeting physician emigration would help improve health in the region. / Thesis (BA) — Boston College, 2013. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: College Honors Program. / Discipline: Economics Honors Program. / Discipline: Economics.

School-based sexual health education is commonly used to promote the sexual health of young people and guide them in their relationships. This thesis reports on research that aimed to provide evidence-based recommendations to optimise the effectiveness of school-based sexual health education in sub-Saharan Africa (sSA). There are six chapters in the thesis. Chapter 1 introduces the thesis, Chapters 2 to 5 consist of four empirical studies, and Chapter 6 provides an overall discussion and looks at the strengths, limitations, and implications of the findings. Chapter 2 is a systematic review and meta-analysis of school-based sexual health education in sSA. It provides some evidence of the interventions in promoting self-reported condom use. However, it shows there are no harmful or beneficial effects with respect to sexually transmitted infections (STI) as evidenced by biomarkers. It highlights the paucity of evaluated interventions using biomedical markers, and reports on the process of evaluation, which limits our understanding of why interventions work or do not work. Features associated with effective interventions are noted. Chapter 3 is a case study involving MEMA Kwa Vijana, an adolescent sexual and reproductive health intervention implemented in Tanzania. This study highlights the influence of structural factors in schools and wider environmental factors on the effectiveness of school-based sexual health interventions. Furthermore, it identifies the social and cultural factors that influence young people’s sexual behaviours and that must be addressed beyond the education and health sectors. Chapter 4 is a multiple case study of seven school-based sexual health interventions implemented in five sub-Saharan African countries. It 4 identifies the design, implementation, and evaluation features that differentiate between effective and ineffective interventions. Chapter 5 is a qualitative study of researchers’ experiences of school-based sexual health education in sSA. This study extends previous work by generating a set of valuable recommendations based on researchers’ experiences of interventions that could improve future interventions in sSA. Overall, this research project demonstrates the potential of school-based sexual health education in promoting sexual health and preventing STIs in sSA. It provides a series of recommendations for the design, implementation, and evaluation of school-based sexual health interventions.

