Amalavoyal V. Chari

Disparities in Time Spent Seeking Medical Care in the United States

recommendation for their use. Despite the lack of guidelinebased recommendations and little evidence to support IABP use, the study by Inohara et al2 finds that IABPs continue to be used frequently and that their use is associated with increased inhospital mortality. Although there has been enthusiasm about newer PVADs (eg, Impella LP2.5 [Abiomed Europe GmbH] and TandemHeart [Cardiac Assist]), initial studies regarding their use to treat cardiogenic shock have not shown any significant survival benefit compared with IABPs and observed increased bleeding and a tendency toward more limb ischemia from the use of larger sheaths with PVADs.7 Similar to IABPs, no net benefit was demonstrated in hemodynamically stable patients with an implanted PVAD undergoing high-risk angioplasty, another common clinical scenario for the use of PVADs.8 Why is there reluctance to abandon these invasive, expensive, and seemingly ineffective therapies? The answer might be multifactorial. Cardiogenic shock complicating myocardial infarction remains a formidable foe and is associated with 40% to 50% in-hospital mortality.9 In this setting, only early revascularization has shown improved survival. In some of these critically ill patients, it may seem reasonable to use mechanical circulatory support devices as salvage therapy. However, they offer little benefit in reducing clinical events, and have high costs and significant complication rates. Inohara et al2 confirm previous findings that IABPs and PVADs are being increasingly used in patients without indications for their use. Although the precise reasons for such excessive use remain to be established, misaligned financial incentives might have a role. Furthermore, continued use of IABPs may be due to established routines or treatment protocols, with commission bias tending toward action rather than inaction.10 Based on available data, the use of these invasive and expensive mechanical circulatory support devices should be critically appraised and limited because of significant complication rates associated with their use and a lack of evidence demonstrating any benefit. In the use of IABPs and PVADs, it seems appropriate to conclude that perhaps less is more.

The Aggregate Productivity Effects of Entry and Output Restrictions: An Analysis of License Reform in India

How do restrictions on entry and output affect aggregate productivity? I propose and implement a simple methodology that empirically identifies their separate effects on aggregate TFP and apply it to an analysis of the policy of industrial licensing in India. The licensing policy was notably reformed in the mid-1980s, and I take advantage of this policy experiment to identify the effects of the licensing regime. Using plant-level data covering this period, I find that the reform resulted in an aggregate TFP improvement of nearly 28% in the deregulated sector, and that the reductions in entry and output restrictions stemming from the reform contributed almost equally to this TFP gain.

The effect of increasing the supply of skilled health providers on pregnancy and birth outcomes: evidence from the midwives service scheme in Nigeria

BackgroundLimited availability of skilled health providers in developing countries is thought to be an important barrier to achieving maternal and child health-related MDG goals. Little is known, however, about the extent to which scaling-up supply of health providers will lead to improved pregnancy and birth outcomes. We study the effects of the Midwives Service Scheme (MSS), a public sector program in Nigeria that increased the supply of skilled midwives in rural communities on pregnancy and birth outcomes.MethodsWe surveyed 7,104 women with a birth within the preceding five years across 12 states in Nigeria and compared changes in birth outcomes in MSS communities to changes in non-MSS communities over the same period.ResultsThe main measured effect of the scheme was a 7.3-percentage point increase in antenatal care use in program clinics and a 5-percentage point increase in overall use of antenatal care, both within the first year of the program. We found no statistically significant effect of the scheme on skilled birth attendance or on maternal delivery complications.ConclusionThis study highlights the complexity of improving maternal and child health outcomes in developing countries, and shows that scaling up supply of midwives may not be sufficient on its own.

Why farmers sometimes love risks: evidence from India

Using a unique data set collected among farmers in India’s semiarid tropics, we document the surprising prevalence of risk-taking behavior in the face of realistically framed high-stakes gambles. We hypothesize that this apparently anomalous behavior is due to a combination of credit constraints and nonconvexities in production. In particular, the high-stakes nature of the gambles creates the potential for a farmer to undertake a productive investment that would normally be unaffordable and thereby move to a permanently higher level of income. We show that the degree to which farmers are willing to accept risk in return for this opportunity appears to relate in an intuitive way to their current agricultural production technology as well as the demographic composition of their household.

