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Can cash aid harm nonrecipients by raising local prices? We show that a household-targeted cash transfer in the Philippines increases the prices of perishable foods in some markets and raises stunting among nonbeneficiary children by 11 percentage points (34%). Impacts increase in the size of the village income shock and remoteness---and are sustained two and a half years after program introduction. Price effects from an experimental sample are confirmed with national expenditure surveys collected during program scale-up. Household-targeted cash transfers can thus generate local spillovers that undermine program goals. Selected geographic targeting may avoid price spillovers at moderate additional cost.

Physical effort is a primary component in models of economic behavior. However, applications that measure effort are historically scarce. This paper assesses the differences in physical activity between men and women through wearable accelerometers and uses these activity measures as a proxy for physical effort. Crucially, the accelerometer-generated data measures the level of physical activity associated with each activity or task recorded in the data. In this rural setting, women exert marginally higher levels of physical effort. However, differences in effort between men and women among married partners are strongly associated with differences in bargaining power, with larger husband-wife effort gaps alongside differences in age, individual land ownership, and an overall empowerment index. Physical activity can exhibit an unequal distribution between men and women suggesting that gender disadvantage, at least within couples, extends to the domain of physical effort.

The identification of key determinants of aid effectiveness is a long-standing question in the development community. This paper reviews the literature on aid effectiveness at the project level and then extends the inquiry in a variety of dimensions with new data on World Bank investment project financing. It confirms that the country institutional setting and quality of project supervision are associated with project success, as identified previously. However, many aspects of the development project cycle, especially project design, have been difficult to measure and therefore under-investigated. The paper finds that project design, as proxied by the estimated value added of design staff, the presence of prior analytic work, and other specially collected measures, is a significant predictor of ultimate project success. These factors generally grow in predictive importance as the income level of the country rises. The results also indicate that a key determinant of the staff's contribution is their experience with previous World Bank projects, but not other characteristics such as age, education, or country location. Key inputs to the project production process associated with subsequent performance are not captured in routine data systems, although it is feasible to do so. Further, the conceptualization and measurement of the success of project-based aid should be revisited by evaluative bodies to reflect a project's theorized contribution to development outcomes.

In lower-income countries, the economic contractions that accompany lockdowns to contain COVID-19 transmission can increase child mortality, counteracting the mortality reductions achieved by the lockdown. To formalize and quantify this effect, we build a macrosusceptible-infected-recovered model that features heterogeneous agents and a country-group-specific relationship between economic downturns and child mortality and calibrate it to data for 85 countries across all income levels. We find that in some low-income countries, a lockdown can produce net increases in mortality. The optimal lockdown that maximizes the present value of aggregate social welfare is shorter and milder in poorer countries than in rich ones.

Although many education and health programs aim to improve early childhood development, it is challenging to assess developmental levels of infants and small children through large household surveys. The Caregiver Reported Early Development Instruments (CREDI) has been proposed as an adaptable, practical, and low‐cost instrument for measuring the developmental status of children under 3 years of age at scale, as it is relatively short and collected by caregiver report. This study employed the CREDI to measure the development of a sample of 994 children ages 22–35 months in rural India and compared the results to those obtained using the Bayley Scales of Infant and Toddler Development (Bayley‐III), a reliable and widely used instrument, albeit one not always suited to large‐scale data collection efforts given its length, cost, and complexity of administration. The CREDI validation exercise showed that caregivers can provide assessments in keeping with the more interactive (hence more time‐consuming and training‐intensive) Bayley‐III instrument. Noteworthy, there was no indication that concordance of the instruments differed by education of the caregiver. This is important as it points to alternate feasible tools to measure child development outcomes through large‐scale surveys., The Caregiver Reported Early Development Instruments (CREDI) has been proposed as an adaptable, practical, and low‐cost tool for measuring the developmental status of children under 3 years of age at scale, as it is relatively short and collected by caregiver report. This study employed the CREDI to measure the development of a sample of 994 children ages 22–35 months in rural India and compared the results to those obtained using the Bayley Scales of Infant and Toddler Development, a reliable and widely used instrument.

