Human resource challenges in health systems: evidence from ten African countries.

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 ten 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 work demonstrates 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.

How to recruit teachers for hard-to-staff schools: A systematic review of evidence from low- and middle-income countries.

Education systems struggle to staff schools in rural areas or in areas with high concentrations of poverty. Potential policy solutions include financial incentives, mandatory rotations, and local recruitment drives, among others. First, this systematic review provides evidence on challenges with teacher staffing in certain types of schools. We observe lower teacher skill and higher teacher absence in rural areas in many countries. Second, the review synthesizes available experimental and quasi-experimental studies of government-implemented policies to increase the quantity or quality of teachers in hard-to-staff schools in low- or middle-income countries. Financial incentives-the most evaluated policies-are often effective at increasing the supply or reducing the turnover of teachers in hard-to-staff schools, and well-designed incentives can also increase the quality of teachers in these schools. Impacts on student outcomes are often positive. Although there are fewer evaluations, behavioral and informational interventions have been cost-effective in reducing vacancies in two countries.

Live tutoring calls did not improve learning during the COVID-19 pandemic in Sierra Leone.

Education systems regularly face unexpected school closures, whether due to disease outbreaks, natural disasters, or other adverse shocks. In low-income countries where internet access is scarce, distance learning - the most common educational solution - is often passive, via TV or radio, with little opportunity for teacher-student interaction. In this paper we evaluate the effectiveness of live tutoring calls from teachers, designed to supplement radio instruction during the 2020 school closures prompted by the COVID-19 pandemic. We do this with a randomised controlled trial with 4,399 primary school students in Sierra Leone. Tutoring calls led to some limited increase in educational activity, but had no effect on mathematics or language test scores, whether for girls or boys, and whether provided by public or private school teachers. Even having received tutoring calls, one in three children reported not listening to educational radio at all, so limited take-up may partly explain our results.

Teacher pay in Africa: Evidence from 15 countries.

Pay levels for public sector workers-and especially teachers-are a constant source of controversy. In many countries in Sub-Saharan Africa, protests and strikes suggest that pay is low, while comparisons to average national income per capita suggest that it is high. This study presents data on teacher earnings from 15 African countries. The results suggest that in several (seven) countries, teachers' monthly earnings are lower than other formal sector workers with comparable levels of education and experience. However, in all of those countries, teachers report working significantly fewer hours than other workers, such that hourly earnings are significantly lower for teachers in only one country. The study documents non-pecuniary benefits (such as medical insurance or a pension) for teachers relative to other workers: of the 13 country surveys that report non-pecuniary benefits, teachers are more likely to receive at least one benefit than other workers in 11. Teachers who report fewer hours are no more likely to report holding a second job, although teachers overall are nearly two times more likely to hold a second job than other workers. The study documents other characteristics of the teacher labor force across countries-e.g., mostly male but less so than other workers, mostly employed by the public sector. The study also documents within-country variation across types of teacher contracts-e.g., teachers on fixed term contracts make about 70 percent of teachers on permanent contracts, with wide variation across countries. The large heterogeneity in teacher earnings premia is not easily explained by observed characteristics of the countries' economies or education systems. Nonetheless, after taking hours and non-pecuniary benefits into account, we find no evidence that teachers are systematically underpaid in this sample of countries.

Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries.

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.

Practical lessons for phone-based assessments of learning.

School closures affecting more than 1.5 billion children are designed to prevent the spread of current public health risks from the COVID-19 pandemic, but they simultaneously introduce new short-term and long-term health risks through lost education. Measuring these effects in real time is critical to inform effective public health responses, and remote phone-based approaches are one of the only viable options with extreme social distancing in place. However, both the health and education literature are sparse on guidance for phone-based assessments. In this article, we draw on our pilot testing of phone-based assessments in Botswana, along with the existing literature on oral testing of reading and mathematics, to propose a series of preliminary practical lessons to guide researchers and service providers as they try phone-based learning assessments. We provide preliminary evidence that phone-based assessments can accurately capture basic numeracy skills. We provide guidance to help teams (1) ensure that children are not put at risk, (2) test the reliability and validity of phone-based measures, (3) use simple instructions and practice items to ensure the assessment is focused on the target skill, not general language and test-taking skills, (4) adapt the items from oral assessments that will be most effective in phone-based assessments, (5) keep assessments brief while still gathering meaningful learning data, (6) use effective strategies to encourage respondents to pick up the phone, (7) build rapport with adult caregivers and youth respondents, (8) choose the most cost-effective medium and (9) account for potential bias in samples.

