How do educated mothers affect their children's education, particularly w... more How do educated mothers affect their children's education, particularly when in a typical developing country, they themselves are barely educated? We answer this question using detailed data from rural Pakistan to examine a rich source of channels including detailed mothers' and children's time. By matching the availability of schools in the mother's birth village to her educational levels, we are
Abstract:Using a new census of private educational institutions in Pakistan together withthe popu... more Abstract:Using a new census of private educational institutions in Pakistan together withthe population census, we present evidence that private schooling, particularly at the primary level is indeed a large and increasingly important factor in education in Pakistan both in absolute terms and relative to public schooling. While the rural-urban gap still remains, the growth trends showed a marked improvement in
This article reports on the quality of care delivered by private and public providers of primary ... more 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.
This paper documents the quality of medical advice in low-income countries. Our evidence on healt... more This paper documents the quality of medical advice in low-income countries. Our evidence on health care quality in low-income countries is drawn primarily from studies in four countries: Tanzania, India, Indonesia, and Paraguay. We provide an overview of recent work that uses two broad approaches: medical vignettes (in which medical providers are presented with hypothetical cases and their responses are compared to a checklist of essential procedures) and direct observation of the doctor-patient interaction These two approaches have proved quite informative. For example, doctors in Tanzania complete less than a quarter of the essential checklist for patients with classic symptoms of malaria, a disease that kills 63,000-96,000 Tanzanians each year. A public-sector doctor in India asks one (and only one) question in the average interaction: "What's wrong with you?" We present systematic evidence in this paper to show that these isolated facts represent common patterns. We find that the quality of care in low-income countries as measured by what doctors know is very low, and that the problem of low competence is compounded due to low effort -- doctors provide lower standards of care for their patients than they know how to provide. We discuss how the properties and correlates of measures based on vignettes and observation may be used to evaluate policy changes. Finally, we outline the agenda in terms of further research and measurement.
The quality of medical care received by patients varies for two reasons: differences in doctors' ... more The quality of medical care received by patients varies for two reasons: differences in doctors' competence or differences in doctors' practice. Using medical vignettes, we evaluated competence for a sample of doctors in Delhi. One month later, we observed the same doctors in their practice. We find three patterns in the data. First, doctors do less than what they know they should do. Second, the more competent the doctor, the greater the effort exerted. Third, competence and practice diverge in different ways in the public and private sectors. Urban India pays a lot of “Money for Nothing”: in the private sector there is a lot of expenditure on unnecessary drugs. In the public sector, education subsidies and salary payments translate into little (and in small clinics, very little) effort and care. Provider training has a small impact on the actual quality of advice; under the circumstances, awareness campaigns to create a more informed clientele may be the best option.
We develop a method in which vignettes–a battery of questions for hypothetical cases–are evaluate... more We develop a method in which vignettes–a battery of questions for hypothetical cases–are evaluated with item response theory to measure the clinical competence of doctors. The method, which allows us to simultaneously estimate competence and validate the test instrument, is applied to a sample of medical practitioners in Delhi, India. The method gives plausible results, rationalizes different perceptions of competence in the public and private sectors and pinpoints several serious problems with health care delivery in urban India. The findings confirm, for instance, that the competence of private providers located in poorer areas of the city is significantly lower than those in richer neighborhoods. Surprisingly, similar results hold for providers in the public sector with important implications for inequalities in the availability of health care.
India Health Beat, Public Health Foundation of India, Jun 1, 2010
Health outcomes in India are abysmal with current maternal mortality rates higher than in England... more Health outcomes in India are abysmal with current maternal mortality rates higher than in England and Wales or Sweden at the turn of the century. What role does the quality of health care play in resolving the puzzle of simultaneous high expenditures and poor health? We summarize findings from recent research on the quality of health care in Delhi, focusing on the competence of health care providers, the effort they exert with their patients and the relationship between the two. Incorporating a `quality' lens into how we think about health systems can lead to very different policies from those which policy makers currently advocate for. In our particular, our research suggests that policy makers should rethink the accepted link between health care system inputs, like physical facilities and the quality of care received by patients.