Financial incentives for health providers and households are increasingly used to improve reproductive, maternal, and child health service coverage in low- and middle-income countries. This study provides a quantitative synthesis of their effectiveness. A systematic review was conducted of the effects of performance-based financing, voucher, and conditional cash transfer programs on six reproductive, maternal, and child health service indicators, with eligible evidence coming from randomized controlled trials and studies using double-difference, instrumental variables, and regression discontinuity designs. Four literature searches were conducted between September 2016 and March 2021 using seven academic databases, Google Scholar, development agency and think tank websites, and previous systematic reviews. Random effects meta-analysis was used to obtain mean effect sizes. From 58 eligible references 212 impact estimates were extracted, which were synthesized into 130 program-specific effect sizes. Financial incentives increase coverage of all considered reproductive, maternal, and child health indicators, but mean effects sizes are of modest magnitude. Effect size heterogeneity is typically low to moderate, and there is no indication that study bias risk, baseline indicator levels, or a combination of provider- and household-level incentives impact effect sizes. There is, however, weak evidence that mean effect sizes are somewhat smaller for performance-based financing than for voucher and conditional cash transfer programs, and that the increase in income, rather than the incentive itself, drives coverage improvements. Financial incentives improve reproductive, maternal, and child health service coverage. If future research confirms the preliminary finding that performance-based financing has smaller effects, voucher and conditional cash transfer programs are the preferred policy option among incentive interventions to achieve higher reproductive, maternal, and child health service coverage. The relative effectiveness and efficiency of incentives compared with unconditional increases of provider and household incomes, however, need to be studied further.

This paper examines the relationship between physical activity and individual productivity among agricultural workers paid on a piece-rate basis. In the context studied, physical activity has a clear correspondence with worker effort. Agricultural workers’ physical activity is directly observed from accelerometer data and is robustly associated with their daily productivity. In addition the impact of a health intervention, which provides malaria testing and treatment, on physical activity and productivity, indicates that the increased daily productivity of workers who are offered this program is explained by worker effort reallocation from low-intensity to high-intensity work within a fixed time period. This demonstrates, in settings when individual productivity is observed, that physical activity measures can help disentangle productivity effects due to effort. When productivity is unobserved, physical activity measures may proxy for individual productivity in physically demanding tasks. The challenges and limitations of physical activity measurement using accelerometers is discussed including their potential use for alternative contexts and the importance of field and data analysis protocols.

Agricultural and other physically demanding sectors are important sources of growth in developing countries, but prevalent diseases such as malaria can adversely impact the productivity and labor supply of workers. We estimate the impact of malaria infection on worker earnings, labor supply, daily productivity, and task selection by using a phased-in design where we randomize the study week in which piece-rate workers at a large sugarcane plantation in Nigeria are offered malaria testing and treatment. Two estimation strategies indicate a significant and substantial intent to treat effect of the intervention. The program increases worker weekly earnings by 11%–13% over the weeks following the offer, depending on the reference period, estimated using a between-worker estimator that exploits the experimental design. A within-worker estimate provides similar but smaller estimates of 8%–10%. We identify different pathways through which this effect occurs. For workers who test positive for malaria, the treatment of illness principally increases labor supply, leading to higher earnings. For workers who test negative, the health information leads to increased earnings via augmented daily productivity. This productivity response arises, in part, from selection into higher return tasks within their job at the plantation. The results underline the importance of medical treatment but also of improved access to information about one's health status, as the absence of either leads workers to work less or choose lower return tasks when working.

The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March–July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.

Background: The COVID-19 pandemic has had wide-reaching direct and indirect impacts on population health. We describe one of the most critical of these secondary consequences, the decrease in the utilization of health services and the resulting consequences for mortality. In low- and middle-income countries, these disruptions can halt progress towards reducing maternal and child mortality. Methods: Data on service utilization from January 2018 to June 2021 is extracted from health management information systems of 18 low- and lower-middle-income countries. Interrupted time series design is used to estimate percent change in the volumes of essential health services delivered during the pandemic compared to projected volumes based on pre-pandemic trends. The Lives Saved Tool mathematical model is used to estimate the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions are also correlated to the COVID-19 burden, time since the start of the pandemic, and relative severity of mobility restrictions. Findings: We estimate that decreases in essential health service utilization between March 2020 and June 2021 led to 113,873 additional deaths in the 18 countries, representing 3.8% and 1.4% increases in child and maternal mortality, respectively. This corresponds to an average of 2.6 indirect deaths per COVID-19 death officially reported in the same period. This excess mortality results from the decline in utilization of the RMNCH services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, resulting in 27.5% of the excess death, occurred during the second quarter of 2020, regardless of whether countries experienced the highest rate of COVID-19-related deaths during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. Interpretation: Large declines in health care utilization during the COVID-19 pandemic amplify the pandemic's harmful impacts on health outcomes. As efforts and resource allocation towards prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low and middle-income countries. Funding: The Global Financing Facility for Women, Children, and Adolescents. Declaration of Interests: We declare no competing interests.

