This research program spans the full gamut of human development — education, health, labor markets, and social protection. It examines the performance of the sectors in terms of levels and inequalities in utilization, quality and outcomes, as well as methods for improving performance, whether aimed at households, service providers, politicians and policymakers, or donors. More »
Are India’s quacks the answer to its shortage of doctors? A study led by Jishnu Das, lead economist in the development research group at the World Bank, found that qualified doctors were only about 30.9 percentage points more likely than unqualified healthcare providers to treat three diseases correctly. Das and colleagues sent 22 coached patients to present symptoms of unstable angina, asthma, and dysentery to a cross section of unqualified and qualified doctors in six villages of Madhya Pradesh. They scored the doctors on how many of a checklist of essential diagnoses questions they asked, how often they arrived at correct diagnoses, and how often they prescribed unnecessary treatments, such as antibiotics.The researchers found that although qualified doctors were more likely than unqualified doctors to treat diseases correctly, they were also more likely to prescribe unnecessary antibiotics—public and private doctors with MBBS qualifications prescribed antibiotics for unstable angina and asthma 48% and 45% of the time, respectively, whereas informal providers did so only about 28% of the time. This finding challenges the common perception that only quacks overtreat patients and shows that “bad practices are more likely to come from an MBBS doctor,” says Das.Das and Chowdhury advocate a system of training unqualified doctors to administer basic care to patients and to refer patients with more difficult problems to qualified doctors.
The last few years have seen a growing commitment worldwide to universal health coverage (UHC). Yet there is a lack of clarity on how to measure progress towards UHC. We propose a ‘mashup’ index that captures both aspects of UHC: that everyone—irrespective of their ability-to-pay—gets the health services they need; and that nobody suffers undue financial hardship as a result of receiving care.
This paper evaluates the impact on cost and utilization of a shift from fee-for-service to capitation payment of district hospitals by Vietnam's social health insurance agency. Hospital fixed effects analysis suggests that capitation leads to reduced costs. Hospitals also increased service provision to the uninsured who continue to pay out-of-pocket on a fee-for-service basis. The study points to the need to anticipate unintended effects of payment reforms, especially in the context of a multiple purchaser system.
Subsidized voluntary enrollment in government-run health insurance schemes is often proposed as a way of increasing coverage among informal sector workers and their families. We report the results of a cluster randomized experiment, in which 3000 households in 20 communes in Vietnam were randomly assigned at baseline to a control group or one of three treatments: an information leaflet about Vietnam's government-run scheme and the benefits of health insurance, a voucher entitling eligible household members to 25% off their annual premium, and both. At baseline, the four groups had similar enrollment rates (4%) and were balanced on plausible enrollment determinants.
Non-monetary indicators of poverty routinely tell us that substantive gaps persist among household members in terms of access to other resources such as schooling services and protection against shocks. Gender and age are arguably key fault lines along which these differences emerge. Yet there are some practical explanations as to why monetary poverty estimates typically don’t distinguish among individuals within households.
Most of us would agree that when it comes to healthcare providers, some training is better than none. Yet even this seemingly innocuous statement is highly contentious in India, where training primary care providers who lack formal medical qualifications is anathema to the professional medical classes.
Until quite recently, things were looking good for health in the SDG process. It wasn’t always so. Two and a half years ago, at the time of the high-level panel report on the SDGs, the health SDG discussion was actually stuck in the doldrums. Health was the only area to get less column inches than in the MDGs. The proposed goals and targets were pretty much business as usual. The only real hint of any new thinking was the addition of a target to reduce non-communicable diseases, but it was subsumed within an old target and looked very much like an afterthought.
Just under two years ago, I, along with a team from across the World Bank, co-authored a report, Youth Employment in Sub-Saharan Africa, which tackled the growing gap between the aspirations of African youth and the realities of the job markets and what governments should do about it. With an expected 11 million young Africans entering the labor market every year well into the next decade, the findings and main messages of the report remain relevant.
Poverty in a Rising Africa: Africa Poverty Report October 2015: According to latest World Bank estimates, the share of Africans who are poor fell from 56% in 1990 to 43% in 2012. The report argues that the poverty rate may have declined even more if the quality and comparability of the underlying data are taken into consideration. However, because of population growth many more people are poor, the report says. The most optimistic scenario shows about 330 million poor in 2012, up from about 280 million in 1990. Poverty reduction has been slowest in fragile countries, the report notes, and rural areas remain much poorer, although the urban-rural gap has narrowed.
Right to Work? Assessing India's Employment Guarantee Scheme in Bihar February 2014: India's 2005 National Rural Employment Guarantee Act creates a justiciable "right to work" by promising up to 100 days of wage employment per year to all rural households whose adult members volunteer to do unskilled manual work. Work is provided in public works projects at the stipulated minimum wage. The study finds that the scheme is falling well short of its potential impact on poverty in Bihar. Analysis of the study’s survey data points to a number of reasons. Workers are not getting all the work they want, and they are not getting the full wages due. And participation in the scheme is far from costless to them. Many report that they had to give up some other income-earning activity when they took up work. The unmet demand for work is the single most important policy-relevant factor in accounting for the gap between actual performance and the scheme’s potential impact on poverty.
