Improving the quality of health care when health workers are in short supply

A number of low- and middle-income countries have a severe shortage of health workers. This paper studies how health workers’ choices of labour supply and work effort impact on the quality of health services when health workers are in short supply. We analyse how policy measures such as monetary incentives, monitoring, provisions of quality-enhancing inputs, and the building of professionalism and organisational identity can improve the quality of health care in the presence of a health worker shortage. We find that to pay health workers based on the number of patients may have a positive impact on the quality of health care even if quality does not affect demand. Furthermore, provision of quality-enhancing drugs and equipment may reduce health workers’ effort in delivering quality care, thus diminishing the positive impact of such interventions. Our most surprising result is that if the actual quality of health care is far below a professional standard, measures to build a professional mindset among health workers may reduce the quality of care.Public Goods; Laboratory; Individual Behavior

Challenges and success factors for implementation of lean manufacturing in European SMES

Small and medium-sized enterprises are crucial to value creation in the European economy. The SMEs need continuous improvement initiatives to stay competitive. However, SMEs are less likely to implement lean practices compared to larger companies. Limited research exists on the factors that are vital for succeeding with Lean implementations in SMEs. A case study of Norwegian and Belgium SMEs has been conducted in the European research project ERIP (European Regions for Innovative Productivity). Six critical success factors are suggested, which correspond well with previous research: 1) Ensure strong management involvement. 2) Develop thorough employee participation. 3) Allocate sufficient time for preparing the organisation. 4) Focus on creating motivation to complete initiatives. 5) Build competence internally in the organisation. 6) Establish a performance evaluation system

Overworked? The relationship between workload and health worker performance in rural Tanzania

The current shortage of health workers in many low-income countries poses a threat to the quality of health services. When the number of patients per health worker grows sufficiently high, there will be insufficient time to diagnose and treat all patients adequately. This paper tests the hypothesis that a high caseload reduces the level of effort per patient in the diagnostic process, using a new data set from rural Tanzania. Tanzania has a severe shortage of health workers, and previous research has pointed at high workload as a main reason for sub-standard clinical performance. We observed and evaluated the level of effort of 159 clinicians in 2,095 outpatient consultations at 126 health facilities with different levels of caseload per clinician. Surprisingly, we find no association between caseload and the level of effort per patient in the diagnostic process. In fact, clinicians appear to have ample amounts of idle time. We conclude that health workers are not overworked and that scaling up the number of health workers in this setting is unlikely to raise the quality of health services. A more promising measure for improved quality is to raise the level of formal clinical training among the clinicians, although training alone seems far from enough to raise quality to adequate levels.Health personnel Tanzania

Overworked? The relationship between workload and health worker performance in rural Tanzania

The current shortage of health workers in many low-income countries poses a threat to the quality of health services. When the number of patients per health worker grows sufficiently high, there will be insufficient time to diagnose and treat all patients adequately. This paper tests the hypothesis that a high caseload reduces the level of effort per patient in the diagnostic process, using a new data set from rural Tanzania. Tanzania has a severe shortage of health workers, and previous research has pointed at high workload as a main reason for sub-standard clinical performance. We observed and evaluated the level of effort of 159 clinicians in 2,095 outpatient consultations at 126 health facilities with different levels of caseload per clinician. Surprisingly, we find no association between caseload and the level of effort per patient in the diagnostic process. In fact, clinicians appear to have ample amounts of idle time. We conclude that health workers are not overworked and that scaling up the number of health workers in this setting is unlikely to raise the quality of health services. A more promising measure for improved quality is to raise the level of formal clinical training among the clinicians, although training alone seems far from enough to raise quality to adequate levels.Human Resources; Quality health services; Workload; Tanzania

Timber trade restrictions and tropical deforestation : a forest mining approach

Timber trade restrictions have been proposed as a means to reducing tropical deforestation. This paper analyses the consequences of such trade interventions, emphasising the effects on logging behaviour and the allocation of land between forestry and alternative activities (e.g., agriculture). Tropical forestry is modelled as the mining of a heterogeneous, non-renewable resource. Two different harvesting procedures – sequential and simultaneous harvest – are examined. The analysis suggests that logging will be reduced if timber trade restrictions reduce the log price equally for all tree qualities. But if the price reduction is non-uniform, logging may increase in some fields. In fact, total logging may increase as well. It is also shown that timber trade restrictions do not necessarily promote the conversion of forestland to alternative uses. Key words: Tropical forest, deforestation, mining, trade policy. JEL classification: F13, Q23, Q24, Q28

Maakasutuse ja kliimamuutuse mõju Eesti jõgede hüdroenergeetilisele potentsiaalile

