Principal investigator: Eduarda Miller de Figueiredo
Article title: LOSING PROSOCIALITY IN THE QUEST FOR TALENT? SORTING, SELECTION, AND PRODUCTIVITY IN THE DELIVERY OF PUBLIC SERVICES
Article authors: Nava Ashraf, Oriana Bandiera, Edward Davenport and Scott S. Lee
Sample size: 1.585 individuals
Location of the interventionZambia
Sector: Health
Type of interventionPosition for a formal public health employee.
Main variable of interestNumber of home visits
Assessment methodOther – Experiment
Policy Problem
Providing health services in remote rural areas is a challenge for all countries at different levels of development, as medical teams trained for the region have high turnover rates (World Health Organization, 2006).
In Zambia, in 2010, the average health post had 1,5 Ministry of Health employees, including those who were not permanent staff. Because of this, the government created the position of... Community Health Assistant (CHA), which is a position for formally trained government health officials rather than informal community health workers.
Furthermore, given the scarcity of skilled jobs, the Zambian government's program may have the added benefit of creating employment opportunities in these communities.
Assessment Context
Through the program of Community Health AssistantTwo health professionals were deployed in each of the 167 communities across Zambia's 48 districts, where the primary task of the Community Health Agents (CHAs) is to visit families and refer them to health units as needed. Therefore, such a position requires medical skills – vital signs, diagnoses, screening for common illnesses – and social skills – counseling, support, patient education.
In this program adopted by Zambia, healthcare workers join the civil service, allowing for advancement, through additional training, to higher and better-paid positions. Thus, the initial monthly salary is US$290 for CHAs (Health Care Assistants) and US$530 for entry-level nurses. As CHAs are part of the civil service, they are eligible for on-the-job training, meaning they attend school (medical or nursing school) while continuing to receive their salary or some form of tuition sponsorship.
The Ministry of Health periodically requests district medical officials to nominate candidates based on merit, not performance. Therefore, promotions to higher positions are not automatic, but have a high expected return, since job opportunities that allow for a government career are rare in the remote communities to which health professionals are recruited.
This model was chosen by the country's government in the hope of attracting agents with strong technical skills to do community work; however, there was a risk of excluding candidates motivated to help the community. And this was the case. trade-offs which encouraged the experiment carried out by the authors.
Policy Details
Aiming to assess whether a career in public service attracts talent for pro-sociality and whether this affects who is hired and their performance, the authors designed an experiment, given the relevance of evaluating the role of selection in the provision of public services. In this experiment, the main challenge was to separate the selection effect from the incentive effect at work; to this end, the study approached it in two stages: (i) opening the selection channel; (ii) closing the incentive channel.
- Opening the selection channel
For this purpose, recruitment posters and informational materials with detailed instructions were distributed to health workers.
The treatment poster emphasizes the identity of public service in the new CHA position, relating it to the benefit of career advancement opportunities within the public service. Furthermore, the material explicitly fosters a sense of belonging to the public service.
The control poster, on the other hand, uses the standard community health recruitment approach, emphasizing the social identity of the position and highlighting the impact of acquiring skills to promote the health of one's family and neighbors.
Therefore, what changes between treatment and control posters is the wording of the benefits.
- Closing the incentive channel:
All successful candidates are eligible for career opportunities once hired. After recruitment, agents train together for one year, receiving the same information about career opportunities that civil servants are entitled to.
Therefore, treatment and control have the same incentives when contracted, differing only in the selection method.
Methodology Details
Since recruitment was organized by district employees, the authors randomized treatment at the district level, thus maximizing compliance along with experimental assignment. The 48 districts were divided into two groups, implying that each employee is exposed to only one treatment.
The recruitment campaign yielded 1.585 applications from candidates who were eligible for the position, as they were required to provide information on skills, career ambition, and prosociality. This information was used to measure the effects of the treatment on the overall composition of the candidates. To measure prosociality, the authors combined the candidate's self-reported willingness to remain in the community long-term with a scale... Inclusion of Others in Self (IOS) which measures alignment of interests (Aron et al., 2004).
Results
Evidence suggests that career opportunities attract candidates with diverse skill sets, career motivations, and pro-sociality, with a greater propensity to choose candidates who rank highly in all three areas.
The results also demonstrate that agents attracted by career opportunities are more effective, providing more inputs at the same cost. They also observed an increase in the number of children undergoing health checkups, which was 24% higher in the treatment group. Furthermore, the presence of CHAs (Community Action Teams) showed an improvement in a number of family health practices.
Regarding home visits, there was a significant effect, with healthcare professionals recruited through career opportunities conducting 94 more visits, or 29% more, than the control group over 18 months. Given that for most of these families, these recruited healthcare professionals are the sole providers of healthcare services, the intervention may have positive implications for community health.
Another point is that the program leads to a substantial increase in the number of health professionals operating in the communities, an increase from 1,5 to 3,5 on average. Given the size of the increase and the magnitude of the effect, the authors expected the intervention to increase the utilization of health facilities and practices through increased demand, behavioral changes, information provision, etc. In turn, better utilization of health facilities and practices leads to better outcomes.
The results do indeed suggest that career opportunities improve the utilization of healthcare facilities. And, when it comes to the number of women giving birth, a 30% increase was observed compared to the average in the control areas.
On the other hand, it was observed that agents in the career incentive treatment group may leave their positions earlier than agents in the control group. Thus, whether this entails a welfare cost depends on whether they can be easily replaced and whether the government can utilize their skills in other roles.
Lessons in Public Policy
The results indicate that offering a position in a public service with career opportunities attracts healthcare workers, causing a significant impact on community health. Furthermore, as healthcare work generates more social value, a position with the possibility of career growth in the public sector improves social well-being.
Reference
ASHRAF, Nava et al. Losing prosociality in the quest for talent? Sorting, selection, and productivity in the delivery of public services. American Economic Review, vol. 110, no. 5, p. 1355-94, 2020.
