Search

Begin New Search

35701. The Cost and Cost-Effectiveness of Alternative Strategies to Expand Treatment to HIV-Positive South Africans: Scale Economies and Outreach Costs

Author:
Mead Over, Gesine Meyer-Rath, Daniel J. Klein, and Anna Bershteyn
Publication Date:
04-2015
Content Type:
Policy Brief
Institution:
Center for Global Development
Abstract:
The South African government is currently discussing various alternative approaches to the further expansion of antiretroviral treatment (ART) in public-sector facilities. Alternatives under consideration include the criteria under which a patient would be eligible for free care, the level of coverage with testing and care, how much of the care will be delivered in small facilities located closer to the patients, and how to assure linkage to care and subsequent adherence by ART patients. We used the EMOD-HIV model to generate 12 epidemiological scenarios. The EMOD-HIV model is a model of HIV transmission which projects South African HIV incidence and prevalence and ARV treatment by age group for alternative combinations of treatment eligibility criteria and testing. We treat as sunk costs the projected future cost of one of these 12 scenarios, the baseline scenario characterizing South Africa's 2013 policy to treat people with CD4 counts less than 350. We compute the cost and benefits of the other 11 scenarios relative to this baseline. Starting with our own bottom-up cost analyses in South Africa, we separate outpatient cost into non-scale-dependent costs (drugs and laboratory tests) and scale-dependent cost (staff, space, equipment and overheads) and model the cost of production according to the expected future number and size of clinics. On the demand side, we include the cost of creating and sustaining the projected incremental demand for testing and treatment. Previous research with EMOD-HIV has shown that more vigorous recruitment of patients with CD4 counts less than 350 appears to be an advantageous policy over a five-year horizon. Over 20 years, however, the model assumption that a person on treatment is 92 percent less infectious improves the cost-effectiveness of higher eligibility thresholds over more vigorous recruitment at the lower threshold of 350, averting HIV infections for between $1,700 and $2,800 (under our central assumptions), while more vigorous expansion under the current guidelines would cost more than $7,500 per incremental HIV infection averted. Granular spatial models of demand and cost facilitate the optimal targeting of new facility construction and outreach services. Based on analysis of the sensitivity of the results to 1,728 alternative parameter combinations at each of four discount rates, we conclude that better knowledge of the behavioral elasticities would be valuable, reducing the uncertainty of cost estimates by a factor of 4 to 10
Political Geography:
South Africa

35702. The World Bank: Why It Is Still Needed and Why It Still Disappoints

Publication Date:
04-2015
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
<p>Do we still need the World Bank, given how much the global financial sector has expanded since the institution was founded? The paper argues that there is a continuing role for the Bank and that it is complementary to private finance.</p>

35703. Do Mobile Phone Surveys Work in Poor Countries?

Author:
Ben Leo, Robert Morello, Jonathan Mellon, Tiago Peixoto, and Stephen Davenport
Publication Date:
04-2015
Content Type:
Working Paper
Institution:
East-West Center
Abstract:
In this project, we analyzed whether mobile phone-based surveys are a feasible and cost-effective approach for gathering statistically representative information in four low-income countries (Afghanistan, Ethiopia, Mozambique, and Zimbabwe). Specifically, we focused on three primary research questions. First, can the mobile phone survey platform reach a nationally representative sample? Second, to what extent does linguistic fractionalization affect the ability to produce a representative sample? Third, how effectively does monetary compensation impact survey completion patterns? We find that samples from countries with higher mobile penetration rates more closely resembled the actual population. After weighting on demographic variables, sample imprecision was a challenge in the two lower feasibility countries (Ethiopia and Mozambique) with a sampling error of +/- 5 to 7 percent, while Zimbabwe's estimates were more precise (sampling error of +/- 2.8 percent). Surveys performed reasonably well in reaching poor demographics, especially in Afghanistan and Zimbabwe. Rural women were consistently under-represented in the country samples, especially in Afghanistan and Ethiopia. Countries' linguistic fractionalization may influence the ability to obtain nationally representative samples, although a material effect was difficult to discern through penetration rates and market composition. Although the experimentation design of the incentive compensation plan was compromised in Ethiopia and Zimbabwe, it seems that offering compensation for survey completion mitigated attrition rates in several of the pilot countries while not reducing overall costs. These effects varied across countries and cultural settings.
Topic:
Economics
Political Geography:
Afghanistan, Mozambique, Zimbabwe, and Ethiopia

