Edward N. Okeke

Brain drain: Do economic conditions "push" doctors out of developing countries?

Health worker migration is an issue of first order concern in global health policy circles and continues to be the subject of much policy debate. In this paper, we contribute to the discussion by studying the impact of economic conditions on the migration of physicians from developing countries. To our knowledge, this is one of the first papers to do so. A major contribution of this paper is the introduction of a new panel dataset on migration to the US and the UK from 31 sub-Saharan Africa countries. The data spans the period 1975-2004. Using this data, we estimate the impact of changes in economic conditions on physician migration. In our preferred specification that allows for country-specific time trends, we find that a temporary one percentage point decline in GDP per capita increases physician migration in the next period by approximately. 3 percent. In our IV models a one percentage point decline in GDP per capita increases physician migration in the next period by between 3.4 and 3.6 percent. Overall, our results suggest a significant effect of developing country economic conditions on physician migration.

AIDS treatment and mental health: evidence from Uganda.

Increased access to antiretroviral therapy (ART) in developing countries over the last decade is believed to have contributed to reductions in HIV transmission and improvements in life expectancy. While numerous studies document the effects of ART on physical health and functioning, comparatively less attention has been paid to the effects of ART on mental health outcomes. In this paper we study the impact of ART on depression in a cohort of patients in Uganda entering HIV care. We find that 12 months after beginning ART, the prevalence of major and minor depression in the treatment group had fallen by approximately 15 and 27 percentage points respectively relative to a comparison group of patients in HIV care but not receiving ART. We also find some evidence that ART helps to close the well-known gender gap in depression between men and women.

What is the Price of Prevention? New Evidence from a Field Experiment

How does increasing access to treatment affect the demand for preventive testing? In this paper we present results from a field experiment in Nigeria in which we offered cervical cancer screening to women at randomly chosen prices. To test our hypothesis, we also offered women a lottery where the payoff was a subsidy towards the cost of cervical cancer treatment (conditional upon a diagnosis of cervical cancer). We find that women randomly selected to receive the conditional cancer treatment subsidy were about 4 percentage points more likely to take up screening than those in the control group. We also show that reducing the price of screening by 10 cents increased take-up by about 1 percentage point. These results offer compelling evidence that the optimal set of subsidies to increase take-up of preventive testing in developing countries, must include subsidies towards treatment costs (in addition to price subsidies).

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.

African Doctor Migration: Are Economic Shocks to Blame?

It is widely believed that poor economic conditions in developing countries contribute to the migration of health professionals. In this paper we test this hypothesis using new panel data on the annual flow of physicians from 31 African countries to the United States and the United Kingdom. The data spans the period 1975-2004. Using a variety of fixed effects and instrumental variable models, we show that economic shocks have a statistically significant impact on the migration of physicians. Results from the fixed effects models suggest that a one-percentage point decline in lagged economic growth increases physician migration in year t by approximately 0.3 percent. The IV estimates are several orders of magnitude larger implying that a one percentage point decline in economic growth in t − 1 causes an increase in physician migration in year t of between 3.4 and 3.6 percent.

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 …

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.

Does Price Affect the Demand for Information about New Health Technologies? Evidence from a Field Experiment in Nigeria

We study how prices influence the demand for information about a new preventative health technology. We conducted a field experiment in Nigeria where women were offered the opportunity to get screened for cervical cancer (at baseline 2/3 of women had no knowledge of cervical cancer screening). Field staff made house calls to give women information about the test and also distributed vouchers that randomly varied the price of screening at the point of service. We find an inverse U-shaped relationship between prices and the demand for information: going from zero to a small positive price increased the demand for information about the test, but increasing the price further (by 100%) resulted in a net decrease in the demand for information. We argue that these results have interesting implications for the debate about the pricing of new health technologies in developing countries.

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.