INTRODUÇÃO: As prevalências de desnutrição infantil ainda são altas nos países da África Subsaariana; porém, há indícios de que a obesidade em adultos esteja aumentando. Neste cenário, se, por um lado, é importante combater a desnutrição, por outro, é fundamental identificar as tendências do excesso de peso ao longo do tempo, a fim de prevenir grandes elevações de obesidade e doenças crônicas. Com isso, os objetivos desta pesquisa foram: descrever as tendências de obesidade ao longo das últimas décadas em mulheres em idade fértil e em crianças menores de 5 anos, paralelamente àquelas de desnutrição nesse mesmo grupo de crianças em países da África Subsaariana; e identificar os fatores associados à desnutrição em crianças menores de 2 anos em um município de Luanda, Angola. MÉTODOS: Para descrever as tendências da situação nutricional, foram utilizados dados de inquéritos nacionais (Demographic and Health Surveys e Multiple Indicator Cluster Samples) de 13 países do continente africano, que tinham pelo menos quatro inquéritos disponíveis. Foram traçadas tendências para os desfechos: obesidade em mulheres com idade entre 15 e 49 anos, e sobrepeso, baixa estatura (stunting), baixo peso para altura (wasting), baixo peso para idade (underweight) e baixo peso ao nascer em crianças com menos de 5 anos. Para as tendências individuais de cada país, foi realizada regressão linear, enquanto para as tendências considerando o conjunto dos 13 países, empregou-se modelo de regressão multinível. Quanto à identificação dos fatores associados com a desnutrição, foram utilizados dados de um estudo transversal de base populacional realizado em Cacuaco, município da província de Luanda, em 2010. Os desfechos estudados foram baixa estatura (stunting) e baixo peso para idade (underweight). Foram estimadas razões de prevalência (RP) por regressão de Poisson com variância robusta utilizando modelo hierarquizado. RESULTADOS: A prevalência de obesidade cresceu entre mulheres em idade fértil na maior parte dos países estudados, em média 2,8 pontos percentuais por década (P<0,001), acompanhada por importante diminuição de stunting, em média de 5,6 pontos percentuais por década (P<0,001) e diminuição bem menor de wasting, em média de 1,1 ponto percentual por década (P=0,09), sem evidência, até o momento, de aumento de sobrepeso em crianças abaixo de 5 anos (aumento de 1,0 ponto percentual por década, P=0,14). Em Angola, das 749 crianças incluídas no estudo, 232 [32,0% (IC 95%: 28,7-35,5%)] tinham baixa estatura e 109 [15,1% (IC 95%: 12,6-17,9%)] estavam com peso baixo para idade. Na análise multivariável final, foram identificados os seguintes fatores associados com os desfechos pesquisados: ocorrência de diarreia nos últimos 15 dias (RP 1,39 [IC95% 1,06-1,84]) para baixa estatura; e presença de óbito de outros filhos (RP 1,52 [IC95% 1,01-2,28]) para baixo peso para idade. Em modelo composto apenas de fatores distais e intermediários, a presença de cuidador principal (outro que não a mãe) aumentou a prevalência de baixa estatura em 42% (RP 1,42; IC95% 1,10-1,84) e para cada mês mais tarde que a mãe o iniciou pré-natal, a prevalência de baixo peso para idade aumentou em 20% (RP 1,20; IC95% 1,03-1,40). CONCLUSÃO: Foi possível descrever a tendência preocupante de aumento de obesidade em mulheres em idade fértil nos países estudados. Em Angola, poucos fatores individuais foram descritos, sugerindo que a influência de fatores coletivos é importante. Esses dados devem ser úteis para o planejamento de ações visando, por um lado, à prevenção de uma epidemia de obesidade em crianças na África Subsaariana e, por outro, ao enfrentamento atual das altas taxas de desnutrição em crianças em Angola e outros países. / INTRODUCTION: The prevalence of child malnutrition is still high in sub-Saharan Africa; however, there is evidence that obesity in adults is increasing. In this scenario, on the one hand, it is important to tackle malnutrition, while on the other, it is essential to identify trends in excess weight over time, so as to focus attention on the prevention of large increases in obesity and the chronic diseases it causes. Thus, the objectives of this study were to describe trends in sub-Saharan Africa in obesity over the past decades in women of childbearing age and in children under 5 years of age, in parallel with those of malnutrition in the same group of children; as well as to identify factors associated with malnutrition in children under 2 years living in the suburban area of Luanda, Angola. METHODS: To describe the trends in nutritional status, secondary data from national surveys (Demographic and Health Surveys and Multiple Indicator Cluster Samples) of 13 African countries having at least four available surveys, were used. Trends were described for the outcomes obesity in women aged 15 to 49, and overweight, stunting, wasting, underweight and low birthweight in children under 5 years. For individual trends in each country, linear regression was performed. For trends considering the group of 13 countries, we used a multilevel regression model. To identify the factors associated with malnutrition, data from a cross-sectional population-based study held in Cacuaco, a municipality of Luanda, in 2010 were used. The outcomes studied were stunting and underweight. Prevalence ratios (PR) were estimated by Poisson regression with robust variance using a hierarchical model. RESULTS: The prevalence of obesity increased among women of reproductive age in most of the countries studied, on average 2.8 percentage points per decade (P<0.001), accompanied by significant reduction of stunting, on average 5.6 percentage points per decade (P<0.001) and a decrease, though much smaller, of wasting, on average 1.1 percentage points per decade (P=0.09), with no evidence, to date, of an increase in overweight in children under 5 years (increase of 1.0 percentage points per decade, P = 0.14).In Angola, among the 749 children included in the study, 232 [32.0% (95% CI: 28.7 to 35.5%)] were stunted and 109 [15.1% (95% CI: 12.6- 17.9)] were underweight. In the final multivariate analysis model, the following factors have been identified as associated with the studied outcomes: occurrence of diarrhea in the last 15 days (PR 1.39 [95% CI 1.06 to 1.84]) for stunting; and death of other children from the same mother (PR 1.52 [95% CI 1.01-2.28]) for underweight. In a model composed only of distal and intermediate factors, the primary caregiver not being the mother increased the prevalence of stunting by 42% (PR 1.42, 95%CI 1.10- 1.84) and each month that prenatal care was delayed increased the prevalence of underweight by 20% (PR 1.20, 95% CI 1.03-1.40). CONCLUSION: These results enabled the identification of a worrying increasing trend of obesity in women of childbearing age in the studied countries, in a context in which child malnutrition still prevails, especially stunting. In Angola, although it was possible to identify factors associated with malnutrition never before studied in Luanda, few individual factors were identified that increased the prevalence of malnutrition, suggesting that the problem results primarily from factors affecting society as a whole. These data should be useful for planning aimed, on the one hand, to prevent an epidemic of obesity in children in sub-Saharan Africa, and on the other, meeting the challenge of current widespread childhood malnutrition in Angola and other countries.

