Rudolf Knippenberg

Rudolf Knippenberg
Rudolf Knippenberg

Clinical Professor of Global Health

Professional overview

As a public health professional and a physician who witnessed the negative impact of poor maternal, newborn, and child healthcare, Dr. Rudolf Knippenberg has guided the identification and implementation of effective strategies and policies for public health programs and healthcare systems strengthening in South and East Asia and Sub-Saharan Africa.

During his tenure with the United Nations Children’s Fund (UNICEF), Dr. Knippenberg facilitated strategic planning, monitoring, and evaluation of maternal and child health programs in over twenty countries. He supported UNICEF's Bamako Initiative, which intended to increase community-based decision making, cost sharing, monitoring, and access to primary healthcare and low cost essential drugs. With the World Bank, he developed the Marginal Budgeting for Bottlenecks (MBB) tool to simulate the costs of service delivery models and thus inform governmental budgeting and policies for health and nutrition. The MBB tool has been used to measure cost-effectiveness and health system strengthening in over 50 countries.  He is refining the MBB tool to analyze and model equity in the context of the Sustainable Development Goals and public health responses to global epidemics, such as Ebola and Zika.

He has served on various advisory panels, such as Roll Back Malaria, Stop TB, and Partnership for Maternal, Newborn, and Child Health. He is also the author of various journal articles, book chapters, reports, manuals, and technical guidelines.

Dr. Knippenberg’ practice-driven approach provides students with the concepts and skills to utilize quantitative data to analyze health programs and systems. These measures can then be translated into equity-focused decision making, monitoring, management, and financing of global public health programs and national health systems.

Education

MD, Medicine, State University Utrecht, Utrecht, Netherlands
Diploma, Tropical Medicine, Royal Tropical Institute, Amsterdam, Netherlands
MPH, International Health, Johns Hopkins University, Baltimore, MD
DrPH, International Health, Johns Hopkins University, Baltimore, MD

Areas of research and study

Cost-effective Health Programs and Policies
Economic Evaluation
Public Health Systems

Publications

Publications

Reproduction number of Ebola falls below critical threshold in Liberia

Nyenswah, T., Cummings, D., Read, J., Lessler, J., Rodriguez-Barraquer, I., Bawo, L., Mulbah, M., Kateh, F., Massaquaoi, M., Rivers, C., Lewis, B., Glass, N., Knippenberg, R., Epstein, J., Hynes, N., Ahmed, T., T., K., Perl, T., & Peter, D.

Publication year

2014

Journal title

New England Journal of Medicine

The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: A modelling approach

Carrera, C., Azrack, A., Begkoyian, G., Pfaffmann, J., Ribaira, E., O’Connell, T., Doughty, P., Aung, K. M., Prieto, L., Rasanathan, K., Sharkey, A., Chopra, M., & Knippenberg, R.

Publication year

2012

Journal title

The Lancet

Volume

380

Issue

9850

Page(s)

1341-1351
Abstract
Progress on child mortality and undernutrition has seen widening inequities and a concentration of child deaths and undernutrition in the most deprived communities, threatening the achievement of the Millennium Development Goals. Conversely, a series of recent process and technological innovations have provided effective and efficient options to reach the most deprived populations. These trends raise the possibility that the perceived trade-off between equity and efficiency no longer applies for child health - that prioritising services for the poorest and most marginalised is now more effective and cost effective than mainstream approaches. We tested this hypothesis with a mathematicalmodelling approach by comparing the cost-effectiveness in terms of child deaths and stunting events averted between two approaches (from 2011-15 in 14 countries and one province): an equity-focused approach that prioritises the most deprived communities, and a mainstream approach that is representative of current strategies. We combined some existing models, notably the Marginal Budgeting for Bottlenecks Toolkit and the Lives Saved Tool, to do our analysis. We showed that, with the same level of investment, disproportionately higher effects are possible by prioritising the poorest and most marginalised populations, for averting both child mortality and stunting. Our results suggest that an equityfocused approach could result in sharper decreases in child mortality and stunting and higher cost-effectiveness than mainstream approaches, while reducing inequities in effective intervention coverage, health outcomes, and out-ofpocket spending between the most and least deprived groups and geographic areas within countries. Our findings should be interpreted with caution due to uncertainties around some of the model parameters and baseline data. Further research is needed to address some of these gaps in the evidence base. Strategies for improving child nutrition and survival, however, should account for an increasing prioritisation of the most deprived communities and the increased use of community-based interventions.