India Health Beat, Public Health Foundation of India, Jun 1, 2010
Much of what we know about morbidity and health seeking behavior in India is based on household s... more Much of what we know about morbidity and health seeking behavior in India is based on household surveys with recall periods of 2 weeks or 1 month. Given the salience of this information for policy, it is surprising that there are no studies on how the length of the recall period changes household reports of health related behavior. Using a unique study design from Delhi, we find that the length of the recall period has a large impact on reported morbidity, doctor's visits, time spent sick and the reported use of self-medication. The effects are more pronounced among the poor than the rich. In one particularly dramatic example, differential recall effects across income groups reverse the sign of the gradient between doctor visits and per-capita expenditures such that the poor use health care providers more than the rich in the weekly surveys but less in monthly recall surveys. Based on these results, we argue that access, as conventionally measured is not a problem for the urban poor. Indeed conventional measures of `access' are uninformative unless they are combined with information on provider quality.
The quality of medical care is a potentially important determinant of health outcomes, but remain... more The quality of medical care is a potentially important determinant of health outcomes, but remains an understudied area. The limited research that exists defines quality either on the basis of drug availability or facility characteristics, but little is known about how provider quality affects the provision of health care. We address this gap through a survey in Delhi with two related components. We evaluate 'competence' (what providers know) through vignettes and practice (what providers do) through direct clinical observation. Overall quality, as measured by the competence necessary to recognise and handle common and dangerous conditions, is quite low albeit with tremendous variation. While there is some correlation with simple observed characteristics, there is still an enormous amount of variation within such categories. Further, even when providers know what to do they often don't do it in practice. This appears to be true in both the public and private sectors but for very different, and systematic, reasons. The study has important policy implications for our understanding of how market failures and failures of regulation in the health sector affect the poor.
For US $17 a child can be immunized against six major illnesses. Even at this price, a country su... more For US $17 a child can be immunized against six major illnesses. Even at this price, a country such as India would
have to spend halfits health budget on providing vaccinations. Given the wide variation in immunization costs it may
be possible to decrease this cost to more sustainable levels, but to do so we need to arrive at a more thorough
understanding of factors affecting household demand for vaccination. Using data on vaccination and pre-natal care
collected by the authors in the Garhwal region ofIndia, we explore one aspect ofthe demand for vaccination in some
detail. We show that informational constraints play an important role in the household decision to seek vaccination,
and moreover, that learning about the efficacy of vaccinations only through empirical observation may be hard even in
environments with variation in vaccination and the high incidence ofvaccine-preventable diseases. We argue that when
learning about vaccination is inefficient, households use concurrent interventions with easily observable outcomes to
evaluate the veracity ofa provider’s claim regarding preventive care. Hence, the success ofimmunization programs
becomes crucially linked to the success ofparallel programs by the same provider.
… on the Provision of Education (June …, Mar 1, 2013
With an estimated one hundred fifteen million children not attending primary school in the develo... more With an estimated one hundred fifteen million children not attending primary school in the developing world,
increasing access to education is critical. This paper highlights a supply-side factor – the availability of
low-cost teachers – and the resulting ability of the market to offer affordable education. We first show that private
schools are three times more likely to emerge in villages with government girls' secondary schools (GSSs).
Identification is obtained by using official school construction guidelines as an instrument for the presence of
GSSs. In contrast, private school presence shows little or no relationship with girls' primary or boys' primary
and secondary government schools. In support of a supply-channel, we then show that, villages which received
a GSS have over twice as many educated women, and private school teachers' wages are 27% lower in these villages.
In an environmentwith lowfemale education and mobility, GSSs substantially increase the local supply of
skilled women lowering wages locally and allowing the market to offer affordable education. These findings
highlight the prominent role of women as teachers in facilitating educational access and resonate with similar
historical evidence from developed economies. The students of today are the teachers of tomorrow.
Increasing evidence suggests that the level and distribution of cognitive skills is more importan... more Increasing evidence suggests that the level and distribution of cognitive skills is more important to economic development than absolute measures of schooling attainment, and that income and skill inequality are inextricably linked. Yet for most of the developing world no internationally comparable estimates of
cognitive skills exist. This paper uses student answers to publicly released questions from an international testing agency together with statistical methods from Item Response Theory to place secondary students from two Indian states—Orissa and Rajasthan—on a worldwide distribution of mathematics achievement.
These two states fall below 43 of the 51 countries for which data exist. The bottom 5% of children rank higher than the bottom 5% in only three countries—South Africa, Ghana and Saudi Arabia. But not all students test poorly. Inequality in the test-score distribution for both states is next only to South Africa. The combination of India's size and large variance in achievement give both the perceptions that India is shining even as Bharat,
the vernacular for India, is drowning. How India's development unfolds will depend critically on how the skill distribution evolves and how low- and high-skilled workers interact in the labor market.