Philosophiae Doctor - PhD (Economics) / The main objective of this thesis was to closely examine several nancial and economic aspects of the stock markets in Sub-Saharan Africa. Thus, the objectives of this thesis were to explore the interdependence, the time-varying conditional correlation and the volatility linkages among Sub-Saharan African and developed stock markets; to investigate the relationship between - nancial liberalization and the development of stock markets; and to examine the patterns of the aggregate market liquidity and the relevance of the mainstream determinants of market liquidity in the chosen Sub-Saharan African stock markets. The study was composed of three standalone essays. The rst essay, which investigated stock price co-movements and the volatility linkages between selected Sub-Saharan African markets and the key developed markets, used the Johansen cointegration test, the VECM and the GARCH models for the sample period 2 January 2009 { 31 December 2016. The second essay, examining the e ect of nancial liberalization on the development of stock markets in Sub-Saharan Africa, employed the Bayesian VAR for the sample period 1975Q1 { 2014Q4. Lastly, the third essay, which investigated the determinants of liquidity levels in Sub-Saharan African stock markets employed the Markov Switching Vector Autoregressive model for the sample period 2 January 2009 { 31 December 2016.This study aimed at contributing to the already existing literature by focusing on analysing four key stock markets in the region, namely the Nigerian Stock Exchange, the Kenyan Securities Exchange.

The primary objective of this thesis is to analyse the public private partnership (PPP) framework for infrastructure development in developing countries across the six regions of the world. The thesis utilises the World Bank's private participation in infrastructure (PPI) dataset for the period 1980–2014, and examines three thematic areas. The first comprises of an exploratory analysis of the PPI dataset. The second research area focuses on the relationship between countries' attractiveness for PPPs and the characteristics of the countries, including: macroeconomic and market; fiscal constraints; regulatory and governance; and experience in PPPs, by utilising the Zero-Inflated Negative Binomial and Cragg's Double Hurdle models in an attempt to model private investors' decision to engage in PPPs as separate participation and consumption decisions. The third research area employs the methodology of survival analysis to investigate the risk of failure of PPP projects based on the allocation of residual facility ownership between the partners. The thesis's primary contributions include the utilisation of a wider and more informative range of econometric methodologies which have not been previously applied to the PPI dataset, and for the first time also, provides a framework to select an appropriate structure for PPPs that will enhance project survival. A key finding of the thesis is that private investors prioritise macroeconomic and market variables, such as price stability over regulatory and governance variables, such as corruption, in their determination as to which country to engage in PPPs. Contrary to previous research, corruption was found to be of no consequence to private investors who wish to engage in PPPs even for developing countries. Another key finding is that PPP projects which confer residual ownership on the public sector have lower risk of failure than those for which such ownership is conferred on the private sector. Evidence also suggests that the size of the project and the participation of multilateral institutions in PPPs also affect the risk of project failure.