Faced with COVID-19 (Coronavirus), countries are taking drastic action based on little information. Two tests can help governments shorten and soften economically costly suppression measures while still containing the novel coronavirus (COVID-19) pandemic. The first—a PCR assay—identifies people currently infected by testing for the presence of live virus in the subject. The second—an antibody test—identifies those rendered immune after being infected by searching for COVID-19-specific antibodies. The first test can help contain the disease because it facilitates the identification of infected persons, the tracing of their contacts, and isolation in the very early stages of an epidemic—or after a period of suppression, in case of a resurgent epidemic. The second can help us assess the extent of immunity in the general population or subgroups, to finetune social isolation and to manage health care resources. Wide application of the two tests could transform the battle against COVID-19 (Coronavirus), but implementing either on a large scale in developing countries presents challenges. The first test is generally available, but needs to be processed in adequately equipped laboratories with trained staff. The second test is easy to perform and can be processed quickly on the spot, but at this stage it is produced and available only on a limited basis in a few countries. This policy brief reviews the use of both tests, suggests strategies to target their use, and discusses the benefits and costs of such strategies. If PCR assay testing, together with tracing and isolation, helps reduce the duration of suppression measures by two weeks, and antibody testing allows one-fifth of the immune return to work early, the gain could be about 2 percent of national income, or about $8 billion for a country like the Philippines. Because the estimated economic benefits of the tests are likely to far outweigh the cost, the international community must help countries develop the capacity to process the first test and procure the second.