How do educated mothers affect their children's education, particularly w... more How do educated mothers affect their children's education, particularly when in a typical developing country, they themselves are barely educated? We answer this question using detailed data from rural Pakistan to examine a rich source of channels including detailed mothers' and children's time. By matching the availability of schools in the mother's birth village to her educational levels, we are
Abstract:Using a new census of private educational institutions in Pakistan together withthe popu... more Abstract:Using a new census of private educational institutions in Pakistan together withthe population census, we present evidence that private schooling, particularly at the primary level is indeed a large and increasingly important factor in education in Pakistan both in absolute terms and relative to public schooling. While the rural-urban gap still remains, the growth trends showed a marked improvement in
This article reports on the quality of care delivered by private and public providers of primary ... more 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.
This paper documents the quality of medical advice in low-income countries. Our evidence on healt... more This paper documents the quality of medical advice in low-income countries. Our evidence on health care quality in low-income countries is drawn primarily from studies in four countries: Tanzania, India, Indonesia, and Paraguay. We provide an overview of recent work that uses two broad approaches: medical vignettes (in which medical providers are presented with hypothetical cases and their responses are compared to a checklist of essential procedures) and direct observation of the doctor-patient interaction These two approaches have proved quite informative. For example, doctors in Tanzania complete less than a quarter of the essential checklist for patients with classic symptoms of malaria, a disease that kills 63,000-96,000 Tanzanians each year. A public-sector doctor in India asks one (and only one) question in the average interaction: "What's wrong with you?" We present systematic evidence in this paper to show that these isolated facts represent common patterns. We find that the quality of care in low-income countries as measured by what doctors know is very low, and that the problem of low competence is compounded due to low effort -- doctors provide lower standards of care for their patients than they know how to provide. We discuss how the properties and correlates of measures based on vignettes and observation may be used to evaluate policy changes. Finally, we outline the agenda in terms of further research and measurement.
The quality of medical care received by patients varies for two reasons: differences in doctors' ... more The quality of medical care received by patients varies for two reasons: differences in doctors' competence or differences in doctors' practice. Using medical vignettes, we evaluated competence for a sample of doctors in Delhi. One month later, we observed the same doctors in their practice. We find three patterns in the data. First, doctors do less than what they know they should do. Second, the more competent the doctor, the greater the effort exerted. Third, competence and practice diverge in different ways in the public and private sectors. Urban India pays a lot of “Money for Nothing”: in the private sector there is a lot of expenditure on unnecessary drugs. In the public sector, education subsidies and salary payments translate into little (and in small clinics, very little) effort and care. Provider training has a small impact on the actual quality of advice; under the circumstances, awareness campaigns to create a more informed clientele may be the best option.
We develop a method in which vignettes–a battery of questions for hypothetical cases–are evaluate... more We develop a method in which vignettes–a battery of questions for hypothetical cases–are evaluated with item response theory to measure the clinical competence of doctors. The method, which allows us to simultaneously estimate competence and validate the test instrument, is applied to a sample of medical practitioners in Delhi, India. The method gives plausible results, rationalizes different perceptions of competence in the public and private sectors and pinpoints several serious problems with health care delivery in urban India. The findings confirm, for instance, that the competence of private providers located in poorer areas of the city is significantly lower than those in richer neighborhoods. Surprisingly, similar results hold for providers in the public sector with important implications for inequalities in the availability of health care.
India Health Beat, Public Health Foundation of India, Jun 1, 2010
Health outcomes in India are abysmal with current maternal mortality rates higher than in England... more Health outcomes in India are abysmal with current maternal mortality rates higher than in England and Wales or Sweden at the turn of the century. What role does the quality of health care play in resolving the puzzle of simultaneous high expenditures and poor health? We summarize findings from recent research on the quality of health care in Delhi, focusing on the competence of health care providers, the effort they exert with their patients and the relationship between the two. Incorporating a `quality' lens into how we think about health systems can lead to very different policies from those which policy makers currently advocate for. In our particular, our research suggests that policy makers should rethink the accepted link between health care system inputs, like physical facilities and the quality of care received by patients.
India Health Beat, Public Health Foundation of India, Jun 1, 2010
Much of what we know about morbidity and health seeking behavior in India is based on household s... more Much of what we know about morbidity and health seeking behavior in India is based on household surveys with recall periods of 2 weeks or 1 month. Given the salience of this information for policy, it is surprising that there are no studies on how the length of the recall period changes household reports of health related behavior. Using a unique study design from Delhi, we find that the length of the recall period has a large impact on reported morbidity, doctor's visits, time spent sick and the reported use of self-medication. The effects are more pronounced among the poor than the rich. In one particularly dramatic example, differential recall effects across income groups reverse the sign of the gradient between doctor visits and per-capita expenditures such that the poor use health care providers more than the rich in the weekly surveys but less in monthly recall surveys. Based on these results, we argue that access, as conventionally measured is not a problem for the urban poor. Indeed conventional measures of `access' are uninformative unless they are combined with information on provider quality.