Youth Employment in Sub-Saharan Africa January 2014: The report examines obstacles faced by households and firms in meeting the youth employment challenge. It focuses primarily on productivity, in agriculture, in nonfarm household enterprises (HEs), and in the modern wage sector, because productivity is the key to higher earnings as well as to more stable, less vulnerable, livelihoods. To respond to the policy makers' dilemma, the report identifies specific areas where government intervention can reduce those obstacles to productivity for households and firms, leading to brighter employment prospects for youth, their parents, and their own children.
Risking Your Health: Causes, Consequences, and Interventions to Prevent Risky Behaviors November 2013: Individuals all over the worlds engage in behaviors that are risky for their health: smoking, drugs, alcohol, unhealthy food, and risky sexual encounters. They increasingly affect the health of individual and their populations. This report examines the causes, consequences and interventions to prevent these growing threats.
The Fiscal Cost of Weak Governance: Evidence from Teacher Absence in India Karthik Muralidharan, Jishnu Das, Alaka Holla, and Aakash Mohpal Working Paper 7579, February 2016 The relative return to input-augmentation versus inefficiency-reduction strategies for improving education system performance is a key open question for education policy in low-income countries. Using a new nationally-representative panel dataset of schools across 1297 villages in India, this paper shows that the large investments over the past decade have led to substantial improvements in input-based measures of school quality, but only a modest reduction in inefficiency as measured by teacher absence. In the data, 23.6 percent of teachers were absent during unannounced visits with an associated fiscal cost of $1.5 billion/year. There are two robust correlations in the nationally-representative panel data that corroborate findings from smaller-scale experiments. First, reductions in student-teacher ratios are correlated with increased teacher absence. Second, increases in the frequency of school monitoring are strongly correlated with lower teacher absence. Simulations using these results suggest that investing in better governance by increasing the frequency of monitoring could be over ten times more cost effective at increasing teacher-student contact time (net of teacher absence) than hiring more teachers. Thus, at current margins, policies that decrease the inefficiency of public spending in India are likely to yield substantially higher returns than those that augment inputs.
Measuring progress towards universal health coverage: With an application to 24 developing countries Adam Wagstaff, Daniel Cotlear, Patrick Hoang-Vu Eozenou, and Leander R. Buisman Working Paper 7470, November 2015 The last few years have seen a growing commitment worldwide to universal health coverage (UHC). Yet there is a lack of clarity on how to measure progress towards UHC. This paper proposes a ‘mashup’ index that captures both aspects of UHC: that everyone—irrespective of their ability-to-pay—gets the health services they need; and that nobody suffers undue financial hardship as a result of receiving care. Service coverage is broken down into prevention and treatment, and financial protection into impoverishment and catastrophic spending; nationally representative household survey data are used to adjust population averages to capture inequalities between the poor and better off; nonlinear tradeoffs are allowed between and within the two dimensions of the UHC index; and all indicators are expressed such that scores run from 0 to 100, and higher scores are better.
On the delegation of aid implementation to multilateral agencies Kurt Annen and Stephen Knack Working Paper 7455, October 2015 The rapid growth of trust funds at multilateral development organizations has been widely neglected in the academic literature so far. Using a simple illustrative model, this paper examines the choice by sovereign donors among various trust fund options. The authors contend that the choice among the different trust funds involves a fundamental trade-off: larger funds provide donors with the benefit of burden sharing. Conversely, each donor can better assert its individual preferences in a fund with fewer other donors. The theoretical considerations yield testable implications on a range of factors affecting this fundamental tradeoff, most notably the area of intervention of the trust fund and competing domestic interests of donor countries. Using a sample of World Bank trust funds, the paper examines the participation decisions of Organisation for Economic Co-operation and Development/Development Assistance Committee donors over the past decade.
Which donors, which funds? the choice of multilateral funds by bilateral donors at the World Bank Bernhard Reinsberg, Katharina Michaelowa, and Stephen Knack Working Paper 7441, October 2015 The rapid growth of trust funds at multilateral development organizations has been widely neglected in the academic literature so far. Using a simple illustrative model, this paper examines the choice by sovereign donors among various trust fund options. The authors contend that the choice among the different trust funds involves a fundamental trade-off: larger funds provide donors with the benefit of burden sharing. Conversely, each donor can better assert its individual preferences in a fund with fewer other donors. The theoretical considerations yield testable implications on a range of factors affecting this fundamental tradeoff, most notably the area of intervention of the trust fund and competing domestic interests of donor countries. Using a sample of World Bank trust funds, the paper examines the participation decisions of Organisation for Economic Co-operation and Development/Development Assistance Committee donors over the past decade.