Health care at birth and infant mortality: evidence from nighttime deliveries in Nigeria

High rates of home births in developing countries are often linked to high rates of newborn deaths, but there is considerable debate about how much of this is causal. This paper weighs in on this question by analyzing data on the timing of birth, health care utilization, and mortality for a sample of births between 2009-2014 in 7021 rural Nigerian households. First, we show that timing of birth is strongly linked to use of institutional care: women with a nighttime birth are significantly less likely to use a health facility because of the difficulties associated with accessing care at night. In turn, this is associated with a sharp increase in the rate of newborn mortality at night. Leveraging variation in household proximity to a health care facility that offers 24-h coverage, we show that this increase in mortality is plausibly due to lack of formal health care at the time of birth: infants born at night to households without a nearby health care facility that offers 24-h coverage, experience an increase in mortality equivalent to about 10 additional newborn deaths per 1000 live births. In contrast, when households have a nearby health facility that provides care at night, there is no detectable increase in mortality. These results suggest that well-designed policies to increase access to (and quality of) formal care at birth may lead to significant reductions in newborn deaths.

Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RANDs publications do not necessarily reflect the opinions of its research clients and sponsors. R® is a registered trademark. iii Preface Limited availability of skilled providers, particularly in rural areas, is thought to be an important constraint to increasing rates of use of maternal and child health services in low-and middle-income countries. There are, however, few well-identified studies of the relationship between the supply of skilled workers and outcomes. In this project, we studied the effects of a government program in Nigeria that sought to alleviate supply-side constraints by deploying skilled midwives to primary health facilities in rural communities to provide round-the-clock access to skilled care. The contents of this report will be of interest to policymakers and public health professionals interested in improving maternal and child health. Summary We evaluate the impact of the Midwives Service Scheme (MSS), a government program introduced in 2009 to increase access to skilled care in rural underserved areas in Nigeria. At rollout, the MSS deployed nearly 2,500 midwives to 652 primary health care centers across 36 states. To evaluate the impact of the program, we surveyed 7,104 women with a birth within the preceding five years in 386 communities across 12 states. The intervention group consisted of communities that participated in the initial rollout; the comparison group consisted of communities that would later receive the program (approximately three years later). To understand implementation challenges and contextualize the quantitative results, we carried out a nested qualitative study in three states, consisting of in-depth interviews and focus group discussions with policymakers, providers, childbearing women, and community stakeholder groups. Overall, we find that the programs effects are smaller than anticipated. The main effect is a 7.3-percentage-point increase in antenatal …

Assessing the Spatial Concentration of Indonesia's Manufacturing Sector: Evidence from Three Decades

Beyond the role of economic forces, many theories of economic geography emphasize the way politics can shape the spacial configuration of economic activity. We investigate the impact of changes in political regimes on industrial concentration using 30 years of data on Indonesian manufacturers. These data span both the reign of Suharto, one of the strongest central governments in Southeast Asia, and its collapse and the subsequent decentralization of power. Using the canonical measure of Ellison and Glaeser, we show that in the mid 1980s, Indonesias firms exhibited a similar degree of agglomeration as seen in the United States. Spatial concentration then declined until the 1998 Asian Financial Crisis, and has since begun to rise during the decentralization period. We also measure concentration using the continuous measure developed by Duranton and Overman (2005), and find that the agglomeration exhibited by Indonesian firms is also broadly similar to that documented by Duranton and Overman (2005 ) for the United Kingdom, although localization drops off more gradually in Indonesia than in the United Kingdom. Using this continuous measure of agglomeration, we identify 32 manufacturing clusters in Indonesia, and investigate the correlates of concentration. We find that the most robust drivers of agglomeration have been natural resources and supply chain linkages, especially with respect to explaining long-term changes in spatial concentration.

