Conditional cash transfers for school attendance can reduce teenage pregnancies and early marriage as well as increase enrollment
October 2009
Malawi’s Zomba Cash Transfer Program is randomized and targets young women. It provides incentives (in the form of school fees and cash transfers, equivalent to US$10/month) to current schoolgirls and recent dropouts to stay in or return to school. The program has led to significant declines in early marriage, teenage pregnancy, and self-reported sexual activity among program beneficiaries after just one year of implementation. For program beneficiaries who were out of school at baseline, the probability of getting married and becoming pregnant declined by more than 40 percent and 30 percent, respectively. In addition, the incidence of the onset of sexual activity was 38 percent lower among all program beneficiaries than the control group.
Working Paper 5089 

Data reveal no clear-cut generalizeable relationships between HIV/AIDS prevalence and indicators of socioeconomic and demographic status
October 2009
Understanding the demographic and socioeconomic patterns of the prevalence and incidence of HIV/AIDS in Sub-Saharan Africa is crucial for developing programs and policies to combat HIV/AIDS. This paper shows how weak the evidence base is on the subject, reflecting problems surrounding definitions, samples, and empirical methods. The paper concludes that there are few consistent and significant patterns of prevalence by socioeconomic and demographic status.
Working Paper 5076 |  Research Digest (Fall)

Tamil Nadu, unlike the rest of India, has maintained separate medical and public health services, apparently strengthening its health system
October 2009
Public health systems in India have weakened since the 1950s, after central decisions to amalgamate the medical and public health services, and to focus public health work largely on single-issue programs. Tamil Nadu chose the opposite course. This paper describes its public health system, and argues that Tamil Nadu’s separate and strong public health system has helped it conduct long-term planning to avert outbreaks, manage endemic diseases, prevent disease resurgence, manage disasters and emergencies, and support local bodies to protect public health in rural and urban areas. Tamil Nadu’s health indicators are better than those of other states, despite its limited government health expenditure. 
Working Paper 5073 

When do donors trust country systems to manage their aid rather than micro-managing aid using their own systems and procedures?
July 2009
In a new working paper, Stephen Knack and Nicholas Eubank conclude from their empirical cross-country analysis that donors’ trust in recipient country systems is positively related to: the trustworthiness or quality of those systems; tolerance for risk on the part of the donor’s constituents, as measured by public support for providing aid; and the donor’s ability to internalize more of the benefits of investing in country systems, as measured by the donor’s share of all aid provided to a recipient.
Working Paper 5005 

Own and sibling effects of conditional cash transfer programs : theory and evidence from Cambodia
July 2009
Conditional cash transfers have been adopted by a large number of countries in the past decade. Although the impacts of these programs have been studied extensively, understanding of the economic mechanisms through which cash and conditions affect household decisions remains incomplete. This paper uses evidence from a program in Cambodia, where eligibility varied substantially among siblings in the same household, to illustrate these effects. A model of schooling decisions highlights three different effects of a child-specific conditional cash transfer: an income effect, a substitution effect, and a displacement effect. The model predicts that such a conditional cash transfer will increase enrollment for eligible children - due to all three effects - but have an ambiguous effect on ineligible siblings. The ambiguity arises from the interaction of a positive income effect with a negative displacement effect. These predictions are shown to be consistent with evidence from Cambodia, where the child-specific program makes modest transfers, conditional on school enrollment for children of middle-school age. Scholarship recipients were more than 20 percentage points more likely to be enrolled in school and 10 percentage points less likely to work for pay. However, the school enrollment and work of ineligible siblings was largely unaffected by the program.
Working Paper 5001 