The quality of medical care is a potentially important determinant of health outcomes, but remain... more The quality of medical care is a potentially important determinant of health outcomes, but remains an understudied area. The limited research that exists defines quality either on the basis of drug availability or facility characteristics, but little is known about how provider quality affects the provision of health care. We address this gap through a survey in Delhi with two related components. We evaluate 'competence' (what providers know) through vignettes and practice (what providers do) through direct clinical observation. Overall quality, as measured by the competence necessary to recognise and handle common and dangerous conditions, is quite low albeit with tremendous variation. While there is some correlation with simple observed characteristics, there is still an enormous amount of variation within such categories. Further, even when providers know what to do they often don't do it in practice. This appears to be true in both the public and private sectors but for very different, and systematic, reasons. The study has important policy implications for our understanding of how market failures and failures of regulation in the health sector affect the poor.
For US $17 a child can be immunized against six major illnesses. Even at this price, a country su... more For US $17 a child can be immunized against six major illnesses. Even at this price, a country such as India would
have to spend halfits health budget on providing vaccinations. Given the wide variation in immunization costs it may
be possible to decrease this cost to more sustainable levels, but to do so we need to arrive at a more thorough
understanding of factors affecting household demand for vaccination. Using data on vaccination and pre-natal care
collected by the authors in the Garhwal region ofIndia, we explore one aspect ofthe demand for vaccination in some
detail. We show that informational constraints play an important role in the household decision to seek vaccination,
and moreover, that learning about the efficacy of vaccinations only through empirical observation may be hard even in
environments with variation in vaccination and the high incidence ofvaccine-preventable diseases. We argue that when
learning about vaccination is inefficient, households use concurrent interventions with easily observable outcomes to
evaluate the veracity ofa provider’s claim regarding preventive care. Hence, the success ofimmunization programs
becomes crucially linked to the success ofparallel programs by the same provider.
… on the Provision of Education (June …, Mar 1, 2013
With an estimated one hundred fifteen million children not attending primary school in the develo... more With an estimated one hundred fifteen million children not attending primary school in the developing world,
increasing access to education is critical. This paper highlights a supply-side factor – the availability of
low-cost teachers – and the resulting ability of the market to offer affordable education. We first show that private
schools are three times more likely to emerge in villages with government girls' secondary schools (GSSs).
Identification is obtained by using official school construction guidelines as an instrument for the presence of
GSSs. In contrast, private school presence shows little or no relationship with girls' primary or boys' primary
and secondary government schools. In support of a supply-channel, we then show that, villages which received
a GSS have over twice as many educated women, and private school teachers' wages are 27% lower in these villages.
In an environmentwith lowfemale education and mobility, GSSs substantially increase the local supply of
skilled women lowering wages locally and allowing the market to offer affordable education. These findings
highlight the prominent role of women as teachers in facilitating educational access and resonate with similar
historical evidence from developed economies. The students of today are the teachers of tomorrow.
Increasing evidence suggests that the level and distribution of cognitive skills is more importan... more Increasing evidence suggests that the level and distribution of cognitive skills is more important to economic development than absolute measures of schooling attainment, and that income and skill inequality are inextricably linked. Yet for most of the developing world no internationally comparable estimates of
cognitive skills exist. This paper uses student answers to publicly released questions from an international testing agency together with statistical methods from Item Response Theory to place secondary students from two Indian states—Orissa and Rajasthan—on a worldwide distribution of mathematics achievement.
These two states fall below 43 of the 51 countries for which data exist. The bottom 5% of children rank higher than the bottom 5% in only three countries—South Africa, Ghana and Saudi Arabia. But not all students test poorly. Inequality in the test-score distribution for both states is next only to South Africa. The combination of India's size and large variance in achievement give both the perceptions that India is shining even as Bharat,
the vernacular for India, is drowning. How India's development unfolds will depend critically on how the skill distribution evolves and how low- and high-skilled workers interact in the labor market.
