Developing countries are characterized by high rates of mortality and morbidity. A potential contributing factor is the low utilization of health systems, stemming from the low perceived quality of care delivered by health personnel. This factor may be especially critical during crises, when individuals choose whether to cooperate with response efforts and frontline health personnel. We experimentally examine efforts aimed at improving health worker performance in the context of the 2014–15 West African Ebola crisis. Roughly two years before the outbreak in Sierra Leone, we randomly assigned two social accountability interventions to government-run health clinics — one focused on community monitoring and the other gave status awards to clinic staff. We find that over the medium run, prior to the Ebola crisis, both interventions led to improvements in utilization of clinics and patient satisfaction. In addition, child health outcomes improved substantially in the catchment areas of community monitoring clinics. During the crisis, the interventions also led to higher reported Ebola cases, as well as lower mortality from Ebola — particularly in areas with community monitoring clinics. We explore three potential mechanisms: the interventions (1) increased the likelihood that patients reported Ebola symptoms and sought care; (2) unintentionally increased Ebola incidence; or (3) improved surveillance efforts. We find evidence consistent with the first: by improving the perceived quality of care provided by clinics prior to the outbreak, the interventions likely encouraged patients to report and receive treatment. Our results suggest that social accountability interventions not only have the power to improve health systems during normal times, but can additionally make health systems resilient to crises that may emerge over the longer run.
Individuals care about how they are perceived by others, and take visible actions to signal their type. This paper investigates social signaling in the context of childhood immunization in Sierra Leone. Despite high initial vaccine take-up, many parents do not complete the five immunizations that are required in a child’s first year of life. I introduce a durable signal - in the form of differently colored bracelets - which children receive upon vaccination, and implement a 22-month-long experiment in 120 public clinics. Informed by theory, the experimental design separately identifies social signaling from leading alternative mechanisms. In a first main finding, I show that individuals use signals to learn about others’ actions. Second, I find that the impact of signals varies significantly with the social desirability of the action. In particular, the signal has a weak effect when linked to a vaccine with low perceived benefits and a large, positive effect when linked to a vaccine with high perceived benefits. Of substantive policy importance, signals increase timely and complete vaccination at a cost of approximately 1 USD per child, with effects persisting 12 months after the roll out. Finally, I structurally estimate a dynamic discrete-choice model to quantify the value of social signaling.
We evaluate an intervention to raise young women’s economic empowerment in Sierra Leone, where women frequently experience sexual violence and face multiple economic disadvantages. The intervention provides them with a protective space (a club) where they can …nd support, receive information on health/reproductive issues and vocational training. Unexpectedly, the post-baseline period coincided with the 2014 Ebola outbreak. Our analysis leverages quasi-random across-village variation in the severity of Ebola-related disruption, and random assignment of villages to the intervention to document the impact of the Ebola outbreak on the economic lives of 4 700 women tracked over the crisis, and any ameliorating role played by the intervention. In highly disrupted control villages, the crisis leads younger girls to spend signi…cantly more time with men, out-of-wedlock pregnancies rise, and as a result, they experience a persistent 16pp drop in school enrolment post-crisis. These adverse e¤ects are almost entirely reversed in treated villages because the intervention enables young girls to allocate time away from men, preventing out-of-wedlock pregnancies and enabling them to re-enrol in school post-crisis. In treated villages, the unavailability of young women leads some older girls to use transactional sex as a coping strategy. The intervention causes them to increase contraceptive use so this does not translate into higher fertility. Our analysis pinpoints the mechanisms through which the severity of the aggregate shock impacts the economic lives of young women, and shows how interventions in times of crisis can interlink outcomes across younger and older cohorts. J
In Sierra Leone, we have continued our global tradition of rigorous, applicable research by building foundational research capacity and conducting evaluations in areas of pressing national concern. Examples of our work described in this brief offer promising insights into everyday issues that affect the lives of the poor in Sierra Leone.
This paper presents an experimental approach to measure competition in agricultural markets, based on the random allocation of subsidies to competing traders. We compare prices of subsidized and unsubsidized crop traders to recover the key market structure parameter in a standard model of imperfect competition. By combining the experimental results with quasi-experimental estimates of the pass-through rate, we also estimate market size, or the effective number of traders competing for farmers’ supply. In the context of the Sierra Leone cocoa industry, our results point to a competitive agricultural trading sector and suggest that the market size is substantially larger than the village. The methodology developed in this paper uses purely individual-level treatment to shed light on market structure. This approach may be useful for the many cases in which market-level randomization is not feasible.
In the coming decades, most of the poor will live in fragile states, yet rigorous evidence on how to build peace and stability is still limited. What helps communities heal and prosper after a crisis? How can peace and stability be maintained after war? IPA works with academics from top research institutions to generate evidence on how to facilitate peace and mitigate the negative social and economic impacts of conflicts and crises. We evaluate programs that aim to strengthen state capacities, prevent or reduce violence, or alleviate the fallout from crises ranging from health to natural to human-made. IPA works in fragile states and countries that have recently experienced conflict, violence, or disaster. IPA also collaborates with decision-makers to ensure that this evidence is both useful and implemented at scale.