The fiscal cost of weak governance: Evidence from teacher absence in India.

The relative return to strategies that augment inputs versus those that reduce inefficiencies remains a key open question for education policy in low-income countries. Using a new nationally-representative panel dataset of schools across 1297 villages in India, we show that the large public investments in education over the past decade have led to substantial improvements in input-based measures of school quality, but only a modest reduction in inefficiency as measured by teacher absence. In our data, 23.6% of teachers were absent during unannounced school visits, and we estimate that the salary cost of unauthorized teacher absence is $1.5 billion/year. We find two robust correlations in the nationally-representative panel data that corroborate findings from smaller-scale experiments. First, reductions in student-teacher ratios are correlated with increased teacher absence. Second, increases in the frequency of school monitoring are strongly correlated with lower teacher absence. Using these results, we show that reducing inefficiencies by increasing the frequency of monitoring could be over ten times more cost effective at increasing the effective student-teacher ratio than hiring more teachers. Thus, policies that decrease the inefficiency of public education spending are likely to yield substantially higher marginal returns than those that augment inputs.

Quality and Accountability in Health Care Delivery: Audit-Study Evidence from Primary Care in India.

We present unique audit-study evidence on health care quality in rural India, and find that most private providers lacked medical qualifications, but completed more checklist items than public providers and recommended correct treatments equally often. Among doctors with public and private practices, all quality metrics were higher in their private clinics. Market prices are positively correlated with checklist completion and correct treatment, but also with unnecessary treatments. However, public sector salaries are uncorrelated with quality. A simple model helps interpret our findings: Where public-sector effort is low, the benefits of higher diagnostic effort among private providers may outweigh costs of potential overtreatment.

Measuring Early Childhood Development Among 4-6 Year Olds: The Identification of Psychometrically Robust Items Across Diverse Contexts.

The last 15 years have seen an explosion of measurement tools for assessing the development of young children in low- and middle- income countries. This paper builds on and contributes to that literature by identifying a core set of caregiver-report items and a core set of direct assessment items that measure key developmental domains for children aged 4-6 (48-83 months) and that demonstrate adequate psychometric properties across diverse contexts, the first in this age group to the authors' knowledge. Data were harmonized from previous early childhood measurement efforts in 12 countries that all used the same base measurement tool. Data analyses yielded 20 caregiver report items and 84 child direct assessment items (grouped into 16 tasks) that show strong item-level statistics across countries and that cover the domains of early literacy, early numeracy, executive functioning, and social-emotional competencies. Next steps include adding data and items from other measurement tools to the same analytical framework and field testing across a number of contexts and early childhood measurement efforts. The vision is for the resulting core sets of items, along with guidance on data collection, management, and analysis, to serve as global public goods so that they can (i) present a starting point for linking across different early childhood measurement tools for children aged 4-6; (ii) increase quality across measurement efforts; and (iii) facilitate the scale up of early childhood measurement. When supplemented with items that capture local contexts and their measurement needs, these core sets of items should help to advance understanding of universal and context-specific factors that underlie child development and thus help policymakers make decisions that ensure children receive the quality early childhood care and education they need in order to reach their full potential.

The Influence of Ethnicity and Displacement on Quality of Antenatal Care: The Case of Roma, Ashkali, and Balkan Egyptian Communities in Kosovo.

The conflict in Kosovo created mass displacement and a fractured health system. Roma, Ashkali, and Balkan Egyptian communities are particularly vulnerable to discrimination and exclusion from institutions. We aimed to examine Roma, Ashkali, and Balkan Egyptian disparities in quantity and quality of antenatal care received. We conducted a cross-sectional study in August 2012 with 603 women aged 15 or older who had given birth in the previous two years. We measured quantity of antenatal care using number of visits and quality of care using antenatal checklists. We used linear regression with interaction terms of displacement and type of health institution (for example, Serbian or Kosovar) to assess ethnic disparities in antenatal care. Women from Roma, Ashkali, and Balkan Egyptian communities received poorer quantity and quality of antenatal care compared to Kosovar Albanian and Serbian women. In adjusted models, Roma, Ashkali, and Balkan Egyptian women scored 3.5 points lower [95% CI (-5.2, -1.8)] on the checklists. Roma, Ashkali, and Balkan Egyptian women who were displaced received even poorer quality of care. Ethnic disparities exist in quality of antenatal care. Women from Roma, Ashkali, and Balkan Egyptian communities receive the poorest quality of services. As Kosovo strives to build a multiethnic health care system, a focus on equity is important to ensure the right to health for Roma, Ashkali, and Balkan Egyptian women.

In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps.

This article reports on the quality of care delivered by private and public providers of primary health care services in rural and urban India. To measure quality, the study used standardized patients recruited from the local community and trained to present consistent cases of illness to providers. We found low overall levels of medical training among health care providers; in rural Madhya Pradesh, for example, 67 percent of health care providers who were sampled reported no medical qualifications at all. What's more, we found only small differences between trained and untrained doctors in such areas as adherence to clinical checklists. Correct diagnoses were rare, incorrect treatments were widely prescribed, and adherence to clinical checklists was higher in private than in public clinics. Our results suggest an urgent need to measure the quality of health care services systematically and to improve the quality of medical education and continuing education programs, among other policy changes.

Improving Education in the Developing World: What Have We Learned from Randomized Evaluations?

Across a range of contexts, reductions in education costs and provision of subsidies can boost school participation, often dramatically. Decisions to attend school seem subject to peer effects and time-inconsistent preferences. Merit scholarships, school health programs, and information about returns to education can all cost-effectively spur school participation. However, distortions in education systems, such as weak teacher incentives and elite-oriented curricula, undermine learning in school and much of the impact of increasing existing educational spending. Pedagogical innovations designed to address these distortions (such as technology-assisted instruction, remedial education, and tracking by achievement) can raise test scores at a low cost. Merely informing parents about school conditions seems insufficient to improve teacher incentives, and evidence on merit pay is mixed, but hiring teachers locally on short-term contracts can save money and improve educational outcomes. School vouchers can cost-effectively increase both school participation and learning.