Since the early 1990s electricity reforms across Sub-Saharan Africa have been marked by controversy. Despite the World Bank's major role in driving electricity reform as part of its conditional lending strategy in the electricity sector, its relationship with recipient countries has received little attention within the electricity reform literature. This is surprising given the increasing pressure on the World Bank to improve the effectiveness of its conditional lending more generally. This thesis contributes to filling this gap by exploring how World Bank-recipient country relations shape and constrain the direction of reform. The donor-recipient relationship is commonly espoused in the academic literature as a principal-agent relationship, whereby international aid organisations (principals) delegate authority for implementing their development policies to recipient countries (agents). I develop this framework by incorporating refined concepts of power, partnership, ownership and knowledge, prominent features in development studies literature and recent donor discourse. The analytical framework developed is applied to the process of electricity reform in two countries: Tanzania and Ghana. While the impetus for reform in these two countries was similar, the way in which the reform process unfolded was different. The analysis is based on in-depth, semi-structured interviews and documentary evidence. It uses a process-tracing method, combining within-case and cross-case analysis. A number of insights emerge from the analysis. I find that availability of reform expertise plays a significant role in determining the strength of power relations between donors and recipient countries. It also appears that reform ownership lies within different ‘domains'. Uneven ownership across domains accounts for the inconsistent reform implementation noted in both cases. And knowledge asymmetry provides a useful concept to analyse the impact of decentralised donor staff. In conclusion, this thesis argues that a modified principal-agent framework offers additional insight into the workings of the donor-recipient relationship.

World Bank Development Agenda With Focus on Sub-Saharan Africa Diploma thesis with subject World Bank Development Agenda With Focus on Sub-Ssaharan Africa is dividend into free main chapters. The first one deals with Sub-Saharan Africa as a development region. It briefly describes Africa's history and some of ecomomic and social characteristics, and also mentions main economic and social problems of the region. Second chapter concentrates on World Bank institution and the evolution of its development strategies since 1950s, in context with UN attitudes to development. Third charter looks into finance flows from World Bank to Subsaharan Africa since 1950s upto February 2012.

Population projections for sub-Saharan Africa have, over the past decade, been corrected upwards because in a number of countries, the earlier declining trends in fertility stalled around 2000. While most studies so far have focused on economic, political, or other factors around 2000, here we suggest that in addition to those period effects, the phenomenon also matched up with disruptions in the cohort trends of educational attainment of women after the postindependence economic and political turmoil. Disruptions likely resulted in a higher proportion of poorly educated women of childbearing age in the late 1990s and early 2000s than there would have been otherwise. In addition to the direct effects of education on lowering fertility, these less-educated female cohorts were also more vulnerable to adverse period effects around 2000. To explore this hypothesis, we combine individual-level data from Demographic and Health Surveys for 18 African countries with and without fertility stalls, thus creating a pooled dataset of more than two million births to some 670,000 women born from 1950 to 1995 by level of education. Statistical analyses indicate clear discontinuities in the improvement of educational attainment of subsequent cohorts of women and stronger sensitivity of less-educated women to period effects. We assess the magnitude of the effect of educational discontinuity through a comparison of the actual trends with counterfactual trends based on the assumption of no education stalls, resulting in up to half a child per woman less in 2010 and 13 million fewer live births over the 1995-2010 period.

