Responding to COVID-19 in the Global South: Insights from CEGA research
This post was co-authored by CEGA journalism intern Anne Daugherty and Operations Director Lauren Russell.
In low-income countries, weak health care systems and high rates of poverty are likely to worsen the social and economic impacts of COVID-19. As governments and NGOs scramble to devise effective mitigation strategies, ongoing and completed research led by CEGA affiliates — on topics from handwashing to infectious disease response to cash transfers — can provide clues as to what may unfold in these countries, and the likely effectiveness of proposed policy responses. The capacity and integrity of institutions will further play an important role in shaping the long-term health and economic consequences of the pandemic, especially for the most vulnerable.
We hope the following insights will be useful to Global South decision-makers as they respond to the crisis at hand.
Lessons from Containing Ebola
Where people lack confidence in their health providers, they are less likely to seek testing and treatment when they feel sick. This stymies efforts to identify, treat and isolate infected patients to limit further contagion. Looking at the 2014 Ebola epidemic in Sierra Leone, CEGA Director of Research Bilal Siddiqi, affiliate Darin Christensen (UCLA), and coauthors discovered that low-cost accountability interventions that improved confidence in the health system prior to the Ebola outbreak spurred a vast increase in the number of people who sought to get tested. Ultimately, this led to more effective containment and 30% fewer deaths among Ebola patients. Furthermore, once the outbreak hit, epidemic containment strategies that focused on engaging with communities tripled voluntary testing.
Credible Hygiene Messaging
Information provision is only an effective behavior change strategy if the information is perceived as credible. In Pakistan, CEGA affiliate Dan Bennett (USC) and coauthors ran a randomized evaluation of a novel Microbe Literacy (ML) program that augmented traditional hygiene instruction by showing participants everyday microbes under a microscope. The researchers found that the program drove meaningful improvements in hygiene and health, while instruction alone did not. Traditional medicine, which offers an alternative disease model, may undermine learning by strengthening prior beliefs about hygiene that exacerbate the spread of infectious disease — something health officials attempting to stem the transmission of diseases like COVID-19 should consider seriously.
Changing Handwashing Behavior
Proper handwashing with water and soap is an inexpensive hygiene habit that helps prevent person-to-person spread of viruses like COVID-19. In Peru, affiliate Paul Gertler (UC Berkeley) and co-authors tested a large-scale handwashing intervention that introduced a novel mix of mass media campaigns along with more intensive community activities. Activities included primary school handwashing curriculum and community-based facilitator training for teachers, health workers and community leaders. The program — which they found reached target audiences, improved knowledge related to handwashing, and induced behavior changes — could serve as a model for other countries.
Mobilizing Community Health Workers
Strengthening primary health service delivery in low- and middle-income countries is critical to improving health care utilization and outcomes. Affiliate Daniel Posner (UCLA) and co-authors replicated the evaluation of a 2009 community-based monitoring program for public primary health care providers in Uganda. Ten years later, their 2019 study implies that information-based, bottom-up accountability interventions become less effective as baseline health conditions, utilization, and the quality of health service provision improves. In other words, decision-makers looking to improve the quality of healthcare and other services in low-income settings should consider baseline health conditions first.
Incentivizing Immunizations through Social Signaling
Immunizing children is one of the most cost-effective ways to reduce child mortality, but only 58 percent of children in Sierra Leone complete their first-year series of vaccinations. With funding from CEGA, Berkeley PhD student Anne Karing (now at Princeton) collaborated with Sierra Leone’s Ministry of Health and Sanitation to distribute different colored bracelets to parents when they vaccinated their children. The bracelets served as a signal to others that the parents cared about their child’s health. Karing found this social signaling intervention to be effective at increasing immunization rates to levels necessary for population immunity. Low-cost, easily scalable social signaling initiatives like this could inform local government responses to COVID-19 as vaccines become available.
Low-Cost Instructional Health Videos
Tuberculosis (TB) is one of the top ten causes of death worldwide, but treatable with first-line antibiotics when diagnosed early. Tanzania has both a high TB burden and a low TB case detection rate, with over 100,000 cases of TB missed each year, mostly due to suboptimal laboratory testing and poor quality sputum (spit) samples. CEGA East Africa Social Science Translation (EASST) network research fellow, Grace Mhalu, introduced the use of low-cost instructional videos and supplemental guidance to improve TB sample quality. She is currently evaluating whether this approach improves community understanding of TB (results forthcoming). Accessible and engaging health education content for communities — whether to improve TB test samples or provide critical information about highly contagious viruses like COVID-19 — may improve health outcomes.