A Thesis for applying for the degree of Doctor of Philosophy in Engineering Sciences.Water-related changes are currently receiving the most focus in the context of climate change around the world. The changing climate conditions have already redistributed water resources, including the hydropower potential in Estonian rivers. This phenomenon is expected to continue in the future. However, the effects on land use and climate change on the hydropower potential in Estonia are unclear. The technical hydropower potential was assessed for the territory of Estonia (excluding the Narva River). According to the developed method, the total technically feasible hydropower potential in Estonia was calculated to be approximately 80 MW, which was considerably higher than that previously reported. The SWAT model was employed to assess the potential impact of future climate and land-use change on river flow in various Estonian river watersheds, where hydropower is or has been harvested. The SWAT model demonstrated satisfactory performance in describing the hydrological processes in Estonian rivers by using series of mathematical equations. An evident linear trend between the effects of deforestation and afforestation on yearly river flow was observed. The following general rule can be applied to Estonia; a 5% forest change induces a 1% change in annual average flow. Hydrological modeling indicated a positive change in river flow according to both climate scenarios. Increases in the mean annual flow of 10% and 33% were predicted by the climate projections KNMI and DMI, respectively. Hydropower potential is expected to increase in Estonia by the end of the century, compared with the baseline period. The installation of additional turbines, along with upgrading existing turbines, could increase the installed capacity. Furthermore, with the projected overall increase of hydropower potential in Estonia, the construction of new stations becomes more economically feasible and profitable.Veeressursidega seonduvad küsimused on viimastel kümnenditel olnud ülemaailmselt üks huvipakkuvamaid temaatikaid teadlaste seas. Seda just seetõttu, et vee ajaline ja koguseline kättesaadavus on kliimamuutuse tõttu muutumas, mis on mõjutanud ka Eesti jõgede hüdroenergeetilist potentsiaali. Nende muutuste jätkumine avaldab mõju ka hüdroenergia tootlikkusele, ent kui suuresti võib Eesti jõgede hüdroenergeetiline potentsiaal muutuda, on teadmata. Doktoritöös antakse uus hinnang Eesti (v.a. Narva jõe) tehniliselt rakendatavale hüdroenergeetilisele potentsiaalile. Selleks tuletati meetod, mille kohaselt Eesti jõgede tehniline hüdroenergeetiline potentsiaal seni hinnatust märkimisväärselt suurem, olles ligikaudu 80 MW. Maakasutuse ja kliima muutumise mõju Eesti jõgede vooluhulkadele hinnati hüdroloogilise mudeli SWAT abil, kalibreerides ja valideerides seda Eesti suurema hüdroenergeetilise potentsiaaliga jõgedele. Selgus, et SWAT- mudel suudab piisava täpsusega matemaatiliselt kirjeldada Eesti jõgedes kulgevaid looduslikke protsesse. Ilmnes tugev lineaarne seos metsasuse ja aastakeskmise vooluhulga muutuse vahel. Seda seost võib üldistada järgmiselt: metsasuse viieprotsendine muutus muudab jõe aastakeskmist vooluhulka 1 % võrra. Kliimamuutuse mõju Eesti jõgede aastakeskmisele vooluhulgale on positiivne — olenevalt kasutatud kliimamudelist 10 kuni 33 protsenti. Hüdroenergeetiline potentsiaal on Eestis suurenemas. Selle positiivse mõju ärakasutamiseks on soovitatav olemasolevaid hüdroelektrijaamu laiendada või uuendada. Eesti jõgede hüdroenergeetilise potentsiaali suurenemine teeb uute hüdroelektrijaamade rajamise majanduslikult otstarbekaks.Publication of this dissertation is supported by the Estonian University of Life Science

Der Runenstein von Tanum - ein religionsgeschichtliches Denkmal aus urnordischer Zeit

The article offers a critical analysis of the inscriptions on three runic stones: the Rök stone from the early Viking Era (800-820), the stone from Stentoften (550-580/699) and the stone from Tanum (200-500). According to the author, all three runic stones seem to have filled a cultic function and can thus shed light on the Old Norse religion

'Margin Insensitivity' and the Analysis of Educational Inequality

A problem in educational attainment research is that measures of association, and not measures of inequality, have been used to observe inequality in the distribution of higher education between classes. While the statistical association between class and education in many countries has been relatively stable, measures of inequality applied to the same data show a marked reduction of inequality in the distribution of higher education over time. This is a result of reduced bias in the allocation mechanisms, most likely facilitated by the increasing provision of higher education. Decreasing inequality means that the conclusion in the literature that egalitarian educational reforms have been ineffective lacks empirical support. One reason why measures of inequality have been overlooked in most educational attainment research may be the firm but unfounded belief in the 'margin insensitivity' of loglinear measures. They are assumed to capture the association net of changes in the marginals of the class-by-education table, thus reflecting the 'true nature' of the allocation mechanism in recruitment to higher education. This notion can be shown to be a logically untenable deduction from the property of loglinear measures of being insensitive in relation to one specific kind of change in the marginals, to the claim that these measures are insensitive to marginal changes in general