After years of bad news from developing countries about high rates of health worker absenteeism, and low rates of delivery of key health interventions, along came what seemed like a magic bullet: financial incentives. Rather than paying providers whether or not they show up to work, and whether or not they deliver key interventions, doesn’t it make sense to pay them—at least in part—according to what they do? And if, after doing their cost-benefit calculations, women decide not to have their baby delivered in a health facility, not to get antenatal care, and not take their child to be immunized, then doesn’t it make sense to try to change the benefit-cost ratio by paying them to do so?
Attempts to understand population growth and the determinants of fertility date as far back as the late 1700s, when Thomas Malthus wrote ‘An Essay on the Principle of Population.’
Postulating that fertility decisions are influenced by women’s opportunity cost of time (Becker, 1960), choice over fertility has been incorporated in more recent times into growth models in order to understand the joint behavior of population and economic development throughout history. The large majority of existing analyses examine individual countries in a closed-economy setting. However, in an era of ever-increasing integration of world markets, the role of globalization in determining fertility can no longer be ignored.
Globally, tremendous progress has been made in reducing extreme poverty in the last 25 years. However, the number of poor remains unacceptably high, at just over 1 billion in 2011 compared with 1.2 billion in 2008, creating a widening gap between the living standards of those in the bottom 40 percent and the top 60 percent of the population. According to the recently released Global Monitoring Report, the well-being of low income households still remains below that of households in the top 60 percent directly impacting young children who are 2-3 times more likely to be malnourished than those in the highest wealth quintiles.
Last week, Mali announced a national strategic plan to scale up Community Health Workers in every region of the country. This initiative has the potential to save tens of thousands of lives, including significantly reducing the risk of an Ebola epidemic.
How was this achieved? Roll back a few years and meet Djeneba, a young girl living in Yirimadjo. Today she goes to school but her life was once threatened. Djeneba started getting high fevers but her parents did not have enough money to pay for care. They tried to break the fever by bathing her in herbal remedies and buying unregulated pharmaceuticals but the fevers persisted and became increasingly severe.
Subsidized health insurance is unlikely to lead to Universal Health Coverage (UHC); insurance coverage doesn’t always improve financial protection and when it does, doesn’t necessarily eliminate financial protection concerns; and tackling provider incentives may be just as – if not more – important in the UHC agenda as demand-side initiatives. These are the three big and somewhat counterintuitive conclusions of the Health Equity and Financial Protection in Asia (HEFPA) research project that I jointly coordinated with Eddy van Doorslaer and Owen O’Donnell.
As we all now know, UHC is all about ensuring that everyone – irrespective of their ability to pay – can access the health services they need without suffering undue financial hardship in the process. The HEFPA project set out to explore the effectiveness of a number of UHC strategies in a region of the world that has seen a lot of UHC initiatives: East Asia. The project pooled the skills of researchers from six Asian countries (Cambodia, China, Indonesia, the Philippines, Thailand and Vietnam), several European universities and the World Bank.
Thanks to Thomas Piketty, we’ve heard a lot this year about rising inequality. And with just over a year to go before the MDG ‘window’ closes, we’ve also heard a lot about the ‘post-2015 agenda’. In a paper with Leander Buisman that just came out in the World Bank Research Observer, we bring these two themes together and ask: “Were the poor left behind by the health MDGs?” Influenced perhaps by all the talk of rising income inequality, there are certainly plenty of pessimistic folks out there who think that health inequalities, too, are on the rise; that the better off are likely to have seen much faster improvements in MDG indicators than the poor.
Following is an abstract from World Bank Policy research working paper no 6779 by Norbert Schady (Inter-American Development Bank), Jere Behrman (University of Pennsylvania), Maria Caridad Araujo (Inter-American Development Bank), Rodrigo Azuero (University of Pennsylvania), Raquel Bernal (Universidad de Los Andes), David Bravo (Universidad de Chile), Florencia Lopez-Boo (Inter-American Development Bank), Karen Macours (Paris School of Economics & World Bank), Daniela Marshall (University of Pennsylvania), Christina Paxson (Brown University), and Renos Vakis (World Bank).
Research from the United States shows that gaps in early cognitive and noncognitive abilities appear early in the life cycle. Little is known about this important question for developing countries. A recent World Bank owrking paper, Wealth gradients in early childhood cognitive development in five Latin American countries, provides new evidence of sharp differences in cognitive development by socioeconomic status in early childhood for five Latin American countries. To help with comparability, the paper uses the same measure of receptive language ability for all five countries. It finds important differences in development in early childhood across countries, and steep socioeconomic gradients within every country. For the three countries where panel data to follow children over time exists, there are few substantive changes in scores once children enter school. These results are robust to different ways of defining socioeconomic status, to different ways of standardizing outcomes, and to selective non-response on the measure of cognitive development.
I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.
I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?