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Human Development and Public Services

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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 »


Observations of infection prevention and control practices in primary health care, Kenya
Guadalupe Bedoya, Amy Dolinger, Khama Rogo, Njeri Mwaura, Francis Wafula, Jorge Coarasa, Ana Goicoechea, and Jishnu Das
Health Organization, March 2017.
To assess compliance with infection prevention and control practices in primary health care in Kenya. We used an observational, patient-tracking tool to assess compliance with infection prevention and control practices by 1680 health-care workers during outpatient interactions with 14 328 patients at 935 health-care facilities in 2015. Compliance was assessed in five domains: hand hygiene; protective glove use; injections and blood sampling; disinfection of reusable equipment; and waste segregation. We calculated compliance by dividing the number of correct actions performed by the number of indications and evaluated associations between compliance and the health-care workers and facility’s characteristics. Across 106 464 observed indications for an infection prevention and control practice, the mean compliance was 0.318 (95% confidence interval, CI: 0.315 to 0.321). The compliance ranged from 0.023 (95% CI: 0.021 to 0.024) for hand hygiene to 0.871 (95% CI: 0.866 to 0.876) for injection and blood sampling safety. Compliance was weakly associated with the facility’s characteristics (e.g. public or private, or level of specialization) and the health-care worker’s knowledge of, and training in, infection prevention and control practices. Conclusion The observational tool was effective for assessing compliance with infection prevention and control practices across multiple domains in primary health care in a low-income country. Compliance varied widely across infection prevention and control domains. The weak associations observed between compliance and the characteristics of health-care workers and facilities, such as knowledge and the availability of supplies, suggest that a broader focus on behavioural change is required.

Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: recommendations of the Simnovate Global Health Domain Group
Lekha Puri, Jishnu Das, Madhukar Pai, Priya Agrawal, J Edward Fitzgerald, Edward Kelley, Sarah Kesler, Kedar Mate, Manoj Mohanan, Allan Okrainec, and Rajesh Aggarwal
BMJ Simulation and Technology Enhanced Learning 3(Suppl 1):S15-S22, March 2017.
Quality of medical care in low income and middle income countries (LMICs) is variable, resulting in significant medical errors and adverse patient outcomes. Integration of simulation-based training and assessment may be considered to enhance quality of patient care in LMICs. The aim of this study was to consider the role of simulation in LMICs, to directly impact health professions education, measurement and assessment. The Simnovate Global Health Domain Group undertook three teleconferences and a direct face-to-face meeting. A scoping review of published studies using simulation in LMICs was performed and, in addition, a detailed survey was sent to the World Directory of Medical Schools and selected known simulation centres in LMICs.Results Studies in LMICs employed low-tech manikins, standardised patients and procedural simulation methods. Low-technology manikins were the majority simulation method used in medical education (42%), and focused on knowledge and skills outcomes. Compared to HICs, the majority of studies evaluated baseline adherence to guidelines rather than focusing on improving medical knowledge through educational intervention. There were 46 respondents from the survey, representing 21 countries and 28 simulation centres. Within the 28 simulation centres, teachers and trainees were from across all healthcare professions. Broad use of simulation is low in LMICs, and the full potential of simulation-based interventions for improved quality of care has yet to be realised. The use of simulation in LMICs could be a potentially untapped area that, if increased and/or improved, could positively impact patient safety and the quality of care.

Examining the Quality of Medicines at Kenyan Healthcare Facilities: A Validation of an Alternative Post-Market Surveillance Model That Uses Standardized Patients
Francis Wafula, Amy Dolinger, Benjamin Daniels, Njeri Mwaura, Guadalupe Bedoya, Khama Rogo, Ana Goicoechea, Jishnu Das and Bernard Olayo
Int J Epidemiol, January 2017.
Promoting access to medicines requires concurrent efforts to strengthen quality assurance for sustained impact. Although problems of substandard and falsified medicines have been documented in low- and middle-income countries, reliable information on quality is rarely available. The aim of this study was to validate an alternative post-market surveillance model to complement existing models. The study used standardized patients or mystery clients (people recruited from the local community and trained to pose as real patients) to collect medicine samples after presenting a pre-specified condition. The patients presented four standardized conditions to 42 blinded facilities in Nairobi, Kenya, resulting in 166 patient-clinician interactions and dispensing of 300 medicines at facilities or nearby retail pharmacies. The medicine samples obtained thus resemble those that would be given to real patients. Sixty samples were selected from the 300, and sent for analysis at the Kenya National Quality Control Laboratory. Of these, ten (17%) did not comply with monograph specifications (three ibuprofen, two cetirizine, two amoxicillin/clavulanic acid combinations, and one each for prednisone, salbutamol and zinc). Five of the ten samples that failed had been inappropriately prescribed to patients who had presented symptoms of unstable angina. There was no association between medicine quality and ownership, size or location of the facilities. The study shows that the standardized patient model can provide insights into multiple dimensions of care, thus helping to link primary care encounters with medicine quality. Furthermore, it makes it possible to obtain medicines from blinded sellers, thus minimizing the risk of obtaining biased samples.