To evaluate the cost-effectiveness of results-based financing and input-based financing to increase use and quality of maternal and child health services in rural areas of Zambia.In a cluster-randomized trial from April 2012 to June 2014, 30 districts were allocated to three groups: results-based financing (increased funding tied to performance on pre-agreed indicators), input-based financing (increased funding not tied to performance) or control (no additional funding), serving populations of 1.33, 1.26 and 1.40 million people, respectively. We assessed incremental financial costs for programme implementation and verification, consumables and supervision. We evaluated coverage and quality effectiveness of maternal and child health services before and after the trial, using data from household and facility surveys, and converted these to quality-adjusted life years (QALYs) gained.Coverage and quality of care increased significantly more in results-based financing than control districts: difference in differences for coverage were 12.8% for institutional deliveries, 8.2% postnatal care, 19.5% injectable contraceptives, 3.0% intermittent preventive treatment in pregnancy and 6.1% to 29.4% vaccinations. In input-based financing districts, coverage increased significantly more versus the control for institutional deliveries (17.5%) and postnatal care (13.2%). Compared with control districts, 641 more lives were saved (lower-upper bounds: 580-700) in results-based financing districts and 362 lives (lower-upper bounds: 293-430) in input-based financing districts. The corresponding incremental cost-effectiveness ratios were 809 United States dollars (US$) and US$ 413 per QALY gained, respectively.Compared with the control, both results-based financing and input-based financing were cost-effective in Zambia.Évaluer le rapport coût-efficacité du financement axé sur les résultats et du financement axé sur les apports pour accroître l'utilisation et la qualité des services de santé maternelle et infantile dans les zones rurales de Zambie.Dans un essai randomisé par grappes mené d'avril 2012 à juin 2014, 30 districts ont été répartis en trois groupes: financement axé sur les résultats (hausse du financement liée aux performances vis-à-vis d'indicateurs préalablement définis), financement axé sur les apports (hausse du financement non liée aux performances) et groupe témoin (pas de financement supplémentaire), qui représentaient respectivement une population de 1,33, 1,26 et 1,40 millions de personnes. Nous avons estimé les coûts financiers supplémentaires de la mise en œuvre et de la vérification des programmes, des consommables et de la supervision. Nous avons évalué la couverture et la qualité des services de santé maternelle et infantile avant et après l'essai, à l'aide de données provenant d'enquêtes auprès des ménages et des établissements, et les avons converties en années de vie ajustées par la qualité (AVAQ) gagnées.La couverture et la qualité des soins ont nettement plus augmenté dans les districts recevant un financement axé sur les résultats que dans les districts témoins: la différence des différences en matière de couverture était de 12,8% pour les accouchements dans des structures médicales, de 8,2% pour les soins postnataux, de 19,5% pour les contraceptifs injectables, de 3,0% pour les traitements préventifs intermittents pendant la grossesse et de 6,1% à 29,4% pour les vaccinations. Dans les districts recevant un financement axé sur les apports, la couverture a nettement plus augmenté que dans les districts témoins pour ce qui est des accouchements dans des structures médicales (17,5%) et des soins postnataux (13,2%). Par rapport aux districts témoins, 641 vies supplémentaires ont été sauvées (bornes inférieure-supérieure: 580–700) dans les districts recevant un financement axé sur les résultats et 362 vies (bornes inférieure-supérieure: 293–430) dans les districts recevant un financement axé sur les apports. Les ratios coût-efficacité correspondants étaient respectivement de 809 dollars des États-Unis ($ US) et 413 $ US en plus par AVAQ gagnée.Comparés au groupe témoin, le financement axé sur les résultats et le financement axé sur les apports présentaient tous deux un rapport coût-efficacité positif en Zambie.Evaluar la relación entre el gasto y la efectividad de la financiación basada en los resultados y la financiación basada en insumos para aumentar el uso y la calidad de los servicios de salud materno-infantil en las zonas rurales de Zambia.En un ensayo aleatorio por conglomerados de abril de 2012 a junio de 2014, se asignaron 30 distritos a tres grupos: financiamiento basado en resultados (aumento de fondos ligados al desempeño en indicadores previamente acordados), financiamiento basado en insumos (aumento de fondos no vinculados a rendimiento) o control (sin financiación adicional), atendiendo poblaciones de 1,33, 1,26 y 1,40 millones de personas, respectivamente. Evaluamos los gastos financieros incrementales para la implementación y verificación del programa, los consumibles y la supervisión. Evaluamos la cobertura y la efectividad de la calidad de los servicios de salud materno-infantil antes y después del ensayo, utilizando datos de encuestas domiciliarias y de establecimientos, y los convertimos en años de vida ajustados por calidad (QALY) obtenidos.La cobertura y la calidad de la atención aumentaron más significativamente en el financiamiento basado en resultados que en los distritos de control: la diferencia de diferencias para la cobertura fue 12,8% para partos institucionales, 8,2% para el cuidado postnatal, 19,5% para anticonceptivos