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Papers by Jishnu Das
have to spend halfits health budget on providing vaccinations. Given the wide variation in immunization costs it may
be possible to decrease this cost to more sustainable levels, but to do so we need to arrive at a more thorough
understanding of factors affecting household demand for vaccination. Using data on vaccination and pre-natal care
collected by the authors in the Garhwal region ofIndia, we explore one aspect ofthe demand for vaccination in some
detail. We show that informational constraints play an important role in the household decision to seek vaccination,
and moreover, that learning about the efficacy of vaccinations only through empirical observation may be hard even in
environments with variation in vaccination and the high incidence ofvaccine-preventable diseases. We argue that when
learning about vaccination is inefficient, households use concurrent interventions with easily observable outcomes to
evaluate the veracity ofa provider’s claim regarding preventive care. Hence, the success ofimmunization programs
becomes crucially linked to the success ofparallel programs by the same provider.
increasing access to education is critical. This paper highlights a supply-side factor – the availability of
low-cost teachers – and the resulting ability of the market to offer affordable education. We first show that private
schools are three times more likely to emerge in villages with government girls' secondary schools (GSSs).
Identification is obtained by using official school construction guidelines as an instrument for the presence of
GSSs. In contrast, private school presence shows little or no relationship with girls' primary or boys' primary
and secondary government schools. In support of a supply-channel, we then show that, villages which received
a GSS have over twice as many educated women, and private school teachers' wages are 27% lower in these villages.
In an environmentwith lowfemale education and mobility, GSSs substantially increase the local supply of
skilled women lowering wages locally and allowing the market to offer affordable education. These findings
highlight the prominent role of women as teachers in facilitating educational access and resonate with similar
historical evidence from developed economies. The students of today are the teachers of tomorrow.
cognitive skills exist. This paper uses student answers to publicly released questions from an international testing agency together with statistical methods from Item Response Theory to place secondary students from two Indian states—Orissa and Rajasthan—on a worldwide distribution of mathematics achievement.
These two states fall below 43 of the 51 countries for which data exist. The bottom 5% of children rank higher than the bottom 5% in only three countries—South Africa, Ghana and Saudi Arabia. But not all students test poorly. Inequality in the test-score distribution for both states is next only to South Africa. The combination of India's size and large variance in achievement give both the perceptions that India is shining even as Bharat,
the vernacular for India, is drowning. How India's development unfolds will depend critically on how the skill distribution evolves and how low- and high-skilled workers interact in the labor market.
have to spend halfits health budget on providing vaccinations. Given the wide variation in immunization costs it may
be possible to decrease this cost to more sustainable levels, but to do so we need to arrive at a more thorough
understanding of factors affecting household demand for vaccination. Using data on vaccination and pre-natal care
collected by the authors in the Garhwal region ofIndia, we explore one aspect ofthe demand for vaccination in some
detail. We show that informational constraints play an important role in the household decision to seek vaccination,
and moreover, that learning about the efficacy of vaccinations only through empirical observation may be hard even in
environments with variation in vaccination and the high incidence ofvaccine-preventable diseases. We argue that when
learning about vaccination is inefficient, households use concurrent interventions with easily observable outcomes to
evaluate the veracity ofa provider’s claim regarding preventive care. Hence, the success ofimmunization programs
becomes crucially linked to the success ofparallel programs by the same provider.
increasing access to education is critical. This paper highlights a supply-side factor – the availability of
low-cost teachers – and the resulting ability of the market to offer affordable education. We first show that private
schools are three times more likely to emerge in villages with government girls' secondary schools (GSSs).
Identification is obtained by using official school construction guidelines as an instrument for the presence of
GSSs. In contrast, private school presence shows little or no relationship with girls' primary or boys' primary
and secondary government schools. In support of a supply-channel, we then show that, villages which received
a GSS have over twice as many educated women, and private school teachers' wages are 27% lower in these villages.
In an environmentwith lowfemale education and mobility, GSSs substantially increase the local supply of
skilled women lowering wages locally and allowing the market to offer affordable education. These findings
highlight the prominent role of women as teachers in facilitating educational access and resonate with similar
historical evidence from developed economies. The students of today are the teachers of tomorrow.
cognitive skills exist. This paper uses student answers to publicly released questions from an international testing agency together with statistical methods from Item Response Theory to place secondary students from two Indian states—Orissa and Rajasthan—on a worldwide distribution of mathematics achievement.
These two states fall below 43 of the 51 countries for which data exist. The bottom 5% of children rank higher than the bottom 5% in only three countries—South Africa, Ghana and Saudi Arabia. But not all students test poorly. Inequality in the test-score distribution for both states is next only to South Africa. The combination of India's size and large variance in achievement give both the perceptions that India is shining even as Bharat,
the vernacular for India, is drowning. How India's development unfolds will depend critically on how the skill distribution evolves and how low- and high-skilled workers interact in the labor market.