System-wide impacts of hospital payment reforms : evidence from central and eastern Europe and central Asia
July 2009
Although there is broad agreement that the way that health care providers are paid affects their performance, the empirical literature on the impacts of provider payment reforms is surprisingly thin. During the 1990s and early 2000s, many European and Central Asian countries shifted from paying hospitals through historical budgets to fee-for-service or patient-based-payment methods (mostly variants of diagnosis-related groups). Using panel data on 28 countries over the period 1990-2004, the authors of this study exploit the phased shift from historical budgets to explore aggregate impacts on hospital throughput, national health spending, and mortality from causes amenable to medical care. They use a regression version of difference-in-differences and two variants that relax the difference-in-differences parallel trends assumption. The results show that fee-for-service and patient-based-payment methods both increased national health spending, including private (out-of-pocket) spending. However, they had different effects on inpatient admissions (fee-for-service increased them; patient-based-payment had no effect), and average length of stay (fee-for-service had no effect; patient-based-payment reduced it). Of the two methods, only patient-based-payment appears to have had any beneficial effect on "amenable mortality," but there were significant impacts for only a couple of causes of death, and not in all model specifications.
Working Paper 4987

Educational and health impacts of two school feeding schemes : evidence from a randomized trial in rural Burkina Faso
June 2009
This paper uses a prospective randomized trial to assess the impact of two school feeding schemes on health and education outcomes for children from low-income households in northern rural Burkina Faso. The two school feeding programs under consideration are, on the one hand, school meals where students are provided with lunch each school day, and, on the other hand, take-home rations that provide girls with 10 kg of cereal flour each month, conditional on 90 percent attendance rate. After running for one academic year, both programs increased girls’ enrollment by 5 to 6 percentage points. While there was no observable significant impact on raw scores in mathematics, the time-adjusted scores in mathematics improved slightly for girls. The interventions caused absenteeism to increase in households that were low in child labor supply while absenteeism decreased for households that had a relatively large child labor supply, consistent with the labor constraints. Finally, for younger siblings of beneficiaries, aged between 12 and 60 months, take-home rations have increased weight-for-age by .38 standard deviations and weight-for-height by .33 standard deviations. In contrast, school meals did not have any significant impact on the nutrition of younger children.
Working Paper 4976

Do international treaties promote development ? the convention on the rights of the child and basic immunization
June 2009
Little evidence is available on whether changing global rules so as to promote human rights can enhance development outcomes. The Convention on the Rights of the Child was almost universally ratified by the mid-1990s, but it is unclear whether treaty ratification was associated with better or wider protection of children’s rights. This paper uses an instrumental variable approach to investigate whether treaty ratification was associated with stronger effort at the country level on child survival, and particularly with higher rates of immunization coverage. The paper finds that ratification of the Convention on the Rights of the Child was correlated with a subsequent increase in immunization rates, but only in upper middle and high-income countries. Treaties can promote development outcomes, but require institutional support to do so.
Working Paper 4964 

How can donors help build global public goods in health?
April 2009
Aid to developing countries has largely neglected the population-wide health services that are core to communicable disease control in the developed world. These mostly non-clinical services generate "pure public goods" by reducing everyone's exposure to disease through measures such as implementing health and sanitary regulations. They complement the clinical preventive and treatment services which are the donors' main focus. Their neglect is manifested, for example, in a lack of coherent public health regulations in countries where donors have long been active, facilitating the spread of diseases such as avian flu. These services can be inexpensive, and dramatically reduce health inequalities. Sri Lanka spends less than 0.2% of GDP on its well-designed population-wide services, which contribute to the country's high levels of health equity and life expectancy despite low GDP per head and civil war. Evidence abounds on the negative externalities of weak population-wide health services. Global public health security cannot be assured without building strong national population-wide health systems to reduce the potential for communicable diseases to spread within and beyond their borders. Donors need greater clarity about what constitutes a strong public health system, and how to build them. The paper discusses gaps in donors' approaches and first steps toward closing them.
Working Paper 4907 

