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 »
Government leaders often fail to adopt and implement policies necessary for sustained economic development. This report focuses on two forces—citizen engagement and transparency—that hold the key to solving government failures by shaping how political markets function.
This column describes a new HIV intervention trialled in Lesotho that used a lottery to target those with risky behavior and incentivise safer practices. HIV incidence was reduced by more than a fifth in treatment groups over the trial period.
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.
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.
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.
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.
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. Download
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. Download
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. Order | Download
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. Order | Download
A substantial literature has examined the impact of stress during the early stages of life on later-life health. This paper contributes to that literature by examining the later-life health impact of stress during adolescence and early adulthood, using a novel proxy for stress: risk of military induction in the United States during the Vietnam War. The paper estimates that a 10 percentage point (2 standard deviation) increase in induction risk in young adulthood is associated with a 1.5 percentage point (8 percent) increase in the probability of being obese, and a 1 percentage point (10 percent) increase in the probability of being in fair or poor health later in life. These findings do not appear to be due to cohort effects; the associations exist only for men who did not serve in the war, and are not present for women or men who did serve. These findings add to the evidence on the lasting consequences of stress, and indicate that induction risk during the Vietnam War may, in certain contexts, be an invalid instrument for education or marriage, because it appears to have a direct impact on health.
To diagnose and treat preventable threats to maternal and neonatal health in Sub-Saharan Africa, a policy focus has been put on increasing coverage rates of targeted health services. Exploiting an experimental design, this study evaluates the impacts of an in-kind conditional transfer intervention in Rwanda that endowed women with gifts for receiving timely antenatal and postnatal care, as well as for delivering in health facilities. The analysis finds that although health centers experienced frequent stock outs of the gifts, the rate of women who initiated antenatal care within the first four months of their pregnancy increased by 7.7 percent, and that of women who received postnatal care in the 10 days following delivery increased by 8.6 percent. No impact was found on the rate of in-facility deliveries, which independently sharply increased during the years of the implementation of the program.
This paper presents the results of a randomized controlled trial set to evaluate the effects of a pay-for-performance scheme that rewarded community health worker cooperatives for the utilization of five targeted maternal and child health services by their communities. The experiment took place in 19 districts in Rwanda between 2010 and 2014. The analysis finds no impact of the performance payments on coverage of the targeted services, attitudes and behaviors of community health workers, or outcomes at the cooperative level. No synergies are found between the scheme and a demand-side, in-kind transfer intervention that was independently effective in increasing coverage rates of targeted services.
This paper examines salary gaps by gender and nationality at the World Bank Group between 1987 and 2015 using a unique panel of all employees over this period. The paper develops and implements a dynamic simulation approach that models existing gaps as arising from differences in job composition at entry, entry salaries, salary growth and attrition. There are three main findings. First, 76 percent of the $27,400 salary gap across the average male and female staff at the World Bank Group can be attributed to composition effects, whereby men entered the World Bank Group at higher paid positions, particularly in the earlier half of the sample. Second, salary gaps 15 years after joining the World Bank Group can favor either men or women depending on their entry position. Third, for the most common entry-level professional position (known as Grade GF at the World Bank Group) there is a gender gap of 3.5 percent in favor of males 15 years after entry. The majority of this gap (84 percent) is due to differences in salary growth rather than differences in entry salaries or attrition. The pattern of these gaps is similar for staff from different nationalities. The dynamic decomposition method developed here thus identifies specific areas of concern and can be widely applied to the analysis of salary gaps within firms.
This paper uses a unique dataset of both public and private sector primary school teachers and their students to present among the first estimates in a low-income country of (a) teacher effectiveness; (b) teacher value added (TVA) and its correlates; and (c) the link between TVA and teacher wages. Teachers are highly effective in our setting: Moving a student from the 5th to the 95th percentile in the public school TVA distribution would increase mean student test scores by 0.54 standard deviations. Although the first two years of experience, as well as content knowledge, are associated with TVA, all observed teacher characteristics explain no more than 5 percent of the variation in TVA. Finally, there is no correlation between TVA and wages in the public sector (although there is in the private sector), and a policy change that shifted public hiring from permanent to temporary contracts, reducing wages by 35 percent, had no adverse impact on TVA, either immediately or after 4 years. The study confirms the importance of teachers in low income countries, extends previous experimental results on teacher contracts to a large-scale policy change, and provides striking evidence of significant misallocation between pay and productivity in the public sector.