Going to scale: design and implementation challenges of a program to increase access to skilled birth attendants in Nigeria

BackgroundThe lack of availability of skilled providers in low- and middle- income countries is considered to be an important barrier to achieving reductions in maternal and child mortality. However, there is limited research on programs increasing the availability of skilled birth attendants in developing countries. We study the implementation of the Nigeria Midwives Service Scheme, a government program that recruited and deployed nearly 2,500 midwives to rural primary health care facilities across Nigeria in 2010. An outcome evaluation carried out by this team found only a modest impact on the use of antenatal care and no measurable impact on skilled birth attendance. This paper draws on perspectives of policymakers, program midwives, and community residents to understand why the program failed to have the desired impact.MethodsWe conducted semi-structured interviews with federal, state and local government policy makers and with MSS midwives. We also conducted focus groups with community stakeholders including community leaders and male and female residents.ResultsOur data reveal a range of design, implementation and operational challenges ranging from insufficient buy-in by key stakeholders at state and local levels, to irregular and in some cases total non-provision of agreed midwife benefits that likely contributed to the program’s lack of impact. These challenges not only created a deep sense of dissatisfaction with the program but also had practical impacts on service delivery likely affecting households’ uptake of services.ConclusionThis paper highlights the challenge of effectively scaling up maternal and child health interventions. Our findings emphasize the critical importance of program design, particularly when programs are implemented at scale; the need to identify and involve key stakeholders during planning and implementation; the importance of clearly defining lines of authority and responsibility that align with existing structures; and the necessity for multi-faceted interventions that address multiple barriers at the same time.

Persistent barriers to care; a qualitative study to understand women’s experiences in areas served by the midwives service scheme in Nigeria

BackgroundThe Nigerian Midwives Service Scheme (MSS) is an ambitious human resources project created in 2009 to address supply side barriers to accessing care. Key features include the recruitment and deployment of newly qualified, unemployed and retired midwives to rural primary healthcare centres (PHCs) to ensure improved access to skilled care. This study aimed to understand, from multiple perspectives, the views and experiences of childbearing women living in areas where it has been implemented.MethodsA qualitative study was undertaken as part of an impact evaluation of the MSS in three states from three geo-political regions of Nigeria. Semi-structured interviews were conducted around nine MSS PHCs with women who had given birth in the past six months, midwives working in the PHCs and policy makers. Focus group discussions were held with wider community members. Coding and analysis of the data was performed in NVivo10 based on the constant comparative approach.ResultsThe majority of participants reported that there had been positive improvements in maternity care as a result of an increasing number of midwives. However, despite improvements in the perceived quality of care and an apparent willingness to give birth in a PHC, more women gave birth at home than intended. There were some notable differences between states, with a majority of women in one northern state favouring home birth, which midwives and community members commented stemmed from low levels of awareness. The principle reason cited by women for home birth was the sudden onset of labour. Financial barriers, the lack of essential drugs and equipment, lack of transportation and the absence of staff, particularly at night, were also identified as barriers to accessing care.ConclusionsOur research highlights a number of barriers to accessing care exist, which are likely to have limited the potential for the MSS to have an impact. It suggests that in addition to scaling up the workforce through the MSS, efforts are also needed to address the determinants of care seeking. For the MSS this means that the while the supply side, through the provision of skilled attendance, still needs to be strengthened, this should not be in isolation of addressing demand-side factors.

Learning Your Child's Price: Evidence from Data on Projected Dowry in Rural India

This paper introduces a new primary dataset on dowry payments in rural India. A novel feature of the data is that in addition to eliciting actual dowry payments, we also asked rural Indian households how much dowry they expected to pay/receive for each of their currently unmarried children. These expectations are presumably the basis of household decision making (as opposed to actual dowries paid and received) with respect to decisions such as human capital investments, saving and consumption, etc. We find that the distribution of dowry forecasts appears to be consistent with the distribution of actual dowry payments, suggesting that dowry perceptions may be quite accurate. Our analysis of dowry forecasts further indicates that (i) Individual-specific attributes are significantly more important than household income and wealth in terms of explaining the magnitude of dowry payments, and (ii) bride quality is also a significant determinant of dowry, which provides a corrective to the emphasis on groom quality in the literature.