inyectables, 3,0% para el tratamiento preventivo intermitente en embarazo y de 6,1% a 29,4% para vacunas. En los distritos de financiación basados ​​en insumos, la cobertura aumentó más significativamente en comparación con el control para los partos institucionales (17,5%) y la atención posnatal (13,2%). En comparación con los distritos de control, se salvaron 641 vidas más (límites inferiores-superiores: 580-700) en distritos de financiamiento basado en resultados y 362 vidas (límites inferiores-superiores: 293-430) en distritos de financiamiento basados ​​en insumos. Las correspondientes ratios incrementales entre gasto y efectividad fueron de 809 dólares estadounidenses (USD) y de 413 USD por AVA, respectivamente.En comparación con el control, tanto el financiamiento basado en resultados como el basado en insumos fueron rentables en Zambia.تقييم فعالية تكلفة التمويل القائم على النتائج والتمويل القائم على المدخلات لزيادة استخدام خدمات الأمومة والطفولة الصحية وجودتها في المناطق القروية بزامبيا.في تجربة عنقودية معشاة استمرت من أبريل/نيسان 2012 إلى يونيو/حزيران 2014، قسم البنك الدولي 30 مقاطعة إلى ثلاث مجموعات: تمويل قائم على النتائج (حيث ترتبط زيادة التمويل بالأداء القائم على مؤشرات مُتفق عليها مُسبقًا)، أو تمويل قائم على المدخلات (حيث لا يوجد ارتباط بين زيادة التمويل والأداء) أو التحكم (لا يوجد تمويل إضافي)، وذلك لخدمة مجتمعات سكانية يبلغ تعدادها 1.33، و1.26 و1.40 مليون نسمة، على الترتيب. حيث قمنا بتقدير التكاليف المالية الإضافية اللازمة لتطبيق البرنامج والتحقق من المواد الاستهلاكية والإشراف. وقمنا بتقييم تغطية خدمات الأمومة والطفولة الصحية وفعالية جودتها قبل التجربة وبعدها، باستخدام البيانات المستخرجة من الاستقصاءات المنزلية والخدمية، وتحويل هذه البيانات إلى عدد سنوات عمر معدلة بحسب جودة الحياة (QALYs) المكتسبة.تصاعدت التغطية والجودة بشكل مميز أكثر في التمويل القائم على النتائج عن مقاطعات التحكم: فرق الاختلافات للتغطية كان 12.8% للولادة بالمؤسسات، 8.2% للرعاية بعد الولادة، و19.5% لوسائل منع الحمل التي تؤخذ بالحقن، و3.0% العلاج الوقائي الدوري أثناء الحمل و6.1% إلى 29.4% للتحصينات. في مقاطعات التمويل القائم على المدخلات، تصاعدت التغطية بشكل مميز أكثر مقابل التحكم بالنسبة للولادة بالمؤسسات (17.5%) والرعاية بعد الولادة (13.2%). مقارنةً بمقاطعات التحكم، حيث تم إنقاذ 641 شخصاً إضافياً (الحدود الدنيا-العليا: 580-700) في مقاطعات التمويل القائم على النتائج و362 شخصاً (الحدود الدنيا-العليا: 293-430) في مقاطعات التمويل القائم على المدخلات. وكانت معدلات فعالية التكلفة الإضافية 809 دولار أمريكي (US$) و413 دولار أمريكي لكل عدد سنوات عمر معدلة بحسب جودة الحياة المكتسبة على الترتيب.مقارنةً بالتحكم، كانت نتائج كلاً من التمويل القائم على النتائج والتمويل القائم على المدخلات أكثر فعالية من حيث التكلفة في زامبيا.旨在评估基于结果融资和基于投入融资的成本效益，以提高赞比亚农村地区妇幼保健服务的使用率和质量。.在 2012 年 4 月至 2014 年 6 月的一项集群随机化试验中，30 个地区被划分为三组：基于结果融资（增加资金与拟议指标的绩效挂钩）、基于投入融资（增加资金未与绩效捆绑）或对照组（无额外资金），服务人群分别为 133 万、126 万和 140 万。我们评估了项目实施和验证、消耗品和监督的增量财务成本。我们使用来自家庭和机构的调查数据，评估了试验前后的母婴健康服务的覆盖率和质量有效性，并将这些数据转换为获得的质量调整寿命年 (QALYs)。.基于结果融资的覆盖率和护理质量明显高于对照组：住院分娩覆盖率的双重差分分析为 12.8％，产后护理为 8.2％，注射避孕药为 19.5％，妊娠间歇性预防性治疗为 3.0％，接种疫苗为 6.1％ 至 29.4％。与对照组相比，在基于投入融资的地区，住院分娩 (17.5％) 和产后护理 (13.2％) 的覆盖率显著增加。与对照组相比，基于结果融资的地区挽救了 641 条生命（下限-上限：580-700），基于投入融资的地区挽救了 362 条生命（下限-上限：293-430）。相应的增量成本效益比率分别为每质量调整寿命年增加 809 美元 (US$) 和 413 美元 (US$)。.与对照组相比，基于结果融资和基于投入融资在赞比亚均具有成本效益。.Оценка рентабельности финансирования на основе результатов и затратного финансирования для улучшения использования и повышения качества медицинского обслуживания матерей и детей в сельской местности Замбии.В кластерном рандомизированном исследовании, проводившемся с апреля 2012 г. по июнь 2014 г., 30 районов были поделены на три группы: финансирование по результатам (увеличение финансирования по результатам деятельности согласно предварительно согласованным показателям), затратное финансирование (увеличение финансирования, не зависящее от результатов деятельности) и контрольная группа (отсутствие дополнительного финансирования). Эти группы подразумевали обслуживание 1,33; 1,26 и 1,40 млн человек соответственно. Была проведена оценка дополнительных финансовых расходов, связанных с реализацией и контролем выполнения программы, расходными материалами и надзором. Авторы проанализировали охват населения, а также качество и эффективность медицинского обслуживания матерей и детей до и после проведения исследования, используя данные, полученные в ходе опросов семейств и медицинских учреждений, и получили показатель продолжительности жизни, скорректированный по качеству (QALY).Охват населения и качество медицинского обслуживания значительно возросли в группе финансирования по результатам в сравнении с районами контрольной группы: разница различий в охвате населения составила 12,8% для родов в медицинских учреждениях, 8,2% для послеродового ухода, 19,5% для инъекционных контрацептивов, 3,0% для периодического профилактического лечения во время беременности и от 6,1 до 29,4% для вакцинаций. В районах группы затратного финансирования охват населения медицинским обслуживанием значительно увеличился в сравнении с контрольной группой для родов в медицинских учреждениях (17,5%) и послеродового ухода (13,2%). В сравнении с районами контрольной группы в районах группы финансирования по результатам было спасено на 641 жизнь больше (нижняя-верхняя границы: 580–700), а в районах группы затратного финансирования — на 362 жизни больше (нижняя-верхняя границы: 293–430). Соответствующие коэффициенты прироста рентабельности составили соответственно 809 и 413 долларов США для полученных показателей продолжительности жизни, скорректированных по качеству (QALY).Группы финансирования по результатам и группы затратного финансирования оказались более рентабельными в сравнении с контрольной группой в Замбии.