Les troubles du comportement sont fréquents chez les sujets âgés avec ou sans troubles cognitifs. En Afrique subsaharienne, très peu de données sont disponibles en population générale sur les troubles du comportement chez le sujet âgé et aucune n’a encore été réalisée en Afrique Centrale. L’objectif général de ce travail était de contribuer à une meilleure connaissance des troubles du comportement chez les sujets âgés en Afrique Centrale en République Centrafricaine et au Congo. Nos objectifs spécifiques étaient de : 1) décrire les troubles du comportement, leur gravité, leur retentissement, leurs facteurs associés et les symptômes associés aux démences ; 2) évaluer l’association entre les troubles du comportement et l’Apolipoprotéine E ε4 ; 3) évaluer l’association entre les troubles du comportement, la mortalité et le déclin cognitif. A partir des données des programmes EPIDEMCA et EPIDEMCA-FU, nous avons pu déterminer que la prévalence des troubles du comportement était de 63,7% (IC95% : 59,5-67,8). Le score médian global de gravité était de 9 [IQR : 6-12] et le score médian global de retentissement était de 7 [IQR : 4-10]. Vivre à Gamboma (zone rurale du Congo), l’audition normale et les liens amicaux étaient protecteurs des troubles du comportement. Le sexe féminin, la démence, la personnalité dépendante et le handicap physique ont été identifiés comme étant associés à la présence des troubles du comportement. Les idées délirantes, la dépression, l’apathie, la désinhibition et le comportement moteur aberrant étaient associés à la présence de démences dans notre étude. Dans nos travaux, les troubles du comportement n’étaient pas associés à l’Apolipoprotéine E ε4. Ces symptômes étaient associés à la mortalité des sujets âgés à deux ans mais pas au déclin cognitif. Ces résultats permettent une amélioration de la connaissance des troubles du comportement en Afrique Centrale et de nombreuses perspectives liées à leur prise en charge s’en dégagent. / Neuropsychiatric symptoms are common among older adults with or without cognitive disorders. In sub-Saharan Africa, few population-based studies are focused on these symptoms and to our knowledge no study was conducted in Central Africa. Our main objectivewas to improve the knowledge of neuropsychiatric symptoms in Central Africa (Central African Republic: CAR and Republic of Congo: ROC). Specifically we aimed at describing the neuropsychiatric symptoms, their severity, their distress and associated factors; 2) evaluating the association between neuropsychiatric symptoms and Apolipoprotein E ε4; 3) evaluating the association between neuropsychiatric symptoms, mortality and cognitive decline among older adults We performed the studies, using data from the EPIDEMCA and EPIDEMCA-FU programmes. The prevalence of neuropsychiatric symptoms was 63.7% (95%CI: 59.5-67.8).The overall median score of severity was 9 [IQR: 6-12] and the overall median score of distress was 7 [IQR: 4-10]. Living in Gamboma (rural ROC), normal hearing and having friends in the community were protective while female sex, dementia, dependent personality, and physical disability were risk factors for neuropsychiatric symptoms. Delusions, depression, apathy, disinhibition and aberrant motor behavior were specifically associated with dementia. We are not able to confirm the relationship between neuropsychiatric symptoms and Apolipoprotein E ε4. Neuropsychiatric symptoms were associated with mortality after two years of follow-up but not associated with cognitive decline. This thesis allowed us to improve the knowledge of behavioral disorders in Central Africa. Due to their burden among caregivers, a better management of these symptoms must be performed.

This thesis examines how gender influences the perceptions of men and women toward different social, economic and political issues in Liberia's post-conflict reconstruction process. While the focus of the thesis is women, a gender framework is utilized and considers the situation of men to have a more comprehensive perspective on sustainable peace and reconstruction in post-conflict Liberia. Previous research has demonstrated that the condition of women and gender inequality must be accurately understood and addressed to ensure sustainable and equitable reconstruction in post-conflict societies. This dissertation seeks to answer the following research questions: To what degree do women perceive the post-conflict reconstruction process differently than do men, and what is the nature of such differences? And, to what degree have women's issues been incorporated in public discourse and reconstruction policy? This study seeks an in-depth understanding of how ideas about women's and men's social participation and responsibilities may be evolving in a time of social reordering and how such changes may shape efforts to positively influence socio-political processes and ultimately, long-term peace. This dissertation examines the actions taken by the reconstruction government to consider the effects of gender on policy and design policy accordingly, in an effort to eliminate gender-based inequalities. Using a country case study methodology, focus groups and key informant interviews were conducted in rural and urban Liberia. Focus groups stratified by ethnicity, gender, urban/rural residence and age were used to help determine how women and men and differing groups of Liberians view and discuss the post-conflict reconstruction process and the different socio-economic issues associated with this process; and what the differences and similarities in these experiences indicate for the success of the reconstruction process as a whole. The findings of this dissertation suggest that this initial post-conflict period has been instrumental to the restructuring of gender roles. Participants perceived that women have entered the political spectrum with a gender-balanced agenda that attempts to correct gender inequalities, although women and men have differing perceptions of the benefit of such agenda. Both men and women perceived that education is being used as a tool for addressing gender inequality and that gender roles in Liberia are changing in part to violent conflict. The information generated by this study will make a useful contribution to the effectiveness of policies and strategies of sustainable peace and reconstruction of Liberia, the West African region and post-conflict societies as a whole / acase@tulane.edu