Bias in patient satisfaction surveys: a threat to measuring healthcare quality.

Patient satisfaction surveys are an increasingly common element of efforts to evaluate the quality of healthcare. Many patient satisfaction surveys in low/middle-income countries frame statements positively and invite patients to agree or disagree, so that positive responses may reflect either true satisfaction or bias induced by the positive framing. In an experiment with more than 2200 patients in Nigeria, we distinguish between actual satisfaction and survey biases. Patients randomly assigned to receive negatively framed statements expressed significantly lower levels of satisfaction (87%) than patients receiving the standard positively framed statements (95%-p<0.001). Depending on the question, the effect is as high as a 19 percentage point drop (p<0.001). Thus, high reported patient satisfaction likely overstates the quality of health services. Providers and policymakers wishing to gauge the quality of care will need to avoid framing that induces bias and to complement patient satisfaction measures with more objective measures of quality.

Health-care quality and information failure: Evidence from Nigeria.

Low-quality health services are a problem across low- and middle-income countries. Information failure may contribute, as patients may have insufficient knowledge to discern the quality of health services. That decreases the likelihood that patients will sort into higher quality facilities, increasing demand for better health services. This paper presents results from a health survey in Nigeria to investigate whether patients can evaluate health service quality effectively. Specifically, this paper demonstrates that although more than 90% of patients agree with any positive statement about the quality of their local health services, satisfaction is significantly associated with the diagnostic ability of health workers at the facility. Satisfaction is not associated with more superficial characteristics such as infrastructure quality or prescriptions of medicines. This suggests that patients may have sufficient information to discern some of the most important elements of quality, but that alternative measures are crucial for gauging the overall quality of care.

A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial.

BACKGROUND: Nutrition guidelines recommendations differ on the use of parenteral nutrition (PN), and existing clinical trial data are inconclusive. Our recent observational data show that amounts of energy/protein received early in the intensive care unit (ICU) affect patient mortality, particularly for inadequate nutrition intake in patients with body mass indices (BMIs) of <25 or >35. Thus, we hypothesized increased nutrition delivery via supplemental PN (SPN) + enteral nutrition (EN) to underweight and obese ICU patients would improve 60-day survival and quality of life (QoL) versus usual care (EN alone). METHODS: In this multicenter, randomized, controlled pilot trial completed in 11 centers across four countries, adult ICU patients with acute respiratory failure expected to require mechanical ventilation for >72 hours and with a BMI of <25 or ≥35 were randomized to receive EN alone or SPN + EN to reach 100% of their prescribed nutrition goal for 7 days after randomization. The primary aim of this pilot trial was to achieve a 30% improvement in nutrition delivery. RESULTS: In total, 125 patients were enrolled. Over the first 7 post-randomization ICU days, patients in the SPN + EN arm had a 26% increase in delivered calories and protein, whereas patients in the EN-alone arm had a 22% increase (both p < 0.001). Surgical ICU patients received poorer EN nutrition delivery and had a significantly greater increase in calorie and protein delivery when receiving SPN versus medical ICU patients. SPN proved feasible to deliver with our prescribed protocol. In this pilot trial, no significant outcome differences were observed between groups, including no difference in infection risk. Potential, although statistically insignificant, trends of reduced hospital mortality and improved discharge functional outcomes and QoL outcomes in the SPN + EN group versus the EN-alone group were observed. CONCLUSIONS: Provision of SPN + EN significantly increased calorie/protein delivery over the first week of ICU residence versus EN alone. This was achieved with no increased infection risk. Given feasibility and consistent encouraging trends in hospital mortality, QoL, and functional endpoints, a full-scale trial of SPN powered to assess these clinical outcome endpoints in high-nutritional-risk ICU patients is indicated-potentially focusing on the more poorly EN-fed surgical ICU setting. TRIAL REGISTRATION: NCT01206166.

Orphans and schooling in Africa: a longitudinal analysis.

AIDS deaths could have a major impact on economic development by affecting the human capital accumulation of the next generation. We estimate the impact of parent death on primary school participation using an unusual five-year panel data set of over 20,000 Kenyan children. There is a substantial decrease in school participation following a parent death and a smaller drop before the death (presumably due to pre-death morbidity). Estimated impacts are smaller in specifications without individual fixed effects, suggesting that estimates based on cross-sectional data are biased toward zero. Effects are largest for children whose mothers died and, in a novel finding, for those with low baseline academic performance.