Employee absence as an indicator of patronage

I attended an interesting presentation recently by Michael Callen (UCSD) on the political economy of public employee absence in Pakistan (PDF).  In an observational study of doctors at public clinics in Pakistan’s Punjab region, he and his co-authors found that doctors who personally knew their MPs were almost twice as likely to be absent as those who did not.  Furthermore, doctors in districts which were less politically competitive, and where their sponsoring MPs would thus face less risk of public backlash over poor service provision, were more more likely to be absent than those in competitive districts.  The idea here is that MPs face two conflicting incentives: it’s cheaper to them to provide patronage goods (like jobs in the public health service) to individuals in exchange for votes, but if they face political competition, they instead have an incentive to try to provide higher quality goods to more voters.

Links of the day

  1. Stability, the International Journal of Security and Development, is a new open-access journal which aims to quickly get relevant academic research to policymakers.
  2. Tom Murphy points out that cancer kills many more people in the developing world each year than does HIV, and Think Africa Press writes that the severe lack of opiates in Africa makes palliative care for cancer victims quite difficult.
  3. Must African presidential aspirants go to prison before they take higher office? (In French)
  4. Videos of cash transfer recipients in Kenya and Mozambique telling their stories in their own words.
  5. A new RCT questions the external validity of RCT-proven results (a political economy story about implementing organizations), and a study from Brazil finds that rainfall fluctuations during pregnancy are associated with changes in infant health outcomes, calling the use of rainfall as an instrument for just about everything into question.

Book review: More Than Good Intentions

Only eight months after I finished the book, I thought I’d finally review More Than Good Intentions, by Dean Karlan* and Jacob Appel.  What I particularly appreciated about the book was its clear explanation of how academic research in behavioral economics can lead to solutions for real problems of social policy in the developing world.  Given the level of popular discontent with neoclassical economics, fairly or unfairly, after the financial crisis, works like this go a long way towards demonstrating that the economist’s conceptual toolbox can contribute to making the world a better place.

More Than Good Intentions opens with a short review of the Easterly-vs.-Sachs saga, and essentially sidesteps the debate about whether aid ever works with a call for more evaluation of extant aid programs.  Their chosen tool is the randomized controlled trial.  Of course, there are any number of development problems that are not amenable to randomized evaluation.  Questions about the ethnicized distribution of government resources or the transnational funding networks of rebel groups really call out for other epistemological approaches.  What RCTs can do well is evaluate program-based aid in contexts where funding shortages mean that some potential beneficiaries can’t be included, and this is precisely the approach taken by the research projects summarized in the book.

The rest of the book is thematically structured around financial activities (borrowing, saving, consumption) and non-financial activities (agriculture, healthcare, education).  The financial sections of the book are the best non-technical introduction to the topic that I’ve seen. Dean’s interests tend towards microfinance and decision-making, and these chapters give a thorough overview of contemporary Western narratives around microfinance and the many reasons why the financial needs of the poor are more varied than simply “getting a loan.”  For instance, whilst an RCT conducted in South Africa showed that randomly extending microfinance loans to people who otherwise wouldn’t have gotten one did raise those clients’ incomes, qualitative data from the Philippines also showed that the rigid structure of microfinance products drives many people back to the neighborhood moneylender.  (The takeaway here isn’t that moneylenders are evil, but that microfinance banks might take a lesson in customizable loan repayments from them.)  Another RCT in Peru used list randomization [PDF] to show that nearly a third of microfinance clients use their loans for household consumption instead of business needs – technically a violation of their loan agreements, but a more accurate reflection of their current financial needs.

The non-financial chapters are also consistently interesting, although they tend towards summarizing notable research and policy innovations rather than placing the results within a global context.  They’re like the greatest hits of development research.  For instance, the agriculture chapter doesn’t provide an overview of agricultural modernization attempts in Africa, but it does shed light on why Kenyan farmers don’t purchase fertilizer when they need it (it’s hard for them to save money after the harvest), and how Ghanaian pineapple farmers spread information about new agricultural technologies.  Similarly, the education chapter doesn’t go into great depth about the history of universal primary education, but it does demonstrate that programs as simple as providing uniforms or cash grants to poor students can dramatically improve attendance.  One of the most remarkable studies of recent years showed that treating Kenyan students for intestinal worms with a twenty-cent pill reduced absence rates by up to 25%.  This result was so spectacular that the researchers started an NGO, Deworm the World, dedicated to reproducing this success.

