Anna Popova

Health-care worker mortality and the legacy of the Ebola epidemic

The recent outbreak of Ebola in West Africa will leave a legacy significantly deeper than the morbidity and mortality caused directly by the disease. Ebola deaths have been disproportionately concentrated among health personnel. The fact that health-care workers are at greater risk of contracting Ebola will exacerbate existing skill shortages in countries that had few health personnel to begin with. The authors modelled how the loss of healthcare workers - defined here as doctors, nurses, and midwives - to Ebola may affect maternal, infant, and under-five mortality in Guinea, Liberia, and Sierra Leone, with the aim of characterizing the order of magnitude of likely effects, not providing specific pre dictions. The model’s use of cross country mortality coefficients assumes that the effect of health-care worker supply on maternal, infant, and under-five mortality in Guinea, Liberia, and Sierra Leone is similar to the cross-country average and has not changed since those coefficients were estimated. This work further assumes that unmeasured elements of health systems (such an overall measure of quality), associated with both health-care worker density and mortality, are not driving the result. The estimates suggest that substantial investment in health systems - and specifically in the health workforce - is urgently required not only to improve future epidemic preparedness and meet basic needs, but also to limit the secondary health effects of the current epidemic owing to the depletion of the health workforce.

What really works to improve learning in developing countries ? an analysis of divergent findings in systematic reviews

In the past two years alone, at least six systematic reviews or meta-analyses have examined the interventions that improve learning outcomes in low- and middle-income countries. However, these reviews have sometimes reached starkly different conclusions: reviews, in turn, recommend information technology, interventions that provide information about school quality, or even basic infrastructure (such as desks) to achieve the greatest improvements in student learning. This paper demonstrates that these divergent conclusions are largely driven by differences in the samples of research incorporated by each review. The top recommendations in a given review are often driven by the results of evaluations not included in other reviews. Of 227 studies with student learning results, the most inclusive review incorporates less than half of the total studies. Variance in classification also plays a role. Across the reviews, the three classes of programs that are recommended with some consistency (albeit under different names) are pedagogical interventions (including computer-assisted learning) that tailor teaching to student skills; repeated teacher training interventions, often linked to another pedagogical intervention; and improving accountability through contracts or performance incentives, at least in certain contexts. Future reviews will be most useful if they combine narrative review with meta-analysis, conduct more exhaustive searches, and maintain low aggregation of intervention categories.

Cash Transfers and Temptation Goods

Cash transfers have been demonstrated to improve education and health outcomes and alleviate poverty in various contexts. However, policy makers and others often express concern that poor households will use transfers to buy alcohol, tobacco, or other “temptation goods.” The income effect of transfers will increase expenditures if alcohol and tobacco are normal goods, but this may be offset by other effects, including the substitution effect and the effect of social messaging about the appropriate use of transfers. The net effect is ambiguous. This article reviews 19 studies with quantitative evidence on the impact of cash transfers on temptation good expenditure, as well as 11 studies that surveyed whether respondents reported they used transfers to purchase temptation goods. We conduct a meta-analysis to gauge the average impact of transfers on temptation goods. Results show that on average cash transfers have a significant negative effect on total expenditures on temptation goods, equal to −0.18 standard deviations. This negative result is supported by data from Latin America, Africa, and Asia, for both conditional and unconditional cash transfer programs. A growing number of studies therefore indicate that concerns about the use of cash transfers for alcohol and tobacco are unfounded.

The Next Wave of Deaths from Ebola? The Impact of Health Care Worker Mortality

The ongoing Ebola outbreak in West Africa has put a huge strain on already weak health systems. Ebola deaths have been disproportionately concentrated among health care workers, exacerbating existing skill shortages in Guinea, Liberia, and Sierra Leone in a way that will negatively affect the health of the populations even after Ebola has been eliminated. This paper combines data on cumulative health care worker deaths from Ebola, the stock of health care workers and mortality rates pre-Ebola, and coefficients that summarize the relationship between health care workers in a given country and rates of maternal, infant, and under-five mortality. The paper estimates how the loss of health care workers to Ebola will likely affect non-Ebola mortality even after the disease is eliminated. It then estimates the size of the resource gap that needs to be filled to avoid these deaths, and to reach the minimum thresholds of health coverage described in the Millennium Development Goals. Maternal mortality could increase by 38 percent in Guinea, 74 percent in Sierra Leone, and 111 percent in Liberia due to the reduction in health personnel caused by the epidemic. This translates to an additional 4,022 women dying per year across the three most affected countries. To avoid these deaths, 240 doctors, nurses, and midwives would need to be immediately hired across the three countries. This is a small fraction of the 43,565 doctors, nurses, and midwives that would need to be hired to achieve the adequate health coverage implied by the Millennium Development Goals. Substantial investment in health systems is urgently required not only to improve future epidemic preparedness, but also to limit the secondary health effects of the current epidemic owing to the depletion of the health workforce.

Training teachers on the job : what works and how to measure it

A significant body of research demonstrates that teachers and the quality of their teaching are crucial components of student learning. Many teachers in resource-poor environments have limited knowledge, skills, or motivation. Some impact evaluations have shown promising results from interventions to improve the quality of teaching. This paper reviews the existing body of evidence on what kinds of in-service teacher training interventions are most effective, and highlights the knowledge gaps. It reveals the dearth of detail on the nature of teacher training interventions and proposes a standard set of indicators -- the In-Service Teacher Training Survey Instrument—for reporting on such programs as a prerequisite for understanding which interventions lead to improved student learning. Across a set of 26 programs with impact evaluations and student learning results, programs that provide complementary materials, focus on a specific subject, and include follow-up visits tend to show higher gains. Programs that use non-education professionals as trainers tend to have worse outcomes. Statistical power to identify these effects is limited, and use of these standard indicators in future impact evaluations will facilitate more precise inference.

Cost-effectiveness measurement in development : accounting for local costs and noisy impacts

As evidence from rigorous impact evaluations grows in development, there have been more calls to complement impact evaluation analysis with cost analysis, so that policy makers can make investment decisions based on costs as well as impacts. This paper discusses important considerations for implementing cost-effectiveness analysis in the policy making process. The analysis is applied in the context of education interventions, although the findings generalize to other areas. First, the paper demonstrates a systematic method for characterizing the sensitivity of impact estimates. Second, the concept of context-specificity is applied to cost measurement: program costs vary greatly across contexts -- both within and across countries -- and with program complexity. The paper shows how adapting a single cost ingredient across settings dramatically shifts cost-effectiveness measures. Third, the paper provides evidence that interventions with fewer beneficiaries tend to have higher per-beneficiary costs, resulting in potential cost overestimates when extrapolating to large-scale applications. At the same time, recall bias may result in cost underestimates. The paper also discusses other challenges in measuring and extrapolating cost-effectiveness measures. For cost-effectiveness analysis to be useful, policy makers will require detailed, comparable, and timely cost reporting, as well as significant effort to ensure costs are relevant to the local environment.