35704. Fiscal Policy, Inequality, and the Ethnic Divide in Guatemala

Author:
Nora Lustig, Maynor Cabrera, and Hilcías E. Morán
Publication Date:
03-2015
Content Type:
Working Paper
Institution:
East-West Center
Abstract:
Guatemala is one of the most unequal countries in Latin America and has the highest incidence of poverty. The indigenous population is more than twice as likely to be poor than the nonindigenous group. Fiscal incidence analysis based on the 2009-2010 National Survey of Family Income and Expenditures shows that taxes and transfers do almost nothing to reduce inequality and poverty overall or along ethnic and rural-urban lines. Persistently low tax revenues are the main limiting factor. Tax revenues are not only low but also regressive. Consumption taxes are regressive enough to offset the benefits of cash transfers: poverty after taxes and cash transfers is higher than market income poverty.
Topic:
Education and Government
Political Geography:
Latin America and Guatemala

35705. Trade, Migration, and the Place Premium: Mexico and the United States

Author:
Raymond Robertson, Davide Gandolfi, and Timothy Halliday
Publication Date:
03-2015
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
Large wage differences between countries (“place premiums”) are well documented. Theory suggests that factor price convergence should follow increased migration, capital flows, and commercial integration. All three have characterized the relationship between the United States and Mexico over the last 25 years. This paper evaluates the degree of wage convergence between these countries during the period 1988 and 2011. We match survey and census data from Mexico and the United States to estimate the change in wage differentials for observationally identical workers over time. We find very little evidence of convergence. What evidence we do find is most likely due to factors unrelated to US-Mexico integration. While migration and trade liberalization may reduce the US-Mexico wage differential, these effects are small when compared to the overall wage gap.
Topic:
World Trade Organization
Political Geography:
United States and Mexico

35706. Corruption and Averting AIDS Deaths

Author:
Willa Friedman
Publication Date:
02-2015
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
This paper looks at the impact of corruption on the effectiveness of antiretroviral drugs in preventing AIDS deaths and the potential channels that generate this relationship. This is based on a unique panel dataset of countries in sub-Saharan Africa, which combines information on all imported antiretroviral drugs (ARVs) from the World Health Organization's Global Price Reporting Mechanism with measures of corruption and estimates of the HIV prevalence and the number of AIDS deaths in each year and in each country. Countries with higher levels of corruption experience a significantly smaller drop in AIDS deaths as a result of the same quantity of ARVs imported. This is robust to different measures of corruption and to a measure of overall death rates as well as HIV-specific death rates as the outcome. A case-study analysis of the Kenyan experience illustrates one potential mechanism for the observed effect, demonstrating that disproportionately more clinics begin distributing ARVs in areas that are predominantly represented by the new leader's ethnic group.
Topic:
World Trade Organization
Political Geography:
Kenya and Africa

35707. The Face of African Infrastructure: Service Availability and Citizens' Demands

Author:
Vijaya Ramachandran, Benjamin Leo, and Robert Morello
Publication Date:
02-2015
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
The need for infrastructure improvements is a top-tier economic, political, and social issue in nearly every African country. Although the academic and policy literature is extensive in terms of estimating the impact of infrastructure deficits on economic and social indicators, very few studies have examined citizen demands for infrastructure. In this paper, we draw upon survey data to move beyond topline estimates of national infrastructure access rates towards a more nuanced understanding of service availability and citizen demands at the regional, national, and sub-national level. We find a predictable pattern of infrastructure services across income levels—lower income countries have fewer services. The survey data also allows us to observe the sequencing of infrastructure services. On the demand side, survey respondents are most concerned with jobs and income-related issues, as well as with the availability of infrastructure: specifically transportation and sanitation. These priorities transcend demographic factors, including gender and location (urban/rural).
Topic:
Health
Political Geography:
Africa

35708. The Chaos in Darfur

Publication Date:
04-2015
Content Type:
Policy Brief
Institution:
International Crisis Group
Abstract:
Violence in the Darfur region of Sudan's far west continues unabated. Some 450,000 persons were displaced in 2014 and another 100,000 in January 2015 alone, adding to some two million long-term internally displaced persons (IDPs) since fighting erupted in 2003. The government remains wedded to a military approach and reluctant to pursue a negotiated national solution that would address all Sudan's conflicts at once and put the country on the path of a democratic transition. Khartoum's reliance on a militia-centred counter-insurgency strategy is increasingly counter-productive – not least because it stokes and spreads communal violence. Ending Darfur's violence will require – beyond countrywide negotiations between Khartoum, the rebel Sudanese Revolutionary Front (SRF) coalition and unarmed players – ad-dressing its local dimensions, within both national talks and parallel local processes.
Political Geography:
Sudan