Orphanhood and the living arrangements of children in sub-saharan Africa
March 2009
Increasing adult mortality due to HIV/AIDS in Sub-Saharan Africa raises considerable concerns about the welfare of surviving children. Studies have found substantial variability across countries in the negative impacts of orphanhood on child health and education. One hypothesis for this variability is the resilience of the extended family network in some countries to care for orphans-networks under increasing pressure by the sheer number of orphans in many settings. Using household survey data from 21 countries in Africa, this study examines trends in orphanhood and living arrangements, and the links between the two. The findings confirm that orphanhood is increasing, although not all countries are experiencing rapid rises. In many countries, there has been a shift toward grandparents taking on increased childcare responsibility-especially where orphan rates are growing rapidly. This suggests some merit to the claim that the extended network is narrowing, focusing on grandparents who are older and may be less able to financially support orphans than working-age adults. However there are also changes in childcare patterns in countries with stable orphan rates or low HIV prevalence. This suggests future work on living arrangements should not exclude low HIV/AIDS prevalence countries, and explanations for changes should include a broader set of factors.
Working Paper 4889 

The demographic and socio-economic distribution of excess mortality during the 1994 genocide in Rwanda
March 2009
There is an extensive literature on violent conflicts such as the 1994 Rwandan genocide, but few papers examine the profiles of victims and perpetrators, or more broadly the micro-level dynamics of widespread violence. This paper studies the demographic consequences of the Rwandan genocide and how the excess mortality due to the conflict was distributed in the population. Data collected by the 2000 Demographic and Health Survey indicate that although there were more deaths across the entire population, adult males were the most likely to die. Using the characteristics of the survey respondent as a proxy for the socio-economic status of the family dead, the results also show that individuals with an urban or more educated background were more likely to die. Over and above the human tragedies, a long-term cost of the genocide is the country's loss of productive skills.
Working Paper 4850 

No more cutting class ? reducing teacher absence and providing incentives for performance
February 2009
Expanding and improving basic education in developing countries requires, at a minimum, teachers who are present in the classroom and motivated to teach, but this essential input is often missing. This paper describes the findings of a series of recent World Bank and other studies on teacher absence and incentives for performance. Surprise school visits reveal that teachers are absent at high rates in countries such as India, Indonesia, Uganda, Ecuador, and Zambia, reducing the quality of schooling for children, especially in rural, remote, and poor areas. More broadly, poor teacher management and low levels of teacher accountability afflict many developing-country education systems. The paper presents evidence on these shortcomings, but also on the types of incentives, management, and support structures that can improve motivation and performance and reduce avoidable absenteeism. It concludes with policy options for developing countries to explore as they work to meet Education for All goals and improve quality.
Working Paper 4847 

Is there an incipient turnaround in Asia's "missing girls" phenomenon?
February 2009
The apparently inexorable rise in the proportion of "missing girls" in much of East and South Asia has attracted much attention amongst researchers and policy-makers. An encouraging trend was suggested by the case of South Korea, where child sex ratios were the highest in Asia but peaked in the mid-1990s and normalized thereafter. Using census data, we examine whether similar trends have begun to manifest themselves in the two large populous countries of this region, China and India. The data indicate that child sex ratios are peaking in these countries, and in many sub-national regions are beginning to trend towards less masculinization. This suggests that, with continuing vigorous efforts to reduce son preference, the "missing girls" phenomenon could be addressed in Asia.
Working Paper 4846 

Social health insurance vs. tax-financed health systems - evidence from the OECD
January 2009
This paper exploits the transitions between tax-financed health care and social health insurance in the OECD countries over the period 1960-2006 to assess the effects of adopting social health insurance over tax finance on per capita health spending, amenable mortality, and labor market outcomes. The paper uses regression-based generalizations of difference-in-differences and instrumental variables to address the possible endogeneity of a country's health system. It finds that adopting social health insurance in preference to tax financing increases per capita health spending by 3-4 percent, reduces the formal sector share of employment by 8-10 percent, and reduces total employment by as much as 6 percent. For the most part, social health insurance adoption has no significant impact on amenable mortality, but for one cause-breast cancer among women-social health insurance systems perform significantly worse, with 5-6 percent more potential years of life lost.
Working Paper 4821