Lessons learned from evolving health care systems and practices

Knippenberg, R. In The State of the World’s Children 2008: Child Survival.

Publication year

2008

Strengthening community partnerships, the continuum of care and health systems

Knippenberg, R. In The State of the World’s Children 2008: Child Survival.

Publication year

2008

1 year after The Lancet Neonatal Survival Series-was the call for action heard?

Lawn, J. E., Cousens, S. N., Darmstadt, G. L., Bhutta, Z. A., Martines, J., Paul, V., Knippenberg, R., & Fogstad, H.

Publication year

2006

Journal title

The Lancet

Volume

367

Issue

9521

Page(s)

1541-1547

Newborn survival

Lawn, J., Zupan, J., Begkoyian, G., & Knippenberg, R. In Disease Control Priorities.

Publication year

2006

Systematic scaling up of neonatal care in countries

Knippenberg, R., Lawn, J. E., Darmstadt, G. L., Begkoyian, G., Fogstad, H., Walelign, N., & Paul, V. K.

Publication year

2005

Journal title

The Lancet

Volume

365

Issue

9464

Page(s)

1087-1098
Abstract
Every year about 70% of neonatal deaths (almost 3 million) happen because effective yet simple interventions do not reach those most in need. Coverage of interventions is low, progress in scaling up is slow, and inequity is high, especially for skilled clinical interventions. Situations vary between and within countries, and there is no single solution to saving lives of newborn babies. To scale up neonatal care, two interlinked processes are required: a systematic, data-driven decision-making process, and a participatory, rights-based policy process. The first step is to assess the situation and create a policy environment conducive to neonatal health. The next step is to achieve optimum care of newborn infants within health system constraints; in the absence of strong clinical services, programmes can start with family and community care and outreach services. Addressing missed opportunities within the limitations of health systems, and integrating care of newborn children into existing programmes - eg, safe motherhood and integrated management of child survival initiatives - reduces deaths at a low marginal cost. Scaling up of clinical care is a challenge but necessary if maximum effect and equity are to be achieved in neonatal health, and maternal deaths are to be reduced. This step involves systematically strengthening supply of, and demand for, services. Such a phased programmatic implementation builds momentum by reaching achievable targets early on, while building stronger health systems over the longer term. Purposeful orientation towards the poor is vital. Monitoring progress and effect is essential to refining strategies. National aims to reduce neonatal deaths should be set, and interventions incorporated into national plans and existing programmes.

Buying results to reach the millennium development goals; Box 8.4

Knippenberg, R. In health and Nutrition Services in World Development Report 2004: Making Services Work for Poor People.

Publication year

2004

The Bamako Initiative: putting communities in charge of health services in Benin, Guinea and Mali

Knippenberg, R. In Word Development Report 2004: Making Services Work for Poor People.

Publication year

2004

Affordability, cost-effectiveness and efficiency of primary health care: The Bamako Initiative experience in Benin and Guinea

Soucat, A., Levy-Bruhl, D., De Bethune, X., Gbedonou, P., Lamarque, J. P., Bangoura, O., Camara, O., Gandaho, T., Ortiz, C., Kaddar, M., & Knippenberg, R.