Could a partial subsidy for child education increase children's participation in paid work? In contrast to much of the theoretical and empirical child labor literature, this paper shows that child work and school participation can be complements under certain conditions. Using data from the randomized evaluation of a conditional cash transfer program in the Philippines, the analysis finds that some children, who were in neither school nor work before the program, increased participation in school and work-for-pay after the program. Earlier cash transfer programs, notably those in Mexico, Brazil, and Ecuador, increased school attendance while reducing child labor. Those programs fully offset schooling costs, while the transfers under the Philippine transfers fall short of the full costs of schooling for a typical child. As a result, some beneficiary children from poor Philippine households increased work to support their schooling. The additional earnings from this work represent a substantive share of the shortfall in the schooling costs net of transfer. The paper rules out several potential alternative explanations for the increase in child labor, including changes in household productive activities, adult labor supply, and household expenditure patterns that, in principle, can arise after a cash transfer and may also affect the supply of or demand for child labor.

Using data from an experimental supportive intervention to India's malaria control program, this paper studies the impact of leveraging local non-state capacity to promote mosquito net usage and recommended fever care-seeking patterns. The supportive activities were conducted simultaneously by three nongovernmental organizations in two endemic districts in the state of Orissa. The study finds that program impact varied significantly by location. Examining three potential sources of this variation (differential population characteristics, differential health worker characteristics, and differential implementer characteristics), the analysis provides evidence that both population and nongovernmental organization characteristics significantly affected the success of the program. The paper discusses these findings as they relate to the external validity of development policy evaluations and, specifically, for the ability of the health system to benefit from limited non-state capacity in under-resourced areas.

We study the relationship between physical activity as a direct measure of effort and productivity. First, we evaluate the association of agricultural workers’ physical activity with their daily productivity, which is directly observed from company personnel piece-rate payment records, and find a positive correlation. Second, we estimate the impact of a health intervention that provides malaria testing and treatment on physical activity and productivity. The results indicate that the increased daily productivity of malaria positive workers who are offered this program is explained by worker effort reallocation from lower intensity to higher intensity work. This demonstrates that, when individual productivity is observed, physical activity measures can help disentangle productivity effects that are attributable to effort. When productivity is unobserved, physical activity measures may proxy for productivity in physically demanding tasks. We discuss challenges and limitations of physical activity measurement, their potential use for alternative contexts, and the importance of field and data analysis protocols.