All in all, More Than Good Intentions makes a strong case for the relevance of behavioral economics to development policy.  It’s also an excellent popular introduction to some of the fundamental questions of foreign aid and development economics.  I gave a copy to my parents to answer their perennial question of “so what exactly do you do in development work again?”  So far it seems to be working.

*Dean is the founder of Innovations for Poverty Action, where I work.  He generously sent me a copy of the book for free.

Travel Advice for the Developing World: Health

Last but not least in the travel advice series: staying healthy.

Don’t bring:

  • An obsessive fear of illness.  Disease-related morbidity is certainly higher in the developing world than in the developed, but, to put it bluntly, if you have the money to travel at all then you have the money to stay healthy.  It’s an object lesson in public health.

Do bring:

  • Sunblock (which you should be wearing every day anyway!).  I like Lubriderm’s SPF 15 moisturizer, which is unscented and non-greasy.
  • Hand sanitizer.  Useful when soap and running water aren’t available.
  • DEET-free bug spray.  DEET is effective, but it’s inconvenient to wash it off before bed every night, and isn’t recommended for use with small children.  I’ve been happy with Repel’s lemon eucalyptus insect spray.
  • Anti-malarial medication.  Malarone and doxycycline are commonly available in the US.  Mefloquine is no longer available by its brand name, Lariam, but is still sold as a generic.  All of them have a non-negligible prevalence of side effects (with mefloquine being known for being hallucinogenic, doxy for causing sun sensitivity, and Malarone for milder effects), so discuss the choice with your doctor.  It is sometimes possible to purchase brand-name anti-malarials like Malarone in developing countries, but it’s not always available and is sometimes counterfeit, so it’s preferable to get them before departure.
  • Extra dosages of prescription medications, and copies of prescriptions.
  • Anti-nausea and anti-diarrhea medication.  If your body truly wants to get rid of something it’s eaten, I usually think it’s wiser to let it do so, but if this conflicts with a 14-hour bus ride then Pepto-Bismol can be a godsend.  (If you’re worried about dehydration, it’s simple enough to make your own ORS from sugar & salt.)

Do get:

  • The rabies vaccine.  Rabies isn’t a huge problem in most places, but it does exist almost everywhere, and is nearly 100% fatal if you contract it and are unable to get treatment.  Getting the prophylactic vaccine before departure will buy you several extra days to get help if you’re bitten by an animal.
  • Deworming pills at a local pharmacy.  Only worthwhile if you think you’ve been exposed to water or food in places where open defecation is common.  Most local pharmacies will have them.

Eight books on development for the interested generalist

A friend recently asked me for a list of interesting books on development, and I thought I’d share the results here.  I read almost randomly in the field when I was still trying to narrow my initial broad interest in development down into something of which a career could be made, and the books below generally struck me as the most interesting, accessible, and generally well-supported introductions to their respective subject areas that I came across.  (I haven’t read some of these in years, but in retrospect I think they’d all stand up decently to a reader with greater existing knowledge of development.)  In roughly descending order of intellectual impact upon me:

  1. Development as Freedom, by Amartya Sen, is one of the best books I’ve read on the general concept of “development.”  It addresses a number of common critiques, and creates a strong philosophical framework to support the argument that “development” is still necessary.
  2. Portfolios of the Poor is my favorite book of 2009 – an incredibly thoroughly-researched look into what poor people do with their money and how microfinance plays into this.  I don’t remember learning more from a single book, well, probably ever.
  3. Understanding Poverty is a great introduction to a huge range of issues in development, from food security to education to microfinance.  It’s written by a group of leading development economists, often from a behavioral perspective, and the thought contained here is both wide-ranging and rigorous.
  4. This is a bit quirky compared to the other recommendations, but I very much liked Expectations of Modernity, an ethnography of Zambian copper miners in the ’70s and ’80s.  The description probably sounds boring, but it’s actually a great critique of the idea that people from the developing world who act in “Western” styles are blindly mimicking the West, instead of consciously bringing elements of Western culture into their lives in ways that reflect their own social & economic interests.  It basically lays out a strong case for relativistic understandings of culture, which I find hugely important for any development worker, without framing it with that potentially off-putting phrase.
  5. The Bottom Billion has held up better in retrospect than its two better-known contemporaries, The End of Poverty and The White Man’s Burden, at least in my recollection.  In a foreshadowing of my current interests, I liked its focus on research methodology in macroeconomics (i.e. where all that data underlying cross-country regressions comes from), and its quantitative look at the connections between war, governance and poverty.  (Edit: David Roodman points out his own and Easterly‘s critiques of Collier for data mining in Wars, Guns and Votes, and believes that they’re applicable to The Bottom Billion as well.  I’d suggest enjoying the intellectual curiosity of Collier’s research, but taking his statistical results with a grain of salt.)
  6. I can’t offer too much on the subject of public health, but I did greatly enjoy The Wisdom of Whores, which is an engaging book about health systems responses to HIV from the ’80s onwards, told by an irreverent epidemiologist with whom I would very much like to have a drink one day.  It’s also a great critical look at where public health data comes from, how it’s used, and to some degree why governments and international organizations choose the health priorities that they do.
  7. Making Globalization Work is something I recalled as insightful on the topics of global financial institutions, markets and trade at the time I read it.
  8. I’ve been trying to find a good overview of the World Bank that I read for a geography class a few years ago, and while I’m not sure that I’ve identified it, The World Bank: From Reconstruction to Development to Equity looks like it covers similar subject matter. I found tracing the Bank’s historical evolution quite interesting, as it also captures the variety of Western thought on “development” that’s occurred over the past 50 years, and explains quite a lot as well about current bilateral and multilateral aid regimes.