Publication year

1997

Journal title

International Journal of Health Planning and Management

Volume

12
Abstract
Since 1986 two West African countries, Benin and Guinea, have actively reorganizing their peripheral health systems according to strategies subsequently called the 'Bamako Initiative'. Two preceding articles described the strategies implemented and the increased the effectiveness of primary health care (PHC) witnessed over a period of six years. This article presents an analysis of cost and coverage data from biannual monitoring sessions between 1988 and 1983 in approximately 200 health centres in Benin and 214 in Guinea. In order to assess affordability, the total and per capita recurrent costs for operational health centres are analysed and then compared. The cost analysis reveals a mean total cost per health centre per year of slightly over US$11,000 in Benin and nearly US$9,000 in Guinea. The median cost per capita per year is approximately US$1.0 in Benin and between US$0.60 and US$0.80 in Guinea. Comparisons of these costs between regions, health centres and over time (as coverage levels evolved) show very little variation in either country. Cost-effectiveness is estimated by allocating these costs to immunization, antenatal and curative care and comparing them to coverage achieved with these interventions. First, the cost-effectiveness of the Bamako Initiative (BI) system as a whole is analysed. The cost per fully vaccinated child is calculated at US$10.9 in Benin and US$8.8 in Guinea. The cost per women receiving at least three antenatal visits is US$7 in Benin and US$4.7 in Guinea. For curative care, cost per full treatment is US$1.6 in Benin and half this amount in Guinea. Cost-effectiveness is variable between regions, health centres and over time. An analysis of the characteristics of the most and least cost-effectiveness centres reveals that these differences in cost-effectiveness are mainly caused by the coverage levels achieved, since total costs are relatively stable. Finally the efficiency of drug management and prescriptions as well as outreach for the expanded programme of immunizations (EPI) is estimated by relating specific drug and outreach costs to the number of beneficiaries. The average cost of drugs per treatment is around US$0.5 in Benin and around US$0.3 in Guinea. Cost analysis of outreach activities undertaken for EPI in Guinea revealed a similar average cost per child completely vaccinated for health centres with different intensities of outreach (approximately US$10) and an additional cost per child vaccinated attributable to outreach of US$1-2.

Eight years of Bamako Initiative implementation

Knippenberg, R.

Publication year

1997

Journal title

Children in the Tropics

Page(s)

229

Epilogue: sustainability of primary health care including immunizations in Bamako Initiatives programs in West Africa: an assessment of 5 years field experience in Benin and Guinea

Vandemoortele, J., Hopwood, I., & Knippenberg, R.

Publication year

1997

Journal title

International Journal of Health Planning and Management

Volume

12

Health seeking behaviour and household health expenditures in Benin and Guinea: The equity implications of the Bamako initiative

Soucat, A., Gandaho, T., Levy-Bruhl, D., De Bethune, X., Alihonou, E., Ortiz, C., Gbedonou, P., Adovohekpe, P., Camara, O., Ndiaye, J. M., Dieng, B., & Knippenberg, R.

Publication year

1997

Journal title

International Journal of Health Planning and Management

Volume

12
Abstract
Curative and preventive care utilization in Bamako Initiative health centres in Guinea and Benin increased significantly. Service based data and household survey results are compared and interpreted to evaluate the equity aspects of the Bamako Initiative programmes in these settings. Improvements in the use of preventive services are shared by the richer and poorer groups of the population. Inequities are more apparent regarding curative care. An important part of the population is not using Bamako Initiative Health Centres for financial reasons. However, the poor were found to use these Health Centres relatively more than richer socio-economic groups. Challenges of the future are identified and recommendations made as to how to tackle the problem of true indigence.

Local cost sharing in Bamako initiative systems in Benin and Guinea: Assuring the financial viability of primary health care

Soucat, A., Levy-Bruhl, D., Gbedonou, P., Drame, K., Lamarque, J. P., Diallo, S., Osseni, R., Adovohekpe, P., Ortiz, C., Debeugny, C., & Knippenberg, R.

Publication year

1997

Journal title

International Journal of Health Planning and Management

Volume

12
Abstract
The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US$0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all, user fee revenue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health Centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed.

The Bamako initiative in Benin and Guinea: Improving the effectiveness of primary health care

Levy-Bruhl, D., Soucat, A., Osseni, R., Ndiaye, J. M., Dieng, B., De Bethune, X., Diallo, A. T., Conde, M., Cisse, M., Moussa, Y., Drame, K., & Knippenberg, R.