Background: The COVID-19 pandemic and its secondary effects pose a major global threat to the continuity of essential health services. Disruptions in essential services can lead to increases in morbidity and mortality and a protracted public health crisis. We quantify the disruption of the COVID-19 crisis on essential health services, focusing on maternal and child health, in eight sub-Saharan countries. Methods: Service volumes are extracted from administrative systems for the months between January 2018 and July 2020 in eight sub-Saharan countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone, and Somalia. We examine monthly data for 59,546 facilities covering eight selected services. We employ a regression model using data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for secular trends, seasonality, and facility characteristics. Estimates of disruption are derived by comparing these predictions to the observed service utilization level during the pandemic period. Findings: All countries experienced service disruptions for at least one month, but the magnitude, and duration of the disruptions vary. Although decreases in service volume were most common in April and May, there were still significant disruptions as of July. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5,445,068 OPD consultations and 277,018 third doses of pentavalent vaccine during the five months in these eight countries. Decreases in maternal health service utilization are less generalized. Significant declines in institutional deliveries, antenatal care, and postnatal care were detected in four, six, and five countries, respectively. Of the eight countries, the strongest and most persistent disruptions were detected in Liberia, Mali, Nigeria, and Sierra Leone. More limited disruptions were found in Cameroon, the Democratic Republic of Congo, Malawi, and Somalia. Interpretation: Results show that the COVID-19 pandemic caused substantial interruptions in the delivery of essential health services, albeit with significant cross-country variation. While this analysis cannot speak to the causes behind the declines in service utilization, they may be driven by changes in care-seeking behavior due to fear of infection, reallocation of resources, lockdown policies, and income shocks. The design of interventions to mitigate these disruptions requires detailed local knowledge and additional data on the behaviors of health providers and households during the pandemic. Timely monitoring of service volumes through administrative data should be an integral component of a responsive pandemic strategy. Funding Statement: The Global Financing Facility for Women, Children, and Adolescents. Declaration of Interests: No conflicts of interest.

Despite increased investments in procurement of essential medicines, their availability at health facilities remains extremely low in many low- and middle-income countries. The lack of a well-functioning supply chain for essential medicines is often the cause of this poor availability. Using a randomized trial conducted in 439 health facilities and 24 districts in Zambia, this study helps understand the optimal supply chain structure for essential medicines distribution in the public sector in low-income countries. It shows that a more direct distribution system where clinics order and receive medicines supply directly from the central agency through a cross-docking arrangement significantly reduces the duration and frequency of stockouts compared to a traditional three-level drug distribution system. As an example, the frequency of stockouts for first line pediatric malaria medicines reduced from 47.9% to 13.3% and the number of days of stockout in a quarter reduced from 27 days to 5 days. The direct flow of demand and order information from health facilities to the central supply agency reduces the problem of diffuse accountability that exists in multi-tiered distribution systems. It also shifts the locus of decision making for complex supply chain functions such as scarce stock allocation and adjustment of health facility order quantities to levels in the system where staff competency is aligned with what the function needs. Even when supply chain system redesign such as the one evaluated in this paper are demonstrated to be technically robust using rigorous evidence, they often require navigating a complex political economy within the overall health system and its actors.

Independent verification is a critical component of performance-based financing (PBF) in health care, in which facilities are offered incentives to increase the volume of specific services but the same incentives may lead them to over-report. We examine alternative strategies for targeted sampling of health clinics for independent verification. Specifically, we empirically compare several methods of random sampling and predictive modeling on data from a Zambian PBF pilot that contains reported and verified performance for quantity indicators of 140 clinics. Our results indicate that machine learning methods, particularly Random Forest, outperform other approaches and can increase the cost-effectiveness of verification activities.

Based on a randomized evaluation, the paper shows that a household-targeted Philippine cash transfer program significantly raised the local price of key foods relevant for child nutritional status. This shift in prices increased stunting among young nonbeneficiary children by 34 percent (11 percentage points). Price and stunting effects increase in program saturation; at median saturation, the village income shock is 15 percent. These effects persist 2.5 years after program introduction. The authors confirm the price patterns in their experimental sample against price information from nationally-representative household expenditure surveys across the 6-year rollout of the program. Failing to consider such general equilibrium effects may overstate the net benefits of targeted cash transfers. In areas where targeting of social programs covers a large proportion of the population, offering the program on a universal basis may avoid such long-lasting negative impacts at moderate additional cost.