The fiscal cost of weak governance: Evidence from teacher absence in India
Karthik Muralidharan, Jishnu Das, Alaka Holla, and Aakash Mohpal
J Public Econ 145: 116-135, January 2017.
The relative return to strategies that augment inputs versus those that reduce inefficiencies remains 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, we show that the large public investments in education 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 our data, 23.6% of teachers were absent during unannounced school visits, and we estimate that the salary cost of unauthorized teacher absence is $1.5 billion/year. We find 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. Using these results, we show that reducing inefficiencies by increasing the frequency of monitoring could be over ten times more cost effective at increasing the effective student-teacher ratio than hiring more teachers. Thus, policies that decrease the inefficiency of public education spending are likely to yield substantially higher marginal returns than those that augment inputs.


Changes in Poverty and Female-Headed Households in Africa
Annamaria Milazzo and Dominique van de Walle
Research Digest, Summer 2016

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.

Should cash transfers be systematically paid to mothers?
Damien de Walque, July 6, 2016

In policy circles, both in low- and high-income countries, it is often assumed that giving transfers to mothers rather than fathers will lead to better outcomes. This research on the transfer recipient’s gender suggests that the assumption that it is always better to give transfers to the mother should be questioned or at least nuanced.

India’s informal doctors are assets not crooks
Jishnu Das, April 28, 2016

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.

Health and the SDGs: Out of the doldrums, heading for the rapids
Adam Wagstaff and Joseph Kutzin, March 23, 2016

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.

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Conducting Ethical Economic Research: Complications from the Field
April 2016: This chapter in The Oxford Handbook of Professional Economic Ethics discusses practical issues confronted when conducting surveys as well as designing appropriate field trials. First, we look at the challenge of ensuring transparency while maintaining confidentiality. Second, we explore the role of trust in light of asymmetric information held by the surveyor and by the respondents as well as the latter’s expectations as to what their participation will set in motion. We present case studies relevant to both of these issues. Finally, we discuss the role of ethical review from the perspective of research conducted through the World Bank.

Right to Work?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?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.
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Youth Employment in SSAYouth 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.
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A Firm of One’s Own: Experimental Evidence on Credit Constraints and Occupational Choice
Andrew Peter Brudevold-Newman, Maddalena Honorati, Pamela Jakiela, Owen Ozier
Working Paper 7977, February 2017

This study presents results from a randomized evaluation of two labor market interventions targeted to young women aged 18 to 19 years in three of Nairobi's poorest neighborhoods. One treatment offered participants a bundled intervention designed to simultaneously relieve credit and human capital constraints; a second treatment provided women with an unrestricted cash grant, but no training or other support. Both interventions had economically large and statistically significant impacts on income over the medium term (7 to 10 months after the end of the interventions), but these impacts dissipated in the second year after treatment. The results are consistent with a model in which savings constraints prevent women from smoothing consumption after receiving large transfers -- even in the absence of credit constraints, and when participants have no intention of remaining in entrepreneurship. The study also shows that participants hold remarkably accurate beliefs about the impacts of the treatments on occupational choice.

A poor means test? Econometric targeting in Africa
Caitlin Susan Brown, Martin Ravallion and Dominique van de Walle
Working Paper 7915, December 2016

Proxy-means testing is a popular method of poverty targeting with imperfect information. In a now widely-used version, a regression for log consumption calibrates a proxy-means test score based on chosen covariates, which is then implemented for targeting out-of-sample. In this paper, the performance of various proxy-means testing methods is assessed using data for nine African countries. Standard proxy-means testing helps filter out the nonpoor, but excludes many poor people, thus diminishing the impact on poverty. Some methodological changes perform better, with a poverty-quantile method dominating in most cases. Even so, either a basic-income scheme or transfers using a simple demographic scorecard are found to do as well, or almost as well, in reducing poverty. However, even with a budget sufficient to eliminate poverty with full information, none of these targeting methods brings the poverty rate below about three-quarters of its initial value. The prevailing methods are particularly deficient in reaching the poorest.

If Politics Is the Problem, How Can External Actors Be Part of the Solution?
Shantayanan Devarajan and Stuti Khemani
Working Paper 7761, July 2016

Despite a large body of research and evidence on the policies and institutions needed to generate growth and reduce poverty, many governments fail to adopt these policies or establish the institutions. Research advances since the 1990s have explained this syndrome, which this paper generically calls "government failure," in terms of the incentives facing politicians, and the underlying political institutions that lead to those incentives. Meanwhile, development assistance, which is intended to generate growth and reduce poverty, has hardly changed since the 1950s, when it was thought that the problem was one of market failure.

A Randomized Control Trial of a Peer Adherence and Nutritional Support Program for Public Sector Antiretroviral Patients
Frederik Booysen, Damien de Walque, Mead Over, Satoko Hashimoto, and Chantell de Reuck
Working Paper 7760, July 2016

Access to antiretroviral treatment has expanded rapidly in South Africa, making it the country in the world with the largest treatment program. As antiretroviral treatment coverage continues to rise in resource-constrained settings, effective community-based adherence support interventions are of central importance in ensuring the long-term sustainability of treatment. This paper reports the findings from a randomized control trial of a peer adherence and nutritional support program implemented in a public health care setting in South Africa's antiretroviral treatment program. The analysis assesses the impact of these peer adherence and nutritional support interventions on self-reported adherence, timeliness of clinic and hospital visits, and immunologic response to antiretroviral treatment. Peer adherence and nutritional support improved the timeliness of adults´ clinic and hospital visits for routine follow-up while on antiretroviral treatment.

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Publications (2008-2017)

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The map shows research on human development by research department staff, 2008-2017.


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