Cash Transfers for Building Economic Resilience
In rural Kenya, research by CEGA Faculty Director Ted Miguel (UC Berkeley), Paul Niehaus (UC San Diego) and coauthors have been exploring whether people are more resilient to economic or health shocks (like COVID-19, for example) after receiving unconditional cash transfers (UCTs). Their research has found that providing $1000 in cash to some of the poorest households improved outcomes for recipients as well as their neighbors who did not receive cash. Total economic activity in the area increased by $2.60 for every $1.00 transferred, with negligible inflation. This general equilibrium effect demonstrates that UCTs can significantly improve not just the economic lives of recipients, but non-recipients as well, making them a particularly attractive policy tool to help vulnerable communities weather COVID-induced shocks. New survey modules will ask Kenyans in the study area about their COVID-19 experiences, knowledge, exposure, and more, providing unique health and financial insights.
Digital Loans for Building Economic Resilience
Instant, automated, and remote lines of credit over mobile money platforms or fintech apps have become a useful financial tool for managing unexpected expenses. In Kenya, affiliate Prashant Bharadwaj (UC San Diego) and coauthors studied the adoption and impacts of M-Shwari, one of the most popular digital loans in the world. They found that households with credit scores just high enough to qualify for loans were more resilient: they were 6.3 percentage points less likely to forego expenses due to negative shocks (as compared to their peers whose credit scores are just low enough to make them ineligible for a digital loan). This financial tool may become increasingly popular and important in a time where lockdowns limit physical mobility and other forms of financial recourse. However, allowing deferred repayments may be needed to include and protect vulnerable households’ whose primary income-generating activities are disrupted or upended.
Universal Basic Income
Hilary Hoynes (UC Berkeley) and Jesse Rothstein (UC Berkeley), Directors of the Opportunity Lab — a sister research Center incubated by CEGA — discuss the potential role of Universal Basic Incomes (UBIs) for building resilience in high-income countries. UBIs are potentially powerful yet understudied tools that could be used by governments to alleviate economic shocks induced by COVID-19. The researchers find that a UBI in the U.S. would direct much larger shares of transfers to childless, non-elderly, non-disabled households than existing programs, and much more to middle-income rather than poor households. They also argue that a UBI large enough to increase transfers to low-income families in the U.S. would be enormously expensive.
Optimizing Social Benefits for the Ultra-Poor
The economic impacts of COVID-19 will be significant, especially for vulnerable populations. Research by Munshi Sulaiman (BRAC) and CEGA affiliate Ethan Ligon (UC Berkeley) may help inform the design of social benefits programs to strengthen resiliency of “ultra poor” populations, whose income levels are insufficient to participate in traditional microfinance programs. With funding from the BRAC-CEGA Learning Collaborative, researchers assessed the impact of a “Targeting the Ultra-Poor” (TUP) program in South Sudan that combined cash transfers and training. Treatment groups were given cash transfers of varying amounts, while the control group received cash, food or other liquid assets of equivalent value to the transfers. Researchers found that targeted asset transfers can play a constructive role in helping the poor respond to economic uncertainty. While all groups receiving cash transfers increased consumption, those provided with additional TUP services experienced greater long-term income or wealth.
Faster Social Safety Net Payments
Digital platforms that securely and efficiently disburse social safety net payments may be essential during the COVID-19 pandemic. As India continues its lock-down, the nearly 50 million most-impoverished rural households who rely on payments from its federal workfare program may no longer be able to access their guaranteed monthly wages if they cannot get to their work sites. Even before the outbreak, workfare wage payments were often delayed well beyond the legally mandated 15 days, reducing households’ ability to manage economic uncertainty and meet basic needs. Research funded by Economic Development and Institutions (EDI), managed in part by CEGA, collaborated with the Indian Ministry of Rural Development and J-PAL to evaluate a real-time mobile application that aims to improve the Indian government’s accountability to timely wage delivery by lowering costs of accessing information for both frontline bureaucrats and their supervisors. Preliminary results show that introducing the app reduced payment processing times by 24 percent in areas with the longest delays, an important improvement for one of the world’s largest social safety nets.
Estimating Vulnerability with Mobile Phone Data
Identifying households that most require assistance as a result of the COVID-19 pandemic will become critical as governments attempt to effectively channel social safety net benefits. Several studies by CEGA Faculty Co-Director Josh Blumenstock (UC Berkeley) use machine learning (ML) to demonstrate that non-traditional data, including detailed mobile phone records, can be used to estimate poverty and vulnerability — including exposure to economic shocks — and identify the most at-risk populations. In Afghanistan, Blumenstock and co-authors confirm that ML methods can accurately differentiate ultra-poor households eligible for program benefits from other poor households deemed ineligible, and that new ML approaches can identify ultra-poor households as accurately as standard survey-based measures of poverty, including consumption and wealth. They also demonstrate that combining survey-based measures with mobile phone data produces more accurate data than those based on a single data source.
Thanks for reading! For updated information about how CEGA is responding to the COVID-19 crisis, and a running list of resources for researchers, please click here.
