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Building Resilient Health Systems: Experimental Evidence from Sierra Leone and the 2014 Ebola Outbreak

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  • Darin Christensen
  • Oeindrila Dube
  • Johannes Haushofer
  • Bilal Siddiqi
  • Maarten Voors

Abstract

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 deliv- ered 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 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 inter- ventions led to improvements in utilization of clinics and patient satisfaction with the health system. 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 mor- tality 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 building trust and confidence in health workers, and improving the perceived quality of care provided by clinics prior to the outbreak, the interventions encouraged patients to report and receive treatment. Our results suggest that 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

Suggested Citation

  • Darin Christensen & Oeindrila Dube & Johannes Haushofer & Bilal Siddiqi & Maarten Voors, 2020. "Building Resilient Health Systems: Experimental Evidence from Sierra Leone and the 2014 Ebola Outbreak," CSAE Working Paper Series 2020-07, Centre for the Study of African Economies, University of Oxford.
  • Handle: RePEc:csa:wpaper:2020-07
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    2. Allakulov, Umrbek & Cocciolo, Serena & Das, Binayak & Habib, Md. Ahasan & Rambjer, Lovisa & Tompsett, Anna, 2023. "Transparency, governance, and water and sanitation: Experimental evidence from schools in rural Bangladesh," Journal of Development Economics, Elsevier, vol. 163(C).
    3. Francis Annan & Belinda Archibong & Uche Ekhator-Mobayode, 2023. "The Epidemic Effect: Epidemics, Institutions and Human Capital Development," Opportunity and Inclusive Growth Institute Working Papers 076, Federal Reserve Bank of Minneapolis.
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    5. Afridi, Farzana & Dhillon, Amrita & Chaudhuri, Arka Roy & Kaur, Dashleen, 2020. "Efficacy of Top down audits and Community Monitoring," OSF Preprints akpdy, Center for Open Science.
    6. Ding, Hui & Chen, Yiwei & Yu, Min & Zhong, Jieming & Hu, Ruying & Chen, Xiangyu & Wang, Chunmei & Xie, Kaixu & Eggleston, Karen, 2021. "The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China," Journal of Health Economics, Elsevier, vol. 80(C).
    7. Archibong, Belinda & Annan, Francis & Ekhator-Mobayode, Uche, 2023. "The epidemic effect: Epidemics, institutions and human capital development," Journal of Economic Behavior & Organization, Elsevier, vol. 211(C), pages 549-566.
    8. Bruno P. Carvalho & Susana Peralta & João Pereira dos Santos, 2022. "Regional and sectorial impacts of the Covid‐19 crisis: Evidence from electronic payments," Journal of Regional Science, Wiley Blackwell, vol. 62(3), pages 757-798, June.
    9. Mehdi Shadmehr & Ethan Bueno de Mesquita, 2020. "Coordination and Social Distancing: Inertia in the Aggregate Response to COVID-19," Working Papers 2020-53, Becker Friedman Institute for Research In Economics.
    10. An Cheng & Tonghui Chen & Guogang Jiang & Xinru Han, 2021. "Can Major Public Health Emergencies Affect Changes in International Oil Prices?," IJERPH, MDPI, vol. 18(24), pages 1-13, December.
    11. Mayhew, Susannah H. & Balabanova, Dina & Vandi, Ahmed & Mokuwa, Gelejimah Alfred & Hanson, Tommy & Parker, Melissa & Richards, Paul, 2022. "(Re)arranging “systems of care” in the early Ebola response in Sierra Leone: An interdisciplinary analysis," Social Science & Medicine, Elsevier, vol. 300(C).
    12. Rubli, Adrian, 2023. "Trade-offs between access and quality in healthcare: Evidence from retail clinics in Mexico," Journal of Public Economics, Elsevier, vol. 224(C).
    13. Jim A. C. Everett & Clara Colombatto & Edmond Awad & Paulo Boggio & Björn Bos & William J. Brady & Megha Chawla & Vladimir Chituc & Dongil Chung & Moritz A. Drupp & Srishti Goel & Brit Grosskopf & Fre, 2021. "Moral dilemmas and trust in leaders during a global health crisis," Nature Human Behaviour, Nature, vol. 5(8), pages 1074-1088, August.
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    JEL classification:

    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health
    • J33 - Labor and Demographic Economics - - Wages, Compensation, and Labor Costs - - - Compensation Packages; Payment Methods
    • M52 - Business Administration and Business Economics; Marketing; Accounting; Personnel Economics - - Personnel Economics - - - Compensation and Compensation Methods and Their Effects
    • O15 - Economic Development, Innovation, Technological Change, and Growth - - Economic Development - - - Economic Development: Human Resources; Human Development; Income Distribution; Migration

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