35709. Myanmar's Electoral Landscape

Publication Date:
04-2015
Content Type:
Policy Brief
Institution:
International Crisis Group
Abstract:
Myanmar is preparing to hold national elections in early November 2015, five years after the last full set of polls brought the semi-civilian reformist government to power. The elections, which are constitutionally required within this timeframe, will be a major political inflection point, likely replacing a legislature dominated by the Union Solidarity and Development Party (USDP), established by the former regime, with one more reflective of popular sentiment. The opposition National League for Democracy (NLD) party of Aung San Suu Kyi is well-placed to take the largest bloc of seats. There have been major improvements in election administration since the deeply flawed 2010 elections and the more credible 2012 by-elections. While the election commission is still widely perceived as close to the government and the USDP, the transparent and consultative approach it has adopted and the specific decisions it has taken suggest it is committed to delivering credible polls. This includes major efforts to update and digitise the voter roll; consultation with civil society and international electoral support organisations on the regulatory framework; invitations to international electoral observers for the first time, as well as to domestic observers; changing problematic provisions on advance voting; and reducing the costs of a candidacy. The broader political environment is also more conducive to credible elections, with a significantly freer media and much improved civil liberties. There remain major challenges to a credible, inclusive and peaceful election. Much of the periphery of the country is affected by armed conflict, and though there have been important steps toward bringing the six-decade civil war to a close, the process remains fragile and incomplete. The vote could be marred by violence in some areas and will not be possible in others. In central Myanmar, rising Burman nationalism and anti-Muslim sentiment have exploded sporadically into violence, something that could happen again in the politically charged context of an election. In Rakhine state, minority Muslim communities have been disenfranchised by a decision to cancel their identification documents. Electoral security and risk management preparations have become a critical priority of the election commission. Capacity constraints will also come into play. The country has very limited experience of democratic polls, including government staff, security services and election commission staff at the local level. Understanding among the electorate is also very low, and major education efforts will be required. For the elections to be successful, there must also be broad acceptance of the results. In a context of divergent expectations and, inevitably, winners and losers, this will be a challenge. While reformist government leaders appear reconciled to the prospect of the NLD winning the most seats, it is unclear whether this sentiment is shared by a majority of the old elite. Similarly, it is unclear whether the NLD's base fully under- stands likely post-election scenarios. With Aung San Suu Kyi constitutionally barred from the presidency and no obvious alternative within its ranks, it is probable that even if the party wins a landslide, it will have to select a compromise candidate for president – potentially a reformist member of the old regime. The some three months between the elections and the presidential electoral college's decision will be a time of considerable uncertainty, possible tension, and intense behind-the-scenes negotiation. The outcome, and the extent to which it is broadly accepted, will determine whether there is a smooth transfer of power and whether the next administration will have the broad support necessary to govern or have its legitimacy constantly questioned. Probably the most important factor will be the support – or at least acquiescence – of the military, which retains strong influence over the process. The commander-in-chief has voiced support for the democratic electoral process and has undoubtedly foreseen the prospect of strong support for the NLD. But this does not mean he would be comfortable with all the potential implications of such an outcome. The elections are coming less than five years into what will continue to be a long and difficult transition for Myanmar. They create a moment of political competition and polarisation in a transition process that requires compromise and consensus. If credible and inclusive, they can help to build confidence that the country is on a new political path and thereby inject fresh momentum into the reforms. Equally, they could damage the delicate set of compromises that has so far kept the process broadly on track. It behoves political leaders on all sides to ensure that they keep this larger prize foremost in their minds.
Political Geography:
Myanmar

35710. Electoral Rentierism? The Cross-National and Subnational Effect of Oil on Electoral Competitiveness in Multiparty Autocracies

Author:
Matthias Basedau and Michael Wahman
Publication Date:
04-2015
Content Type:
Working Paper
Institution:
German Institute of Global and Area Studies
Abstract:
Building on theoretical insights from research on the rentier state and the “resource curse,” several studies have supported the argument that oil hinders democracy. However, previous research on the rentier state has neglected the global surge of multiparty autocracies or “electoral authoritarian” regimes since the end of the Cold War. No systematic study has been carried out on the question of whether or not and how oil affects electoral contests in nondemocratic regimes. In this paper we contribute to filling this gap by combing the literature on multiparty autocracy and the political economy of the rentier state. As oil production creates substantial, nontransparent revenue streams to national and subnational governments, we hypothesize that oil production has a negative effect on electoral competitiveness, both cross‐ and subnationally, in multiparty autocracies. Consequently, the democratic “resource curse” emphasized in earlier work on the rentier state is likely to persist even after the introduction of multipartyism in cases where oil production predates democratic institutions. The paper tests the hypothesis cross‐nationally, using data on all multiparty elections held in the world in the period 1975–2010, and subnationally, using a new data set on subnational election results and oil production in Nigeria. Our results confirm that oil impedes electoral competitiveness, both cross‐ and subnationally, in multiparty autocracies.
Topic:
Cold War, Democratization, and Oil
Political Geography:
Africa and Nigeria