Climate change is increasing the intensity of extreme weather events. Health is a primary channel through which climate change affects welfare. Yet, estimates of the mitigating effects of health system strengthening are largely missing. We combine data from a randomized trial inducing variation in healthcare access with naturally-occurring variation in growing-season precipitation to study the adaptive impact of community healthcare in a low-income country setting. The risk of infant death increases following low growing-season rainfall, but access to community healthcare reduces this risk by 46 %. Using our estimates coupled with projections from climatological models implies even larger potential adaptive effects.

Sub-Saharan Africa has fewer medical workers per capita than any region of the world, and that shortage has been highlighted consistently as a critical constraint to improving health outcomes in the region. This paper draws on newly available, systematic, comparable data from 10 countries in the region to explore the dimensions of this shortage. We find wide variation in human resources performance metrics, both within and across countries. Many facilities are barely staffed, and effective staffing levels fall further when adjusted for health worker absences. However, caseloads—while also varying widely within and across countries—are also low in many settings, suggesting that even within countries, deployment rather than shortages, together with barriers to demand, may be the principal challenges. Beyond raw numbers, we observe significant proportions of health workers with very low levels of clinical knowledge on standard maternal and child health conditions. This study highlights that countries may need to invest broadly in health workforce deployment, improvements in capacity and performance of the health workforce, and on addressing demand constraints, rather than focusing narrowly on increases in staffing numbers.

Identifying individuals most at risk of HIV infection is a priority for policymakers. Apart from specific groups, however, little is known about how to identify those at high risk in the population. Research suggests that attitudes toward risk and time preferences may influence risky sexual behavior, but no studies have so far investigated the interplay between risk attitudes, time preference, and HIV infection. We collect data on risk and time preferences using hypothetical games (multiple price list method) at baseline and data on HIV status at baseline (2010) and endline (2012) allowing us to calculate incidence rate over a 2-year period among 675 participants, males and females 18–32 years old in Lesotho. We find robust evidence of a statistically significant positive associations between HIV incidence and prevalence and risk-loving attitudes, while the associations with risky behaviors and time preferences are not statistically significant. A measure of attitude toward risk, relatively easy to administer to individuals in a survey, is thus associated with future HIV status. This is an important finding for policymakers and suggests the importance of targeting HIV prevention programs to risk-loving individuals and therefore improving program efficiency. 

Smallholder farming in many developing countries is characterized by low productivity and low-quality output. Low quality limits the price farmers can command and their potential income. We conduct a series of experiments among maize farmers in Uganda to shed light on the barriers to quality upgrading and to study its potential. We find that the causal return to quality is zero. Providing access to a market where quality is paid a market premium led to an increase in farm productivity and income from farming. Our findings reveal the importance of demand-side constraints in limiting rural income and productivity growth.

This chapter describes the research by Abhijit Banerjee, Esther Duflo, and Michael Kremer, who pioneered the experimental approach to understanding poverty alleviation, for which they were awarded the 2019 Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel. Economic well-being doubled in the poorest countries between 1995 and 2018. Child mortality has been cut in half relative to 1995, and the proportion of children attending school has gone up from 56 to 80 percent. Any post-intervention differences in the outcome of interest can thus be solely attributed to the treatment. Studies using field experiments are therefore characterized by high internal validity. A key issue is whether experimental results can be generalized to other contexts, whether or not they are externally valid. In the mid-1990s, Michael Kremer and colleagues conducted the first field experiments within development economics in rural Western Kenya.

How can quality be improved in markets in developing countries, which are known to be plagued bysubstandard and counterfeit (“fake”, in short) products? We study the market for antimalarial drugsin Uganda, where we randomly assign entry of a retailer (non-governmental organization (NGO))providing a superior product—an authentic drug priced below the market—and investigate howincumbent firms and consumers respond. We find that the presence of the NGO had economicallyimportant effects. Approximately one year after the new market actor entered, the share of incumbentfirms selling fake drugs dropped by more than 50% in the intervention villages, with higher qualitydrugs sold at significantly lower prices. Household survey evidence further shows that the qualityimprovements were accompanied by consumers expecting fewer fake drugs sold by drug stores. Theintervention increased use of the antimalarial drugs overall. The results are consistent with a simplemodel where the presence of a seller committed to high quality, as opposed to an average firm,strengthens reputational incentives for competing firms to improve quality in order to not be forcedout of the market, leading to “good driving out bad”.

Survey data collected across ten low-income and middle-income countries (LMICs) in Asia, Africa and South America compared with surveys from Russia and the United States reveal heterogeneity in vaccine confidence in LMICs, with healthcare providers being trusted sources of information, as well as greater levels of vaccine acceptance in these countries than in Russia and the United States. Widespread acceptance of COVID-19 vaccines is crucial for achieving sufficient immunization coverage to end the global pandemic, yet few studies have investigated COVID-19 vaccination attitudes in lower-income countries, where large-scale vaccination is just beginning. We analyze COVID-19 vaccine acceptance across 15 survey samples covering 10 low- and middle-income countries (LMICs) in Asia, Africa and South America, Russia (an upper-middle-income country) and the United States, including a total of 44,260 individuals. We find considerably higher willingness to take a COVID-19 vaccine in our LMIC samples (mean 80.3%; median 78%; range 30.1 percentage points) compared with the United States (mean 64.6%) and Russia (mean 30.4%). Vaccine acceptance in LMICs is primarily explained by an interest in personal protection against COVID-19, while concern about side effects is the most common reason for hesitancy. Health workers are the most trusted sources of guidance about COVID-19 vaccines. Evidence from this sample of LMICs suggests that prioritizing vaccine distribution to the Global South should yield high returns in advancing global immunization coverage. Vaccination campaigns should focus on translating the high levels of stated acceptance into actual uptake. Messages highlighting vaccine efficacy and safety, delivered by healthcare workers, could be effective for addressing any remaining hesitancy in the analyzed LMICs.

Objective Assess the quality of healthcare across African countries based on health providers’ clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage.

Methods With nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider  knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme.

Results Across all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers’ absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively.

Conclusion Our findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most  prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers’ absenteeism would only modestly increase the average care readiness that meets minimum quality standards. 

The delivery of basic health products and services remains abysmal in many parts of the world where child mortality is high. This paper shows the results from a large-scale randomized evaluation of a novel approach to health care delivery In randomly selected villages, a sales agent was locally recruited and incentivized to conduct home visits, educate households on essential health behaviors, provide medical advice and referrals, and sell preventive and curative health products. Results after 3 years show substantial health impact: under 5-years child mortality was reduced by 27 percent at an estimated average cost of $68 per life-year saved.