Tell me, dear readers, what else would you recommend for the interested lay reader?

Intra-household resource allocation

I’ve been reading a great deal recently about the linkages between food availability, intra-household resource allocation, and nutritional status, and it’s made me wonder about time-specific determinants of resource allocation.  That is, it’s clear that there are some systematic, long-term differences in allocation connected to overall education levels, overall income, and gender.  What I’m curious about are short-term, potentially more idiosyncratic effects: for instance, are women more or less likely to command adequate nutrition if they fall ill?  Are there differences between the amount of food received at home by, say, a young child in school (potentially also benefiting from a school lunch program) and an older child who drops out to care for younger ones or help in the fields? How much would one discount future education (for the young child) versus immediate ability to do work in that case, and how might one be able to change that calculus if it weren’t a long-term beneficial one?

The obvious connection to pro-poor financial services lies in the oft-noted social “shock” of women suddenly receiving access to credit when they previously had none, which disrupts existing allocation schemes and may result in tension or violence between women and their relatively disempowered husbands.  I can think of a few specific predictors of violence or generally negative reactions in this case – a history of prior violence being the most obvious one, or a husband’s unemployment, or a cultural injunction against women handling money – but I wonder if there are other traits that could be used to predict whether men might react poorly to women’s credit, and perhaps develop plans to defuse this scenario.  I’ll have to think some more about this.  The intersection between culture and credit is a fraught and fascinating one.

Healthcare access & equity

When I was researching microinsurance and maternal mortality last year, I was struck by some of the observations that other researchers felt it necessary to include in their results.  One of them was the finding that distance to a health center affects people’s access to care.  In other news, water quenches thirst!  I had to wonder if this was a relic of the general lack of forethought that must be put into procuring transport in the global North, where it’s more or less equally simple to reach a doctor one kilometer from one’s home as thirty kilometers.  I otherwise fail to see how it’s notable that people who live farther from a clinic may use it less often.

This does highlight the fact that there are fundamental issues of healthcare access that aren’t purely microeconomic in nature.  Distance is one, but the challenge of retaining skilled doctors in a low-wage environment is a second, and difficulties in obtaining and maintaining quality equipment and medication stocks (non-counterfeit medications!) are a third.  The attitudes of healthcare workers also appeared extremely important to low-income patients, who seemed understandably sensitive about their social status, and hesitant to use centers where they would be treated disrespectfully because of their poverty.

The other thing I’ve been thinking of, however, was a little-discussed (at least in the papers that I read) corollary to the observations that microinsurance increases healthcare access, and health centers are favorably inclined towards patients who can actually pay for their care. My immediate concern upon reading these statements was, if access to microinsurance is still uneven, isn’t there a real possibility that patients who are even slightly better off will crowd out those who are too poor to afford $2-a-year insurance at all? If the resource base of health centers is fixed (and it may not be – I don’t have info on that), dramatic increases in patients covered by microinsurance could very well make the poorest of the poor even more vulnerable. I wonder how you’d best be able to test that.  I imagine you’d have to look at the effects of a growing resource base (if the increased payments are used at the local level) or the improved quality of care referenced in the last post, and sort out what effects those have on the healthcare uptake rates of the poorest.  Perhaps the question actually is, does extending microinsurance to some harm the uninsured by crowding them out, or does it improve their situation by letting them get a bit of a free ride on some improvements brought about by the insurance payments?  Interesting.