Informal health care providers (IPs) comprise a significant component of health systems in developing nations. Yet little is known about the most basic characteristics of performance, cost, quality, utilization, and size of this sector. To address this gap we conducted a comprehensive literature review on the informal health care sector in developing countries. We searched for studies published since 2000 through electronic databases PubMed, Google Scholar, and relevant grey literature from The New York Academy of Medicine, The World Bank, The Center for Global Development, USAID, SHOPS (formerly PSP-One), The World Health Organization, DFID, Human Resources for Health Global Resource Center. In total, 334 articles were retrieved, and 122 met inclusion criteria and chosen for data abstraction. Results indicate that IPs make up a significant portion of the healthcare sector globally, with almost half of studies (48%) from Sub-Saharan Africa. Utilization estimates from 24 studies in the literature of IP for healthcare services ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement. IPs operate in a variety of health areas, although baseline information on quality is notably incomplete and poor quality of care is generally assumed. There was a wide variation in how quality of care is measured. The review found that IPs reported inadequate drug provision, poor adherence to clinical national guidelines, and that there were gaps in knowledge and provider practice; however, studies also found that the formal sector also reported poor provider practices. Reasons for using IPs included convenience, affordability, and social and cultural effects. Recommendations from the literature amount to a call for more engagement with the IP sector. IPs are a large component of nearly all developing country health systems. Research and policies of engagement are needed.

How does a court's policy-making authority shape the nature of judicial behavior? We argue that judicial systems that limit policy-making authority also discourage the politicization of courts, encouraging judges to think narrowly about the interests of litigating parties. In contrast, granting a court high policy-making authority-affecting potentially thousands of cases and other branches of government-naturally encourages judges to consider broader ideological principles. Typically, unraveling cause and effect would be difficult, as judicial behavior and institutions are usually stable and endogenous. But an especially stark sequence of political and institutional changes in Brazil affords analytic leverage to explore these questions. A series of judicial reforms greatly expanded the Brazilian Supreme Court's authority, and our analysis of judicial decisions shows the emergence of a political cleavage on the court after these reforms.

Judicial strength and the rule of law are increasingly understood as vital to democratic development. Understanding the sources of strong courts, therefore, is critical, and a growing literature examines the political origins of effective judiciaries. 1 A dominant theoretical strand in this research anticipates that judicial reform is a product of rising electoral competition. That is, electoral uncertainty generates the motivations-conceptualized as material, rational-strategic incentives-required to build stronger judicial institutions. Accounts based on electoral uncertainty, however, raise unresolved puzzles of causation and prediction. Despite a broad consensus regarding the benefits of competitive politics, 2 rival causal logics underpin the effects of competition. Moreover, the incentives generated by electoral uncertainty apply to all politicians equally, thus anticipating that better institutions depend less on the ideas or identity of any given politician and arise automatically, as a quasi-mechanical side effect of competition. Further, dysfunctional institutions persist even in competitive settings; reforms frequently occur long after the start of electoral openings; and the specific content of reforms varies across similarly competitive settings, showing electoral accounts to be overly optimistic, or at least ambiguous, about their predictions regarding both the timing and content of reforms. Introducing additional complications, a core insight of a strategic bargaining account of reform anticipates that competition in previously noncompetitive settings, for example Mexico, increases the number of relevant actors, hindering policy change and inhibiting reform. 3 That is, competition might produce less reform, not more. Indeed, a motivated actor in a noncompetitive setting may have the easiest task of effectuating reform, a task that becomes more difficult as competition increases and power fragments. Electoral accounts do not anticipate this negative effect, and tell us nothing of the underlying motivations of such actors. In sum, current theories of judicial change are inconsistent and inconclusive, suffering from problems of both behavioral equivalence and indeterminacy. Rival hypotheses are in play, obfuscating causation and making predictions unclear, unstable, and even contradictory.

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