This study examines variations in intergenerational support by family size, family composition, and location of children in Vietnam. Results from two regional surveys confirm the central role of children in assisting elderly parents but relationships with family size depend on the type of support considered. Co-residence with married children varies little with family size but incidence of material support, and the numbers providing it, increases with the number of children. Non-co-resident sons and daughters differ minimally in providing material and social support. In the north, co-residence with married children is limited largely to sons while in the south more flexibility is evident. While having a son increases the chance of co-residence, having more than one son has no additional effect. Although future elderly will have smaller family sizes this is unlikely to have a major adverse impact on their well-being except possibly for northern elders without sons.

Background Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers’ job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before–after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. Methods Mixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. Results Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity. Conclusions In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction. Electronic supplementary material The online version of this article (doi:10.1186/s12960-017-0179-2) contains supplementary material, which is available to authorized users.

There is wide variation in how consumption is measured in household surveys both across countries and over time. This variation may confound welfare comparisons in part because these alternative survey designs produce consumption estimates that are differentially influenced by contrasting types of survey response error. Although previous studies have documented the extent of net error in alternative survey designs, little is known about the relative influence of the different response errors that underpin a survey estimate. This study leverages a recent randomized food consumption survey experiment in Tanzania to shed light on the relative influence of these various error types. The observed deviation of measured household consumption from a benchmark is decomposed into item-specific consumption incidence and consumption value so as to investigate effects related to (a) the omission of any consumption and then (b) the error in value reporting conditional on positive consumption. The results show that various survey designs exhibit widely differing error decompositions, and hence a simple summary comparison of the total recorded consumption across surveys will obscure specific error patterns and inhibit the lessons for improved consumption survey design. In light of these findings, the relative performance of common survey designs is discussed, and design lessons are drawn to enhance the accuracy of item-specific consumption reporting and, consequently, the measures of total household food consumption. ispartof: Food Policy vol:72 pages:94-111 status: published

Partnerships between government and non-state actors that aim to enhance the quality or efficiency of service delivery are increasingly common in today's development policy landscape. We investigate the impacts of such an approach using data from an experimental supportive intervention to India's malaria control program that leveraged local non-state capacity in order to promote mosquito net usage and recommended fever care-seeking patterns. The supportive activities were conducted simultaneously by 3 NGOs, contracted out by the Indian government, in 2 endemic districts in the state of Odisha. We find that program impact significantly varied by location. Examining 3 potential sources of this variation (differential population characteristics, differential health worker characteristics, and differential implementer characteristics), we provide evidence that both population and NGO characteristics significantly affected the success of the program. Specifically, the results suggest that the quality and effort of the local implementer played a key role in the differential effectiveness. We discuss these findings as they relate to the external validity of development policy evaluations and, specifically, for the ability of health and other service delivery systems to benefit from limited non-state capacity in underresourced areas.

BACKGROUND Pantawid, a conditional cash transfer (CCT) program in the Philippines, provided grants conditioned on health-related behaviors for children aged 0-5 y and schooling for those aged 10-14 y. OBJECTIVE We investigated whether Pantawid improved anthropometric measurements in children aged 6-36 mo. METHODS We estimated cross-sectional intention-to-treat effects using a 2011 cluster-randomized trial across 130 villages-65 treated and 65 control-with data collected after 31 mo of implementation. Anthropometry characteristics were measured for 241 children in treated areas and 244 children in control areas. Health service use for children aged 6-36 mo and dietary intake for those aged 6-60 mo also were measured. Outcome variables were height-for-age z scores (HAZs) and weight-for-age z scores (WAZs), stunting, severe stunting, underweight, and severely underweight. Impact also was assessed on perinatal care, institutional delivery, presence of skilled birth attendant, breastfeeding practices, immunization, growth monitoring and deworming, care-seeking, and children's intake of protein-rich foods. RESULTS Pantawid was associated with a significant reduction in severe stunting [