Publication year

1997

Journal title

International Journal of Health Planning and Management

Volume

12
Abstract
The objective of the health system revitalization undergone in Benin and Guinea since 1986 is to improve the effectiveness of primary health care at the periphery. Second in a series of five, this article presents the results of an analysis of data from the health centres involved in the Bamako Initiative in Benin and Guinea since 1988. Data for the expanded programme of immunization, antenatal care and curative care, form the core of the analysis which confirms the improved effectiveness of primary health care at the peripheral level over a period of six years. The last available national data show a DPT3 immunization coverage of 80% in 1996 in Benin and 73% in 1995 in Guinea. In the Bamako Initiative health centres included in our analysis, the average immunization coverage, as measured by the adequate coverage indicator, increased from 19% to 58% in Benin and from less than 5% to 63% in Guinea between 1989 to 1993. Average antenatal care coverage has increased from 5% in Benin and 3% in Guinea to 43% in Benin and 51% Guinea. Utilization of coverage with curative care has increased from less than 0.05 visit per capita per year to 0.34 in Guinea and from 0.09 visit pet capita per year to 0.24 in Benin. Further analysis attempts to uncover the reasons which underlie the different levels of effectiveness obtained in individual health centres. Monitoring and microplanning through a problem-solving approach permit a dynamic process of adaptation of strategies leading to a step by step increase of coverage over time. However, the geographical location of centres represents a constraint in that certain districts in both countries face accessibility problems. Outreach activities are shown to play an especially positive role in Guinea, in improving both immunization and antenatal care coverage.

A review of VHW and CHW programs

Knippenberg, R., Ofosu-Amaah, S., & Parker,. In Better Health in Africa: Experience and Lesson learned.

Publication year

1994

Page(s)

55

INTEGRATION DU PEV AUX SOINS DE SANTE PRIMAIRES: L'EXEMPLE DU BENIN ET DE LA GUINEE

Levy-Bruhl, D., Soucat, A., Diallo, S., Lamarque, J. P., Ndiaye, J. M., Drame, K., Osseni, R., Dieng, B., Gbedonou, P., Cisse, M., Yarou, M., & Knippenberg, R.

Publication year

1994

Journal title

Cahiers Sante

Volume

4

Issue

3

Page(s)

205-212
Abstract
Since 1986, two West African countries have been delivering immunizations within the framework of reorganized peripheral health systems. This revitalization is based on strategies which are implemented by an increasing number of African countries under the name 'Bamako Initiative'. It aims at providing universal access to a minimum package of maternal and child health priority interventions starting with immunizations, pre and perinatal care, oral rehydratation for diarrhoea, treatment of malaria and acute lower respiratory infections. Within this package, immunization has been given high priority. Several strategies aimed at improving immunization coverage have been implemented: services have been reorganized so that any child or woman making contact with the health system receives immunization if needed. Health information systems have been revised so as to allow for active individual follow up and better management of health centre resources. Health staff have been given training in management and a biannual monitoring/microplanning process at health centre level has been introduced. The goal of monitoring is to enable health personnel to identify the obstacles to attaining optimum coverages with the priority interventions and to select locally appropriate corrective strategies. Health centres have also been provided with a motorcycle allowing for regular outreach activities. To cover the running costs of the services (mainly restocking of drugs, running and maintenance of the cold chain and the motorbike, and staff incentives), financial contribution from local communities have been sought through a fee-for-treatment system. Prices have been set at an affordable level by limiting the number of drugs to a minimal list purchased under generic names by international tendering procedures. Standardized flow charts for diagnosis and treatment have helped to decrease further the cost of treatment. A major element in the sustainability of the system is active community participation, through management committees, in the decision-making process for choice of strategies and management of financial and other resources. Around 60% of health centres in Benin and 80% in Guinea are currently operating these strategies. Immunization coverages have been steadily increasing in both countries reaching, for DTP3 in 1993, 75% in Benin and 63% in Guinea. There are among the best performances in Africa. Although some issues remain to be addressed such as quality of the services, continuing underutilization of services, depreciation of local currencies, these two countries seem to have succeeded in creating solid foundations for a revitalized and viable peripheral health system. Using this approach, the attainment of the EPI mid-decade goals and end-of-the century world summit goals seem feasible.

Single purpose interventions: a review of studies

Knippenberg, R., Ofosu-Amaah, S., & Parker,. In Better Health in Africa: Experience and Lessons Learned.

Publication year

1994

Page(s)

51

The Bamako Initiative, primary health experience

Knippenberg, R., Levy-Bruhl, D., Osseni, R., Drame, K., Soucat, A., & Debeugny, C.

Publication year

1990

Journal title

Children in the Tropics

Page(s)

184

Contact

rk3002@nyu.edu +1 (212) 998-5928 41-51 East 11Th Street New York, NY 10003